Citation Nr: 1237672 Decision Date: 11/02/12 Archive Date: 11/09/12 DOCKET NO. 07-06 359A ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES Entitlement to an initial rating in excess of 20 percent for right knee arthritis with recurrent effusion (right knee disorder) from January 23, 2005. ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran served on active duty from January 2001 to January 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision by the Department of Veterans Affairs (VA) Regional Offices (RO) in Jackson, Mississippi. The RO in St. Petersburg currently has jurisdiction of the claim. In May 2010 and September 2011, the Board remanded the appeal for further development. FINDINGS OF FACT 1. From January 23, 2005, the more competent, probative, and credible evidence of record does not show that the Veteran's right knee disorder is manifested by ankylosis; flexion of the knee limited to at least 45 degrees even taking into account her complaints of pain; extension of the knee limited to at least 10 degrees even taking into account her complaints of pain; impairment of the tibia and fibula; or adverse neurological symptomatology. 2. From January 23, 2005, the more competent, probative, and credible evidence of record shows that the Veteran right knee disorder is also manifested by slight subluxation. CONCLUSIONS OF LAW 1. From January 23, 2005, the criteria for an initial rating in excess of 20 percent for arthritis of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5256, 5258 to 5261 (2012). 2. From January 23, 2005, the criteria for a separate 10 percent rating for instability of the right knee has been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under 38 U.S.C.A. § 5102 VA has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence she is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (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. See 38 U.S.C. § 5103(a). Initially, the Board finds that there is no issue as to whether the Veteran was provided an appropriate application form or issue as to whether the claimant has veteran status. Next, the Board observes that the Veteran is challenging the initial evaluation assigned following the grant of service connection for her right knee disorder. In Dingess, supra, the Court also held that in cases where service connection has been granted and an initial disability evaluation has been assigned, the service connection claim has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id, at 490-91; Also see Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, because the notice that the Veteran was provided before service connection was granted was legally sufficient (i.e., the April 2005 38 U.S.C.A. § 5103(a) notice letter provided to the Veteran prior to the August 2005 rating decision), VA's duty to notify in this case has been satisfied. Furthermore, the Board finds that if VA had an obligation to provide the Veteran with 38 U.S.C.A. § 5103(a) notice and failed to do so, that this notice problem is harmless error because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claim after reading the rating decision, statement of the case, supplemental statements of the case, and the Board remands. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). VA has also secured all available pertinent evidence and conducted all appropriate development. Specifically, the record shows that VA obtained and associated with the claims file all identified and available post-service medical records including the Veteran's records from the Social Security Administration (SSA), Reza M. Taba, M.D., the VA Gulf Coast Veterans Health Care System, and the North Florida/South Georgia Veterans Health System, and from the Montgomery, Jacksonville, and Gainesville VA Medical Centers in substantial compliance with the Board's remand orders. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The record also shows that the Veteran was afforded VA examinations in June 2005, April 2006, November 2010, and October 2011. Moreover, the Board finds the October 2011 VA examination is adequate to adjudicate the claim and substantially complies with the Board's May 2010 and September 2011 remand instructions because the examiner took a medical history of the claimant that conforms with the evidence found in the record, conducted an in-depth examination of the claimant, and the examiner thereafter provided a medical opinion as to the severity of the disability and a rational for the opinion that allows the Board to rate it under all applicable rating criteria. See 38 U.S.C.A. § 5103A(d); Barr, supra; Dyment, supra; D'Aries, supra. In this regard, while the October 2011 VA examiner did not provide an opinion as to whether the Veteran's right knee disorder was manifested by malunion of the tibia or fibula or nonunion of those bones, with loose motion, requiring a brace, the Board does not find that the failure to provide this opinion renders the examination inadequate because the examiner at this time was unable to take X-rays because of a possible pregnancy and an earlier magnetic resonance imaging evaluation (MRI) discussed by that examiner did not show malunion of the tibia or fibula or nonunion of these bones. Id. The October 2011 VA examiner opined that "pain on use during flare-ups likely to result in transient additional loss of motion" of the right knee. However, the examiner did not quantify this addition limitation of motion. Nonetheless, the Board finds the range of motion studies performed by the examiner adequate under DeLuca v. Brown, 8 Vet. App. 202 (1995) because "transient additional loss of motion" is not cable of quantification. Id. In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A, or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claim below, the Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims files shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Rating Claim The Veteran asserts that her right knee disorder meets the criteria for a higher evaluation. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). In cases where the original rating assigned is appealed, consideration must be given to whether the veteran deserves a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating loss in range of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id, at 206. Under 38 C.F.R. § 4.40, disability of the musculoskeletal system is primarily the inability, due to damage or infection in 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 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 the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. Additionally, 38 C.F.R. § 4.45 provides, as regards to the joints, that the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the spine is considered a major joint. In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The August 2005 rating decision granted service connection for the right knee disorder and rated it as 10 percent disabling from January 23, 2005, under 38 C.F.R. § 4.71a, Diagnostic Code 5010. Thereafter, a February 2011 rating decision rated the Veteran's right knee disorder as 20 percent disabling also from January 23, 2005, also under Diagnostic Code 5010. Under 38 C.F.R. § 4.71a, Diagnostic Code 5010, traumatic arthritis is rated on limitation of motion like degenerative arthritis. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of 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. A rating of 20 percent is assigned for each such major joint or group of minor joints, with occasional incapacitating exacerbations, affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under 38 C.F.R. § 4.71a, Diagnostic Code 5256, ankylosis at a favorable angle in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent rating; ankylosis with flexion between 10 degrees and 20 degrees warrants a 40 rating; ankylosis with flexion between 20 degrees and 45 degrees warrants a 50 rating; and extremely unfavorable ankylosis (flexion at an angle of 45 degrees or more) warrants a 60 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling. And, severe recurrent subluxation or lateral instability warrants a 30 percent rating. The terms "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). The use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, removal of the semilunar cartilage when symptomatic warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. If extension of the knee is limited to 30 degrees a 40 percent rating is in order. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). Under 38 C.F.R. § 4.71a, Diagnostic Code 5262, impairment of the tibia and fibula (nonunion with loose motion requiring a brace or malunion) with slight knee or ankle disability warrants a 10 percent rating; with moderate knee or ankle disability warrants a 20 percent rating; with marked knee or ankle disability warrants a 30 percent rating; and with nonunion (loose motion requiring brace) warrants a 40 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), that Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In this regard, VA General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability, provided of course, that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-1997 (July 1, 1997). As to higher rating under Diagnostic Code 5256, the Board notes VA and private treatment records document lost in right knee motion. Similarly, the range of motion of the right knee was restricted at all of the Veteran's VA examinations. See VA examinations dated in June 2005, April 2006, November 2010, and October 2011. However, the record on appeal never shows the right knee being ankylosed. In fact, the November 2010 and October 2011 VA examiners specifically opined that there was no ankylosis of the right knee. These opinions are not contradicted by any other medical opinion of record. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). In the absence of ankylosis, the Board may not rate her service-connected right knee disorder as ankylosis. Johnston v. Brown, 10 Vet. App. 80 (1997). Consequently, a higher evaluation is not warranted for the Veteran's service-connected right knee disorder under Diagnostic Code 5256. This is true from January 23, 2005, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to higher rating under Diagnostic Codes 5258, 5259, and/or 5263, the Board notes that the disability rating already assigned the Veteran's service-connected right knee disorder meets or exceeds the maximum rating possible under these code sections. Therefore, a higher evaluation under these code sections must be denied as a matter of law despite a recent VA examination revealing genu recurvatum. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive, the Board should deny the claim on the ground of lack of legal merit). This is true from January 23, 2005, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to higher rating under Diagnostic Code 5262, the record on appeal is negative for objective evidence of malunion or nonunion of the tibia and fibula. See, for example, VA examinations dated in June 2005, April 2006, November 2010, and October 2011; Also see right knee X-rays dated in February 2004, June 2005, August 2006, November 2010, and December 2010; and right knee MRIs dated in April 2004, December 2005, April 2006, and November 2010. In the absence of objective evidence of malunion or nonunion of the tibia and fibula, the Board will not rate her service-connected right knee disorder as impairment of the tibia and fibula. See Butts v. Brown, 5 Vet. App. 532 (1993) (holding that the Board's choice of a diagnostic code should be upheld so long as it is supported by explanation and evidence.). Consequently, a higher evaluation is not warranted for the Veteran's service-connected right knee disorder under Diagnostic Code 5262. This is true from January 23, 2005, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to a higher evaluation under Diagnostic Codes 5010, 5260 and/or 5261, at its worst the June 2005, April 2006, November 2010, and October 2011 VA medical examiners opined, after taking into account the Veteran's pain and/or lost motion after repetitive use, that the range of motion of the right knee was from 0 to 65 degrees with swelling, pain, tenderness, and/or effusion. See VA examinations dated in June 2005 (range of motion after taking into account pain and/or after repetitive use was at its worst 0 to 120 degrees); April 2006 (range of motion after taking into account pain and/or after repetitive use was at its worst -10 to 65 degrees); November 2010 (range of motion after taking into account pain and/or after repetitive use was at its worst 0 to 102 degrees); and October 2011 (the range of motion after taking into account pain and after repetitive use was at its worst 0 to 75 degrees). While a review of the record on appeal reveals the Veteran's periodic complaints and treatment for right knee pain and lost motion, swelling, pain, tenderness, and effusion nothing, in these records show the range of motion of the right knee less than what was reported at the above VA examinations. See Colvin, supra. In essence, there is no uncompensated limitation of motion that can form the basis for a higher rating based on pain. As to a higher rating under Diagnostic Code 5260, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, supra, the Veteran's functional losses do not equate to the criteria required for a 30 percent rating because at its worst flexion of the knee is not limited to 15 degrees but instead is 65 degrees. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a. This is true from January 23, 2005, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to a higher rating under Diagnostic Code 5261, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, supra, that the Veteran's functional losses do not equate to the criteria required for a 30 percent rating under Diagnostic Code 5261 because at its worst extension of the knee is not limited to 20 degrees but instead is 0 degrees. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a. This is true from January 23, 2005, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to separate compensable ratings under Diagnostic Code 5260 and Diagnostic Code 5261 under VAOPGCPREC 9-2004, the Board notes that when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, supra, the Veteran's functional losses do not equate to the criteria required for separate compensable ratings under Diagnostic Code 5260 and under Diagnostic Code 5261 because flexion of the knee at its worst was limited to 65 degrees and not 45 degrees and extension of the knee at its worst was limited to 0 degrees and not 10 degrees. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; VAOPGCPREC 9-2004. This is true from January 23, 2005, and therefore the Board finds that consideration of staged ratings is not warranted. Fenderson, supra. As to a separate compensable rating under Diagnostic Code 5257, the Board notes that the record documents the Veteran's periodic complaints of giving way. Moreover, the October 2011 VA examiner opined that the Veteran's right knee had "slight" subluxation. This opinion is not contradicted by any other medical opinion of record. See Colvin, supra. Therefore, while earlier VA examinations did not report similar findings, the Board nonetheless finds that giving the claimant the benefit of the doubt her functional losses equate to the criteria required for a separate compensable rating under Diagnostic Code 5257. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; VAOPGCPREC 23-1997; Esteban, supra; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). This is true from January 23, 2005, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to the Veteran's claims that her right knee disorder is also manifested by adverse neurological symptomatology that warrants a separate compensable rating, the October 2011 VA examiner opined that her right knee disorder did not cause any neurological disorder. This opinion is not contradicted by any other medical opinion of record. See Colvin, supra. In the absence of objective evidence of a separate neurological component, the Board will not grant the Veteran a separate rating for her alleged neurological disability. See Butts, supra; Esteban, supra. Consequently, a separate compensable evaluation is not warranted. This is true from January 23, 2005, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to the Veteran's claims that her right knee disorder is worse than rated, under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's condition with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board further observes that, even if the available schedular evaluation for the disability was inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." While the Veteran told one VA examiner that she lost a week from school and another VA examiner that she had not worked since her separation from military service, there simply is no objective evidence that her right knee disorder, acting alone, has resulted in frequent periods of hospitalization or in marked interference with the Veteran's employment. See Bagwell v. Brown, 9 Vet. App. 337 (1996). In fact, the November 2010 and October 2011 VA examiners opined, in substance, that if appropriate accommodation for her right knee could be made that it did not prevent employment. These opinions are not contradicted by any other medical opinion of record. See Colvin, supra. Therefore, the Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. In short, there is nothing in the record to indicate that the service-connected disability causes impairment with employment over and above that which is contemplated in the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) (2012) is not warranted. As to the various lay statements found in the record, including those found on the video-tape filed by the claimant, while the Veteran is competent and credible to report on what she can see and feel and others are competent and credible to report on what they can see, the Board finds more competent the opinions provided by the medical experts at the VA examinations as to the severity of her service-connected disability than these lay claims. See Davidson, supra; Buchanan, supra; Jandreau, supra; Charles, supra; Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). In reaching the above conclusions, the Board also considered the doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b). However, because the preponderance of the evidence is against the Veteran's claim to the extent outlined above, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The claim for an initial rating in excess of 20 percent for arthritis of the right knee is denied at all times from January 23, 2005. A separate 10 percent rating for instability of the right knee is granted at all times from January 23, 2005, subject to the governing statutes and regulations governing the payment of monetary benefits. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs