Citation Nr: 1237684 Decision Date: 11/02/12 Archive Date: 11/09/12 DOCKET NO. 08-12 628 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a right knee disorder. 2. Entitlement to a rating in excess of 10 percent for residuals of shell fragment wound to the left knee from July 13, 2006 to April 5, 2012. 3. Entitlement to a rating in excess of 20 percent for residuals of shell fragment wound to the left knee on and after April 6, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Suzie S. Gaston, Counsel INTRODUCTION The Veteran served on active duty from November 1951 to November 1953. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a December 2006 rating decision by the Togus, Maine, Regional Office (RO), which denied the Veteran's claims of entitlement to service connection for a right knee disorder, and a compensable evaluation for residuals of shrapnel fragment wound, left knee. He perfected a timely appeal to that decision. In November 2009, the Board remanded the case to the RO for further evidentiary development. By a rating action in November 2011, the Appeals Management Center (AMC) increased the evaluation for residual, shrapnel fragment wound of the left knee from 0 percent to 10 percent, effective July 13, 2006. A supplemental statement of the case (SSOC) was issued in November 2011. In January 2012, the Board again remanded the case to the RO for further evidentiary development. By a rating action in July 2012, the AMC increased the evaluation for residual, shrapnel fragment wound of the left knee from 10 percent to 20 percent, effective April 6, 2012; the AMC also granted service connection for limitation of flexion with degenerative arthritis, left knee and assigned a 10 percent disability rating, effective April 6, 2012. Since this is not the highest possible rating available under the rating schedule for this disability, and the Veteran has not indicated that he is content with this rating, the appeal continues. See AB v. Brown, 6 Vet. App. 35, 39 (1993). An SSOC was issued in August 2012. The Board finds there has been substantial compliance with the past remand. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand 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). (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a) (2) (West 2002).) FINDINGS OF FACT 1. A right knee disorder was not manifested during military service and is not otherwise attributable to service. 2. From July 13, 2006, to April 5, 2012, the Veteran's left knee disability was manifested by subjective complaints of pain and swelling; and objective evidence of pain and tenderness, limitation of flexion to 115 degrees, and by full extension; but without objective evidence of instability or lateral subluxation. 3. Beginning April 6, 2012, the Veteran's left knee disability has been manifested by subjective complaints of pain causing a reduction in physical activity; degenerative changes on x-ray study; and objective evidence of pain, tenderness, and limitation of flexion to115 degrees with medial-lateral instability in the knee. CONCLUSIONS OF LAW 1. The Veteran does not have a right knee disorder that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The criteria for a rating in excess of 10 percent for residuals, shell fragment wound, left knee, prior to April 6, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.71a, Diagnostic Code 5299-5257 (2012). 3. The criteria for a rating in excess of 20 percent for residuals, shell fragment wound, left knee, from April 6, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103 , 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim; and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a statement of the case (SOC) or supplemental SOC (SSOC). Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, VA satisfied its duty to notify by means of letters dated in July 2006 and September 2006 from the RO to the Veteran which were issued prior to the RO decision in December 2006. Additional letters were issued in August 2011, January 2012, and March 2012. Those letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence and/or information in his possession to the RO. The Board finds that the content of the above-noted letters provided to the Veteran complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Regarding the duty to assist, the Veteran was provided an opportunity to submit additional evidence. It also appears that all obtainable evidence identified by the Veteran relative to the claims decided herein has been obtained and associated with the claims file, and that neither he nor his representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of this appeal. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of his claims, and to respond to VA notice. The Board is unaware of any outstanding evidence or information that has not already been requested with respect to the claims at issue. The Veteran has been afforded VA examinations on the issues decided herein. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations afforded the Veteran are adequate. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The examinations were conducted by medical professionals who reviewed the medical records, solicited history from the Veteran, and examined the Veteran. Findings necessary to apply the criteria for rating the left knee disorder have been made. Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in obtaining evidence pertinent to his claims. Therefore, no useful purpose would be served in remanding the issues decided herein for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Factual background. The Veteran entered active duty in November 1951. At his induction examination in November 1951, the Veteran reported occasional pain in both knees 3 to 4 times a year for the past 5 to 6 years; he stated that he saw a doctor who told him that it was rheumatism. Clinical evaluation of the knees was normal. The Veteran was seen in March 1952 with complaints of rheumatism in both knees; examination of the knees was negative. In June 1952, the Veteran was diagnosed with myalgias in both knees. In July 1953, the Veteran sustained a mortar wound to the left knee; it was dressed and cleaned. When seen in September 1953, the Veteran complained of rheumatism in his leg and backache which he has had for 15 years; examination was negative. His separation examination, conducted in November 1953, was negative for any complaints or findings of a right leg disorder; no scars were noted over the right knee. By a rating action in July 1954, the RO granted service connection for residuals of shell fragment wound, left knee; a 0 percent rating was assigned, effective November 20, 1953. The Veteran's claim for service connection for a right knee/leg disorder and increased rating for the left knee was received in July 2006. Submitted in support of the claim were VA progress notes dated from September 2003 to September 2009. These records indicate that the Veteran received ongoing treatment for osteoarthritis of the knees. During a clinical visit in July 2006, the Veteran reported joint pain in the right leg; examination revealed crepitus in both knees, but no pertinent diagnosis was noted. In January 2007, the Veteran was seen for complaints of swelling in the right knee. Examination revealed crepitus in both knees; the assessment was degenerative joint disease, knee. During a clinical visit in August 2007, the Veteran reported problems with his left knee; an orthopedic consultation was placed for the left knee. When seen in consultation in August 2007, the Veteran reported suffering a traumatic injury in 1953 after being hit by shrapnel while in the service; the Veteran complained of intermittent pain throughout the right knee. The assessment was moderate DJD, right knee. The Veteran was afforded a VA examination in July 2010. At that time, he reported suffering a shrapnel injury to the left knee joint while he was in active military service. It was noted that a recent examination revealed degenerative osteoarthritis in the left knee, mild. The Veteran indicated that he had been having pain on and off since service; he denied any specific injuries to the left knee joint during civilian life. No fractures were noted. The Veteran related that he had had left knee pain on and off for several years, but for the last 15 years, he has been having daily pain in the left knee joint. He described the intensity of the pain as an 8 on a scale from 1 to 10. The Veteran also gave a history of popping sensation frequently, with occasional giving out of the knee. The Veteran reported occasional swelling. He denied any locking. He was not using any braces or splints. He has been using a cane for walking on and off for the last 15 years; no frequent falls. He had no restrictions on his daily routine or simple activities. No major incapacitating episodes were noted. The examiner noted that the Veteran's separation examination in November 1953 revealed no documentation of chronic knee conditions. The Veteran stated that he has been having right knee pain since military service in the 1950's; he denied any specific injuries to the right knee joint. There was a documentation of right leg pain actually right thigh pain in the Veteran's old service records, but there was no documentation of any chronic right knee condition in the Veteran's service treatment records, including his separation examination as well as in the civilian medical records immediately after he came out of military service. The Veteran denied any injuries to the right knee joint during civilian life. He stated that he has been having chronic pain in the right knee joint on and off for the last several years, but more so for the last 15 years. The Veteran indicated that the current right knee pain was an 8 on a scale for 1 to 10. On examination, it was observed that the Veteran's gait was normal. He was able to stand on his heels and toes; he was able to heel-to-toe walk. Examination of the left knee joint revealed no joint effusion. Minimal vague tenderness was noted. Crepitus was noted. The circumference of the knee joint was 18". The patellar apprehension test was negative. There was no genu varum or valgus deformity. Range of motion in the left knee was from 0 degrees to 115 degrees of flexion, without pain. Repetitive movements were normal. No further limitation was noted. Maneuvers of the joints were normal. Stability was normal. No signs of inflammatory arthritis were noted. The Veteran was not wearing any braces or splints. No atrophy or wasting of the muscles around the joint. Muscle power was normal. It was noted that the Veteran was walking slowly, but having minimal limping with his lower extremities, secondary to left knee pain. X-ray study of the knees revealed diffuse osteopenia. A bony fragment was seen adjacent to the right medial femoral condyle, may be an osteochondritis dissecans; moderate degenerative change as a moderate tricompartment with reduced joint spaces. The pertinent diagnoses were degenerative joint disease left knee joint; the examiner stated that the Veteran's current left knee condition is not likely related or aggravated by military service. The examiner stated that joint function of the knee joints is not additionally limited by pain, weakness, fatigue or lack of endurance after repetitive use. The examiner reported a diagnosis of degenerative joint disease, right knee. He noted that there is no document of a chronic right knee condition in the Veteran's available STRs except rheumatoid pains related to rheumatism. It was noted that the Veteran has been having a history of rheumatism with pains in the knee joints for 5 to 6 years before induction as per induction examination dated November 20, 1951. The examiner stated that it is not likely related or aggravated by the Veteran's military service. Received in July 2011 were VA progress notes dated from September 2010 to March 2011. These records reflect a history of degenerative joint disease of the knee; however, they do not reflect any treatment for the knees. The Veteran was afforded another VA examination in October 2011. It was noted that the Veteran sustained a shrapnel injury to the left knee/leg in 1953; he had osteoarthritis in both knees. It was also reported that the Veteran injured the right knee from a falling rock in 1953. Range of motion in the right knee was from 0 degrees to 120 degrees, with pain starting at 90 degrees of flexion. The left knee had a range of motion from 0 degrees to 130 degrees with pain starting at 90 degrees. There was no additional limitation of motion of the knees after repetitive use testing. There was also no functional impairment of the knees/legs. It was noted that there was pain and tenderness to palpation on both knees. Joint stability, posterior instability, and medial-lateral stability was normal in both knees. No subluxation or dislocation was noted in the knees. The Veteran was not using any assistive devices during the examination. In an addendum to this examination, dated in November 2011, the examiner stated that it is not as likely as not that any disabilities of the knees were incurred or aggravated by active military service. He added that the right leg condition was not consistent with any injury during combat operations. The examiner explained that a current finding of arthritis of both knees was consistent with Veteran's age and natural progression. The Veteran was afforded another VA examination in April 2012. At that time, he stated that he first experienced right knee pain in 1951; he was examined in Jackson, Mississippi in 1956. The Veteran reported that he right knee pain has been constant since 1951, and it has gotten worse over the years. The pain is located medial and lateral. The Veteran further noted that the pain is worse with walking, going up and down stairs; it improves with rest. The right knee will hurt once a week lasting until he takes "some vitamins and some pain pills and will wrap around a hot towel." Range of motion testing in the right knee revealed a flexion to 115 degrees, with no pain. Extension was 0 degrees. Similarly, the left knee had a range of motion from 0 degrees of extension to 115 degrees of flexion, with no objective evidence of pain. The Veteran did not have additional limitation of motion following repetitive use testing. The Veteran had tenderness to palpation in the joint line. Lachman and posterior drawer tests were normal in both the lower extremities. He had medial-lateral instability in both knees. There was no subluxation or dislocation of the knees. The examiner noted that the Veteran had osteoarthritis in both knees. The examiner opined that the Veteran's right knee disorder is less likely than not incurred in or caused by the claimed inservice injury. The examiner noted that his opinion was based on multiple factors including a normal exit examination, no immediate post-military medical records documenting a right knee condition as well as his current physical and radiographic examination. The examiner stated that the Veteran's right knee showed no evidence of traumatic injury or injury that was accelerated in any manner from trauma. The Veteran's right knee radiograph, performed on September 24, 2011, and his current physical examination is consistent with degenerative arthritis that would be expected in others of similar age and body habitus. The examiner stated that he found no objective evidence of injury to the Veteran's right knee when he was in service. III. Legal Analysis-Service connection. Service connection may be granted for a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110. To establish service connection for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"--the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Holton v. Shinseki, 557 F.3d 1362 (2009). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Certain chronic diseases, including arthritis, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from qualifying military service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Veteran can attest to factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In such cases, the Board is within its province to weigh that testimony and to make a determination as to whether the evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21. Vet. App. 303 (2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After review of the evidentiary record, the Board finds that the preponderance of the evidence is against the Veteran's claim. The Board acknowledges that the STRs indicate that the Veteran received treatment on several occasions for complaints of right knee pain; he indicated that he had had rheumatism. However, no right knee disorder was reported at the time of the Veteran's discharge examination in November 1953; clinical evaluation of the knees was normal. On the occasion of his initial VA examination in January 1954, no objective right knee disorder was found. The first clinical documentation of the onset of a right knee disorder is in July 2006, some 52 years after service separation. A significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See generally Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). In addition, there is no evidence that any arthritis of the right knee was manifested during the one-year presumptive period after separation from active military service. Further, there is no radiographic evidence of arthritis during service or within the year following his discharge. Moreover, the competent evidence of record has not attributed the Veteran's right knee disorder to his period of military service. The Veteran's post-service records are silent as to a right knee disorder until July 2006. Significantly, following a VA examination in July 2010, the VA examiner reported a diagnosis of degenerative joint disease, right knee. He noted that there is no documentation of a chronic right knee condition in the Veteran's available STRs except rheumatoid pains related to rheumatism. It was noted that the Veteran had a history of rheumatism with the pains in the knee joints for 5 to 6 years before induction as per the induction examination dated November 20, 1951. The examiner stated that this condition is not likely related or aggravated by the Veteran's military service. Subsequently, in November 2011, the VA examiner reviewed the Veteran's STRs and prior examination and concluded that it is not as likely as not that any disabilities of the knees were incurred or aggravated by active military service. He added that the right leg condition was not consistent with any injury during combat operations. The examiner explained that a current finding of arthritis of both knees was consistent with Veteran's age and natural progression. More recently, in April 2012, a VA examiner opined that the Veteran's right knee disorder is less likely than not incurred in or caused by the claimed inservice injury. The examiner noted that his opinion was based on multiple factors including a normal exit examination, no immediate post-military medical records documenting a right knee condition as well as his current physical and radiographic examination. The examiner stated that the Veteran's right knee showed no evidence of traumatic injury or injury that was accelerated in any manner from trauma. In fact, the examiner opined that the degenerative changes were entirely consistent with the Veteran's age and body habitus. Although the Veteran attributes his right knee disorder to service, the Board may discount lay evidence when appropriate. While the Veteran can attest to factual matters of which she has first-hand knowledge, e.g., difficulty hearing, neither he nor any lay affiant is capable of making medical conclusions. Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). There is no evidence showing, and the Veteran does not assert, that he has medical training to provide competent medical evidence as to the etiology of the right knee disorder. Here, the Board finds his assertions to be of less value than the contemporaneous records during service and the July 2010, November 2011 and April 2012 VA examiner's opinions. While the evidence of record shows that the Veteran has a right knee disorder, including degenerative joint disease, the Board finds that the more convincing evidence shows that his disability is not attributable to military service. The Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide even an approximate balance of negative and positive evidence on the merits. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, on the basis of the above analysis, and after consideration of all the evidence, the Board finds that the preponderance of the evidence is against the claim of service connection for a right knee disorder. Put simply, the evidence does not establish that the Veteran had a chronic right knee disorder during active service or that a current right knee disorder is otherwise related to active service. Service connection for a right knee disorder is denied. IV. Legal Analysis-Increased rating. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. See 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings apply 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. See 38 C.F.R. § 4.7 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). In addition, a disability rating may require re- evaluation in accordance with changes in a veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. See 38 C.F.R. § 4.1 (2012). Finally, in cases where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). The AOJ has assigned a staged rating and the Board agrees that there has been a change in disability during the appeal period. The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2012) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2012). See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See 38 C.F.R. § 4.40 (2012). The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45 (2012). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. In making its determination, the Board must determine the credibility and probative value of the evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) and cases cited therein (holding that the Board has the duty to assess the credibility and weight to be given to the evidence). The Board may not base a decision on its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). A. Rating in excess of 10 percent from July 13, 2006 to April 6, 2012. The RO has assigned a 10 percent evaluation for the left knee disorder under diagnostic code 5257. This code contemplates only instability or subluxation. Under Diagnostic Code 5257, a 10 percent evaluation is warranted where impairment of the knee involves slight subluxation or lateral instability. A 20 percent evaluation is warranted where the impairment is moderate, and a 30 percent evaluation will be assigned where the impairment is severe. Flexion of the leg limited to 60 degrees warrants a noncompensable rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Code 5260. Extension limited to 5 degrees warrants a noncompensable rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Code 5261. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate II. After review of the evidentiary record, prior to April 6, 2012, the Board concludes that an evaluation in excess of 10 percent is not warranted for the left knee. Inasmuch as there was no instability noted on any VA examination, assigning a compensable rating under the Code 5257 criteria for knee disability manifested by subluxation or instability would be inappropriate. 38 C.F.R. § 4.71a, Code 5257. The Board finds that the Veteran is competent to report that he has frequent popping sensation in the left knee, and a feeling of "giving out" in the left knee, thereby claiming instability. The Board also concludes that the examination reports prepared by skilled examiners are more probative than the Veteran's generally unsupported lay statements. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, the Veteran's report of giving way (instability) was not clinically demonstrated at any time during the period in question. In this case, the Board finds the repeated clinical findings to be more probative than the Veteran's assertions because the clinicians have examined the Veteran with a view toward determining whether there was any ligament or other damage that would cause instability. The more probative evidence establishes that the Veteran's disability does not cause lateral instability or subluxation. Thus, a compensable evaluation is not warranted under Diagnostic Code 5257. In applying the law to the existing facts, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent prior to April 6, 2012. The record does not demonstrate the requisite objective manifestations for a disability evaluation in excess of 10 percent for the left knee disability under Diagnostic Code 5260. The medical evidence demonstrates that on the occasion of the VA examination in July 2010, the Veteran had full range of motion of the left knee. Thus, the Board concludes that a rating in excess of 10 percent is not warranted under either Diagnostic Code 5260 or 5261. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The Board has considered whether a higher rating may be assigned on the basis of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, lack of endurance or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca, supra. Further, when the ranges of motion in the left knee are considered together with the evidence of functional loss due to left knee pathology, the evidence does not support a conclusion that the loss of motion in the left knee more nearly approximates the criteria for a 20 percent rating under either DC 5260 or DC 5261, even with consideration of 38 C.F.R. §§ 4.40 and 4.45. Again, the July 2010 VA examiner stated that there was no objective evidence to show any additional functional loss of range of motion due to pain. During the period prior to April 6, 2012, the left knee disability was not shown to produce functional impairment that would warrant a rating higher than 10 percent. See DeLuca; supra. There is no evidence of additional limitation of flexion or extension of the left knee due to weakness, fatigability, incoordination, or lack of endurance. Based on the objective medical evidence of record, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness, or incoordination, and the Board finds that the assignment of additional disability pursuant to 38 C.F.R. §§ 4.40 and 4.45 is not warranted. Although the Veteran complained of constant pain in the left knee, the Board notes that there is no evidence additional functional impairment the preponderance of the evidence is against a finding that the Veteran's disability warrants an evaluation in excess of 10 percent prior to April 6, 2012. The 10 percent rating contemplates the presence of periarticular pathology productive of pain with full motion in the left knee. The evaluation would also contemplate the functional equivalent of limitation of flexion to 45 degrees. In order to warrant a higher evaluation there would have to be evidence of compensable limitation of extension or the functional equivalent of limitation of flexion to 30 degrees. Neither the objective nor subjective evidence has ever established that flexion has been functionally limited to 30 degrees or that either the left knee has been functionally limited to 30 degrees or that there has been a compensable limitation of extension. Rather, the most probative evidence establishes that there is pain on motion, but functional use remains the greater than 30 degrees of flexion and without compensable limitation of extension. The veteran is competent to report his symptoms. To the extent that he has asserted his service-connected left knee disorder disorder warrants more than a 10 percent evaluation, the Board finds that the medical examinations and opinions do not establish that the Veteran has any more than slight functional impairment of the left knee. Accordingly, for the reasons provided above, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent prior to April 6, 2012 for residuals, shrapnel wound, left knee, and there is no doubt to be resolved. See Gilbert, 1 Vet. App. at 55. B. Rating in excess of 20 percent from April 6, 2012. The Veteran's service-connected left disability has been rated 20 percent disabling under Diagnostic Code 5257 from April 6, 2012. The next higher disability rating under Diagnostic Code 5257 is 30 percent. To warrant a 30 percent disability rating the evidence must demonstrate that subluxation and/or instability of the knee are severe. After careful review of the evidentiary record, the Board concludes that an evaluation in excess of 20 percent is not warranted under the diagnostic code for instability of the knee from April 6, 2012. A higher evaluation is not warranted under Diagnostic Code 5257, as there is no medical evidence that instability is more than moderate. Significantly, during the VA examination in April 2012, the Veteran reported weekly flare-ups that are relieved with pain medication and vitamins. Clinical evaluation revealed medial-lateral instability in the left knee; however, there was no evidence of subluxation or dislocation in the left knee. Moreover, the Veteran was not using any assistive devices, including a cane or brace on the left knee. In light of the above findings, the Board finds that there is no evidence of severe recurrent subluxation or severe lateral instability shown on and after April 6, 2012. Thus, a 30 percent rating under DC 5257 is not warranted. The Board finds that the Veteran is competent to report that he has instability. However, his reports are far less probative than the repeated findings by skilled professionals. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The more probative evidence establishes that the Veteran's disability does not approximate severe lateral instability or subluxation. As severe recurrent subluxation or instability has not been demonstrated as to the left knee, a disability rating in excess of 20 percent, as per Diagnostic Code 5257, must be denied from April 6, 2012. The Board has also considered whether an evaluation in excess of 20 percent is warranted under either DC 5260 or 5261. As noted above, a 30 percent evaluation under DC 5260 requires that flexion be limited to 15 degrees. A 30 percent evaluation under DC 5261 requires that extension be limited to 20 degrees. However, no such limitations are noted in the April 2012 VA examination report. In fact, extension was noted to be normal, and flexion was limited to 115 degrees, well in excess of the limitation needed to justify a 30 percent evaluation under DC 5260. Because there is no evidence of additional limitation due to weakness, fatigability, incoordination, or lack of endurance, there is no basis upon which to award a greater disability evaluation pursuant to 38 C.F.R. §§ 4.40 and 4.45. The Board also finds that the current 20 percent disability evaluation fully contemplates his complaints of pain and the limitations imposed by that pain. There is no indication that the Veteran's complaints of pain have caused additional functional impairment that would warrant an evaluation in excess of the currently assigned 20 percent rating. The above determinations are based upon consideration of applicable rating provisions. It should also be pointed out that there is no showing that the Veteran's left knee disability has reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (1) (2012). The symptoms of his disability have been accurately reflected by the schedular criteria. Without sufficient evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). In fact, during the April 2012 VA examination, the examiner specifically stated that the Veteran's left knee disability did not cause any functional impairment. Consequently, the Board finds no basis for referring the knee instability issue to the Central Office for consideration of extraschedular ratings. ORDER Entitlement to service connection for a right knee disorder is denied. A rating in excess of 10 percent for residuals, shrapnel wound, left knee, from July 13, 2006 to April 5, 2012, is denied. A rating in excess of 20 percent for residuals, shrapnel wound, left knee, from April 6, 2012, is denied. ____________________________________________ L.M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs