Citation Nr: 1242829 Decision Date: 12/14/12 Archive Date: 12/20/12 DOCKET NO. 07-30 636 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for left shoulder labral tear. 2. Entitlement to an initial rating in excess of 10 percent for status-post anterior cruciate ligament and medial meniscal repair of the left knee. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Tenner, Counsel INTRODUCTION The Veteran served on active duty from June 2001 to June 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 decision rendered by the Roanoke, Virginia Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2010, the Veteran testified at a hearing at before the undersigned. A transcript of the proceeding is of record. In November 2010, the Board, in pertinent part, remanded these matters to the RO, via the Appeals Management Center (AMC). FINDINGS OF FACT 1. The Veteran's service-connected left shoulder minor extremity disability is manifested by limitation of motion, but not productive of limitation of motion at shoulder level, and is not manifested by nonunion or dislocation of the clavicle or scapula. 2. The Veteran's service-connected left knee disability is manifested by flexion limited to 135 degrees with pain, but with full leg extension, and without recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating in excess of 10 percent for left shoulder labral tear disability have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.7, 4.71a, Diagnostic Codes 5024, 5201, 5203 (2012). 2. The criteria for entitlement to an initial disability rating in excess of 10 percent for status-post anterior cruciate ligament and medial meniscal repair of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.7, 4.71a, Diagnostic Codes 5024, 5260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). 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 claims. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (the Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claims; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Here, a June 2006 letter from the RO satisfied these criteria. In the letter, the RO advised the Veteran of the basic criteria for service connection and explained VA's duties to assist him in obtaining evidence relevant to the claims. Moreover, as it pertains to the claims for higher initial ratings, where, as here, service connection has been granted and the initial rating has been assigned, the claim of entitlement to service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required, since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). The Board also concludes VA's duty to assist has been satisfied. The Veteran has identified private treatment records and they have been obtained. The Veteran has not referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The Veteran underwent VA examinations in July 2006 and July 2009. Concerning these examinations, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the examination reports reflect that the examiners reviewed the Veteran's medical history, recorded his current complaints, conducted an appropriate examination, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Finally, there is no indication that the shoulder or knee disabilities worsened since the July 2009 examination. Rather, while the Veteran questioned the adequacy of the July 2006 examination, he did not describe any worsening of the disabilities in his testimony before the Board. Regarding this contention, the Veteran states generally that the 2006 examination was cursory. The Board cannot determine that the examination was cursory. Rather, the examination report is thorough and addresses the current nature and severity of several orthopedic disabilities. In this respect, the Court has held that "the Board is entitled to assume the competence of a VA medical examiner." Hilkert v. West, 12 Vet. App. 145, 151 (1999) (en banc) ("[T]he Board implicitly accepted [the VA examiner's] competency by accepting and relying upon the conclusions in her opinion."), aff'd, 232 F.3d 908 (Fed.Cir.2000). The Board therefore concludes that the examinations are adequate for rating purposes. See 38 C.F.R. § 4.2 (2012). Regarding the hearing testimony, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the undersigned explained the issues on appeal and solicited the Veteran to identify evidence relevant to the claims for an increased rating for left shoulder and left knee disabilities. The Veteran did so and further described the impact of the disabilities on his activities of daily living. Finally, there is substantial compliance with the terms of the Board's November 2010 remand directive. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The Veteran was asked on remand to identify and submit private treatment records. He did so. Thereafter, the RO/AMC reconsidered the claim and issued a Supplemental Statement of the Case. Nothing further was required. 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 Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007). II. Analysis The Veteran asserts that his service-connected left shoulder and left knee disabilities are more disabling than initially rated. For both the shoulder and the knee, he contends that a rating in excess of 10 percent is warranted. He reports that he has difficulty lifting his arm past shoulder level and that he may need surgery on the shoulder. (See Transcript at 21 and 26.) Regarding his knee, he asserts that the knee is occasionally unstable, requires that he wear a brace, and that it gets weak and fatigued. (See Transcript at 12-14.) Disability evaluations are determined by comparing a veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 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 of the two evaluations 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 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The effective date of the award of service connection is June 2, 2006. 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. 38 C.F.R. § 4.40. Diagnostic Codes predicated on limitation of motion do not prohibit consideration of a higher rating for flare ups or for functional loss due to weakness, excess fatigability, incoordination, or pain on use. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by visible behavior, such as facial expression or wincing, of the Veteran undertaking the motion. 38 C.F.R. §§ 4.40, 4.59. Notably, the Court has held that pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). A. Left Shoulder Disability The Veteran's service treatment records reveal that he was treated in 2005 with a six month history of left shoulder pain. The pain began after doing incline bench press and pushups. The assessment was a likely labral tear. On VA examination in July 2006, the left shoulder showed no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement. He could perform arm flexion and abduction, each to 180 degrees. He could perform external and internal rotation, each to 90 degrees. The movements were not limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. An x-ray was within normal limits. No diagnosis was rendered as the examiner noted that there was no pathology to render a diagnosis. In August 2007, the Veteran was seen by Commonwealth Orthopaedics with complaints of injury to his left shoulder. On physical examination, he had normal deep tendon reflexes, strength, and sensation. Subjectively, there was dull pain on abduction, forward flexion, and internal and external rotation. X-rays were normal. However, an enhanced MRI revealed a small SLAP tear with no articular disease. In July 2009, he underwent a second VA examination. Therein, the Veteran reported a history of left shoulder pain since the Fall of 2004. He reported that the condition results in weakness, stiffness, swelling, heat, lack of endurance, locking, fatigability, tenderness, pain, and reduced motion. It did not result in any giving way, deformity, effusion, subluxation, or dislocation. Flare-ups of pain occurred following physical activity and were alleviated by rest and over the counter medication. During a flare-up he could not lift his shoulder as high as the right shoulder and arm motion stopped around shoulder level. On physical examination, he could perform flexion and abduction, each to 120 degrees. He could perform external rotation and internal rotation, each to 60 degrees. Motion was not additionally limited due to pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. X-rays of the left shoulder were normal. The diagnosis was tendonitis and impingement. The left shoulder disability is rated pursuant to Diagnostic Code 5024, tenosynovitis, which is to be rated pursuant to the limitation of motion criteria for the shoulder. In determining the appropriate rating criteria for the Veteran's service-connected left shoulder disability, the Board notes at the outset that there is no diagnostic code directly on point. When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Disabilities of the shoulder and arm are evaluated under rating criteria that contemplate ankylosis of scapulohumeral articulation (Diagnostic Code 5200), limitation of motion of the arm (Diagnostic Code 5201), other impairment of the humerus (Diagnostic Code 5202), or impairment of the clavicle or scapula (Diagnostic Code 5203). Normal range of motion of the shoulder is as follows: forward elevation (flexion) to 180 degrees; abduction to 180 degrees; internal rotation to 90 degrees; and external rotation to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5200 rates ankylosis of the scapulohumeral joint. 38 C.F.R. § 4.71a. Where arm limitation of motion is limited to 25 degrees from the side, a 30 percent evaluation is assigned for the minor side, under Diagnostic Code 5201. Limitation of motion midway between the side and shoulder level contemplates a 20 percent evaluation for the minor side, and limitation of motion at shoulder level contemplates a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under Diagnostic Code 5202, for impairment of the humerus, a 20 percent rating is granted when there is malunion, with moderate deformity, for the minor arm; a 20 percent rating is warranted when there is marked deformity of the minor arm. Also under Diagnostic Code 5202, for recurrent dislocations of the minor arm at the scapulohumeral joint, a 20 percent rating is granted with infrequent episodes, and guarding of movement only at shoulder level; a 20 percent rating is granted when there are frequent episodes and guarding of all arm movements for the minor arm. A 40 percent rating is granted for fibrous union of the minor arm; a 50 percent rating is warranted for nonunion (false flail joint) of the minor arm and a 70 percent rating is warranted for loss of head of (flail shoulder) for the minor arm. 38 C.F.R. § 4.71a, Diagnostic Code 5202. Under Diagnostic Code 5203, for impairment of the clavicle or scapula in the minor arm, a 10 percent rating is granted for malunion or nonunion without loose movement and a 20 percent rating is granted for nonunion with loose movement or for dislocation. 38 C.F.R. § 4.71a, Diagnostic Code 5203. The Board notes review of the entirety of the private treatment records on file, the VA examination reports of record, and the lay statements of the Veteran. In consideration of the applicable rating criteria of the shoulder, the Board finds that the objective medical evidence does not support an initial disability rating in excess of 10 percent for left shoulder disability. In consideration of Diagnostic Code 5203, the objective medical evidence of record does not reflect nonunion of the clavicle or scapula with loose movement, and does not reflect dislocation of the clavicle. Rather, neither VA examination report nor private treatment records show any non-union of the clavicle or scapula. While they do show MRI evidence of a small SLAP, they do not show that the tear is of such severity as to result in dislocation or nonunion. In addition, a 20 percent disability rating is not warranted for a minor extremity pursuant to Diagnostic Code 5201, as the objective evidence does not show limitation of motion at shoulder level. As noted, examination in 2006 revealed essentially full arm motion, and on examination in 2009, motion was limited to 120 degrees, which is not comparable to motion to shoulder level. While the Veteran stated that motion was limited to shoulder level on flare-up of the disability, the weight of the objective medical evidence does not support such contention. While the Board acknowledges that the disability results in pain, even in consideration of the Veteran's such, such objective findings do not reflect limitation of motion at shoulder level. In light of such clinical observations, the Board finds that the Veteran's left shoulder disability, a minor extremity, manifests no higher than a 10 percent rating. The Veteran is not entitled to an increased rating under any other diagnostic code as he has no ankylosis of the shoulder (Diagnostic Code 5200) or impairment of the humerus to include fibrous union; nonunion of false flail joint; or, loss of head of flail shoulder (Diagnostic Code 5202). The Board has also considered 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206-07, Mitchell v. Shinseki, 25 Vet. App. 32 (2011). These factors have been taken into consideration in contemplation of the 10 percent evaluation. As detailed, however, in the 2009 VA examiner stated that there were no additional limitations after repetition of motion, due to increased pain, fatigue, weakness, or incoordination with repetitive motion. In consideration of the statements of the Veteran, he is competent to describe observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). Further, there is no evidence of record to indicate that his statements are not credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). However, the Board finds that the currently assigned 10 percent disability rating adequately compensates him for any pain and functional loss. To the extent that additional functional loss is shown, it does not rise to the level that would enable a finding that the overall disability picture most nearly approximates the next-higher 20-percent evaluation. In this regard, the objective evidence of record is of greater probative weight than the Veteran's statements. Finally, the disability does not warrant referral for extra-schedular consideration for any period. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VA O.G.C. Prec. Op. No. 6-96, published at 61 Fed. Reg. 66749 1996). Here, the 2006 VA examination found no left shoulder disability and no effect on his employment. In addition, the 2009 VA examiner did not note any effect on his occupational functioning. Moreover, the Veteran's left shoulder symptomatology is contemplated by the rating schedule. For these reasons, the Board finds that while the Veteran's disability may have an effect on his professional and personal life, the evidence does not reflect impairment of his earning capacity to warrant referral for extraschedular rating for the disability at issue herein. The disability rating assigned squarely contemplates the symptomatology associated with his left shoulder disability. Thun v. Peake, 22 Vet. App. 111 (2008). Additionally, the objective evidence does not reflect frequent periods of hospitalization due to his left shoulder disability. Accordingly, the Board finds that the impairment resulting from the Veteran's left shoulder disability is appropriately compensated by the currently assigned schedular ratings and 38 C.F.R. § 3.321 is inapplicable. B. Left Knee Disability The record reflects that the Veteran injured his left knee in service, incurring an ACL tear and medial meniscus injuries. He underwent surgical correction of such in October 2001, May 2005, and January 2006. On VA examination in July 2006, he reported that he had chronic knee pain. In addition, he noted that the knee shook, was stiff, would swell, and would occasionally buckle. Pain was incapacitating approximately twice per year and would require bed rest and last 14 days. Physical examination of the knee revealed several surgical scars and findings of crepitus. He could perform flexion from 0 to 140 degrees. Joint function was limited following repetitive use due to pain, fatigue, weakness, and lack of endurance. These symptoms resulted in an additional 5 degrees of lost motion. The medial and lateral collateral ligament stability test of the left knee was within normal limits. The medial and lateral meniscus test of the knee was within normal limits. An x-ray revealed status-post surgical anterior cruciate ligament repair with metallic orthopedic screw with the distal portion of the left femur. The examiner found no occupational impairment due to the knee disability, but noted that it made it difficult for him to bend or kneel. A Functional Capacity Certificate dated in August 2007 revealed that the Veteran could not perform activities required of an active duty soldier as a result of his service-connected left knee and shoulder disabilities. On VA examination in July 2009, there were no physical examination findings of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement. In addition, there was no locking pain, genu recurvatum or crepitus. He could perform leg extension to 0 degrees and flexion to 140 degrees. Movements were not additionally limited due to pain. An x-ray revealed status-post ACL repair. The service-connected left knee disability is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5024-5260. Diagnostic Code 5024, pertains to tenosynovitis, which is to be rated pursuant to the limitation of motion criteria for the knee and leg. 38 C.F.R. § 4.71a, Diagnostic Code 5260, addresses limitation of motion with respect to flexion. Flexion limited to 45 degrees warrants a 10 percent evaluation. A 20 percent rating requires flexion limited to 30 degrees. The maximum rating of 30 percent is reserved for flexion limited to 15 degrees. Diagnostic Code 5261 addresses limitation of motion with respect to extension. Extension limited to 10 degrees merits a 10 percent evaluation. A 20 percent rating is reserved for extension limited to 15 degrees, while a 30 percent rating is reserved for extension limited to 20 degrees. Extension limited to 30 degrees warrants a 40 percent evaluation. The maximum 50 percent rating is awarded when there is extension limited to 45 degrees. 38 C.F.R. § 4.71a. Normal range of motion for the knee is from 140 degrees flexion to 0 degrees extension. 38 C.F.R. § 4.71, Plate II. Medial instability of the left knee is rated under Diagnostic Code 5257. Diagnostic Code 5257 sets forth a 10 percent evaluation for slight impairment due to recurrent subluxation or lateral instability of the knee. A 20 percent rating requires moderate impairment due to recurrent subluxation or lateral instability. Severe impairment due to recurrent subluxation or lateral instability results in the maximum 30 percent evaluation. 38 C.F.R. § 4.71a. Several other Diagnostic Codes under 38 C.F.R. § 4.71a pertain to knee disabilities in addition to those above. They include: Diagnostic Code 5256 for ankylosis of the knee, Diagnostic Code 5258 for dislocated semilunar knee cartilage with frequent episodes of "locking," pain, and effusion into the joint, Diagnostic Code 5259 for symptomatic removal of the semilunar knee cartilage, Diagnostic Code 5262 for impairment of the tibia and fibula, and Diagnostic Code 5263 for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Here, even though the disability is rated under Diagnostic Code 5024, pertaining to tenosynovitis, there is no x-ray evidence of arthritis of the knee. Hence, an increased rating under this Diagnostic Code is not warranted. As it pertains to Diagnostic Code 5260, while there is evidence of some reduced leg flexion, even after considering the effects of pain and functional loss, it is not limited to 30 degrees. In addition, a separate rating is not warranted under Diagnostic Code 5261 as the Veteran routinely demonstrated full extension. VAOPGCPREC 9-2004 (2004). Next, the Board has reviewed the evidence in connection with the claim for a separate disability rating for left knee instability. Here, the Board has considered the subjective reports of occasional instability; however, the Board finds the most probative evidence VA examination reports. Significantly, other than a finding of crepitus, those reports contain no objective findings of any left knee instability. As such the Board finds that the preponderance of the evidence is against the claim for a separate rating based on instability. While evaluations in excess of 10 percent are not warranted, the Board has considered other potentially relevant Diagnostic Codes to determine whether a higher rating is warranted. For the period in question, however, the evidence does not support a higher or separate evaluation under other Diagnostic Codes. For instance, there is evidence of surgical scarring to the left knee; however, the Veteran is already in receipt of a 10 percent rating for surgical scarring as a result of an August 2009 decision. The Veteran did not appeal the assignment of the disability rating or effective date assigned. Hence, the Board will not consider whether a higher rating is warranted for surgical scars. In addition, the Board has considered whether a separate compensable rating is warranted based on the removal of semilunar cartilage in the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5258 and 5259. Here, the Veteran underwent surgical repairs to the left knee. However, it does not appear that the reconstruction of the left knee involved removal of semilunar cartilage. Moreover, there is no evidence to show that he has episodes of locking or effusion, or that the condition is symptomatic. The Board has also reviewed the Veteran's lay statements for evidence of a more severe disability picture. He is competent to discuss observable symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994). Further, his statements are credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The Board has considered his statements but finds that the statements alone are insufficient to support the assignment of a higher rating. As regards his statements indicating instability; such was not found on examination. Moreover, to a certain extent, findings of lateral instability or recurrent subluxation require medical expertise. The Veteran is not shown to have that medical expertise and so his statements are less probative. Laypersons have been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). To the extent that he has knee pain, again, the objective evidence did not reveal that pain resulted in functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). However, the rating criteria do describe any limitation of motion. As noted above, on examination, the left leg extension was not limited and flexion was only limited to 5 degrees from normal. Finally, regarding an extraschedular rating, here, the Board finds that the rating criteria contemplate the Veteran's left knee disability for the entire period of time during the pendency of this appeal. The left knee disability is mainly productive of limited of motion and difficulty in stooping and kneeling. These manifestations are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's left knee disability and referral for consideration of extraschedular rating is not warranted. In sum, the Board finds that a 10 percent evaluation for the left knee disability is appropriate based on the evidence of record. As the evidence of record shows that the symptoms of the left knee disability were consistent during the pendency of this appeal, a staged rating is not applicable. The Board considered the most severe manifestations of the left knee disability, and a staged rating would not provide any benefit to the Veteran. See Hart v. Mansfield, 21 Vet. App. 505 (2007). When entitlement to a total disability rating based on individual unemployability (TDIU) under the provisions of 38 C.F.R. § 4.16 is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). In this case, the Veteran has not asserted and the evidence does not show that his disabilities have caused unemployability, or that he is unemployed. Because there is no evidence of unemployability, further consideration of entitlement to TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). ORDER An initial rating in excess of 10 percent for left shoulder labral tear is denied. An initial rating in excess of 10 percent for status-post anterior cruciate ligament and medial meniscal repair of the left knee is denied. ____________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs