Citation Nr: 1300077 Decision Date: 01/02/13 Archive Date: 01/11/13 DOCKET NO. 07-18 150 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Prior to April 15, 2008, entitlement to an evaluation in excess of 10 percent for post operative residuals, left partial medial meniscectomy, cartilage. 2. From April 15, 2008, through September 25, 2008, and from November 1, 2009, to February 23, 2011, entitlement to an evaluation in excess of 30 percent for post operative residuals, left partial medial meniscectomy, cartilage. 3. Beginning February 24, 2011, entitlement to an evaluation in excess of 60 percent for post operative residuals, left unicompartmental knee replacement. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Jeng, Counsel INTRODUCTION The Veteran served on active duty from July 1987 to March 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana, which inter alia, continued a 10 percent disability evaluation for left knee disability. In a February 2009 rating decision, the RO granted a temporary 100 percent evaluation from September 26, 2008, to October 31, 2009, due to a total knee replacement surgery, and assigned a 30 percent evaluation beginning November 1, 2009. Then in a March 2009 rating decision, the RO, in relevant part, increased the disability evaluation for the left knee disability to 30 percent from April 15, 2008, and continued the 100 percent evaluation from September 26, 2008, to October 31, 2009, due to a total knee replacement surgery, and a 30 percent evaluation from November 1, 2009. Thereafter, in September 2009, the Board remanded this matter for further development. Subsequently, in a December 2011 rating decision, the Appeals Management Center (AMC) increased the disability evaluation for the left knee to 60 percent disabling effective February 24, 2011. Since the AMC/RO did not assign the maximum disability rating possible, other than for the temporary 100 percent evaluation, , the appeal for a higher disability evaluation remains before the Board. AB v. Brown, 6 Vet. App. 35(1993) (noting that where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). FINDINGS OF FACT 1. Prior to April 15, 2008, the Veteran's post operative residuals, left partial medial meniscectomy, cartilage were manifested by pain and nearly full range of motion. 2. From April 15, 2008, through September 25, 2008, and from November 1, 2009, to February 23, 2011, the Veteran's post operative residuals, left partial medial meniscectomy, cartilage were manifested by pain and limitation of flexion. 3. Beginning February 24, 2011, the Veteran's post operative residuals, left unicompartmental knee replacement have been manifested by severely painful motion and severe weakness in the affected extremity. CONCLUSIONS OF LAW 1. Prior to April 15, 2008, the criteria for an evaluation in excess of 10 percent for post operative residuals, left partial medial meniscectomy, cartilage have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2012). 2. From April 15, 2008, through September 25, 2008, and from November 1, 2009, to February 23, 2011, the criteria for an evaluation in excess of 30 percent for post operative residuals, left partial medial meniscectomy, cartilage have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5257, 5260, 5261 (2012). 3. Beginning February 24, 2011, the criteria for an evaluation in excess of 60 percent for post operative residuals, left unicompartmental knee replacement have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5257, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Stegall Considerations As previously noted, the Board remanded this case for further development in September 2010. The Board specifically instructed the RO to afford the Veteran the opportunity to identify or submit additional evidence, provide the Veteran with an examination to determine the current severity of his left knee disability, and to readjudicate the claim. Subsequently, the AMC sent the Veteran a letter in October 2012 requesting that he identify outstanding treatment records and/or submit additional evidence in his case. Additionally, he was provided an examination for his left knee in February 2011, and his claim was readjudicated in a December 2011 supplemental statement of the case. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist In correspondence dated in August 2005, September 2005, and October 2005, prior to the January 2006 rating decision, and in a July 2007 letter the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The July 2007 letter notified the Veteran of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claims were subsequently readjudicated in supplemental statements of the case dated in March 2009 and December 2011. See Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (noting that VA cured its failure to afford statutory notice to the claimant prior to an initial rating decision by issuing a notification letter after the decision, readjudicating the claim, and notifying the claimant of such readjudication in the statement of the case). VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). All identified and available treatment records have been secured. As the Board will discuss in detail in its analysis below, the Veteran was provided with VA examinations throughout the appeal period. The reports of these examinations reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Additionally, the Veteran has not stated nor is there evidence indicating that there has been a material change in the severity of his left knee disability since he was last examined in February 2011. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). The Board concludes that these examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 CF.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c) (4) (2012); Barr, 21 Vet. App. at 312. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has declined the opportunity to present evidence and argument in support of his claim before a Veterans Law Judge. Therefore, the duties to notify and assist have been met. Analysis The Veteran essentially contends that his service-connected post operative residuals, left partial medial meniscectomy, cartilage are more disabling than contemplated by the 10 percent evaluation prior to April 15, 2008; 30 percent evaluation from April 15, 2008, through September 25, 2008, and from November 1, 2009, to February 23, 2011; and 60 percent from February 24, 2011. Disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. Each disability must be viewed in relation to its history, with an emphasis on the limitation of activity imposed by the disabling condition. Medical reports must be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7 (2012). While the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Pursuant to Hart, the Board notes that in this case the RO and AMC have already staged the service-connected left knee disability by assigning a 10 percent evaluation prior to April 15, 2008; a 100 percent evaluation from September 26, 2008, to October 31, 2009; a 30 percent evaluation from November 1, 2009, to February 23, 2011; and a 60 percent evaluation from February 24, 2011. The Board will consider whether further staged ratings are appropriate. Additionally, the Board's analysis below will only focus on the periods outside of the 100 percent evaluation. 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 upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 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. 38 C.F.R. § 4.40 (2012). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2012). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). With respect to the joints, 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; and (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. 38 C.F.R. § 4.45 (2012). For the purpose of rating disability from arthritis, the spine is considered a major joint. 38 C.F.R. § 4.45 (2012). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2012). Traumatic arthritis is rated using Diagnostic Code 5010, which directs that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that 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. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1 (2012). In VAOPGCPREC 23-97, the General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Code 5003 and Diagnostic Code 5257, and that evaluation of a knee disability under both of these codes would not amount to pyramiding under 38 C.F.R. § 4.14 (2012). VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); see also Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate rating must be based on additional disability. The Veteran's left knee disability has been evaluated under Diagnostic Code 5055 for status post left total knee arthroplasty in September 2008. 38 C.F.R. § 4.71a , Diagnostic Code 5055. Replacement of either knee joint with a prosthesis warrants a 100 percent evaluation for a one-year period following implantation of the prosthesis. This period commences at the conclusion of the initial grant of a total rating for one month following hospital discharge pursuant to 38 C.F.R. § 4.30 (2012). Thereafter, a 60 percent rating is warranted if there are chronic residuals consisting of severely painful motion or severe weakness in the affected extremity. With intermediate degrees of residual weakness, pain, or limitation of motion, the disability will be rated by analogy to Diagnostic Codes 5256, 5261 or 5262. The minimum evaluation is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055(2012). Diagnostic Codes 5260 (limitation of flexion of the leg), and 5261 (limitation of extension of the leg) are also applicable in this case. Diagnostic Code 5260 provides that limitation of flexion of the knee to 60 degrees warrants a zero percent evaluation, limitation of flexion of the knee to 45 degrees warrants a 10 percent evaluation, limitation of flexion of the knee to 30 degrees warrants a 20 percent evaluation, and limitation of flexion of the knee to 15 degrees warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Diagnostic Code 5261 provides that limitation of extension of the knee to 5 degrees warrants a zero percent evaluation, limitation of extension of the knee to 10 degrees warrants a 10 percent evaluation, limitation of extension of the knee to 15 degrees warrants a 20 percent evaluation, limitation of extension of the knee to 20 degrees warrants a 30 percent evaluation, limitation of extension of the knee to 30 degrees warrants a 40 percent evaluation, and limitation of extension of the knee to 45 degrees warrants a 50 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Normal knee motion is from zero degrees to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). In VAOPGCPREC 9-04, the General Counsel held that separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). Under 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012), the following evaluations are assignable for other impairment of the knee, to include recurrent subluxation or lateral instability: 30 percent for severe, 20 percent for moderate, and 10 percent for slight. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. 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). It should also be noted that use of terminology such as severe by VA examiners and others, although an element 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). Diagnostic Codes 5256 (ankylosis of the knee), 5257 (recurrent subluxation or lateral instability), 5258 (dislocation of semilunar cartilage), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable in this instance, as the medical evidence does not demonstrate any of these disabilities in the present case. Specifically, the Veteran has denied episodes of locking and dislocation, and there are no records demonstrating any objective finding of subluxation, instability, dislocation or locking of the left knee. Similarly, ankylosis of the left knee has not been demonstrated. The Board has evaluated the Veteran's knee disorder under multiple diagnostic codes to determine if there is any basis to increase the assigned ratings. Such evaluations involve consideration of the level of impairment of a veteran's ability to engage in ordinary activities, to include employment, as well as an assessment of the effect of pain on those activities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2012). On VA examination in October 2005, it was noted that the Veteran did not use any assistive devices, and he denied any episodes of dislocation or recurrent subluxation. the Veteran demonstrated left knee flexion from 0 to 125 degrees. There was no discoloration of the knee, the circumference of the left knee was 47.5 centimeters and the right knee was 47 centimeters, there was pain all around the border of the patella, and crepitus in the knee. Apley, McMurray, and Lachman sign were all negative, and repetitive motion was within normal limits. There was no abnormal shoe wear. A diagnosis of status-post meniscectomy of the left knee was given. An April 2008 VA examination report reflects the Veteran's report of using a brace at all times and functional limitation on standing for 15 minutes, and walking approximately 1/4 mile. The left knee symptoms included giving way, instability, pain, tenderness, swelling, weakness, effusion, and severe flare-ups lasting one to two days depending on weather or activity. He denied episodes of dislocation or subluxation. On evaluation, the examiner observed that the Veteran walked with an antalgic gait with evidence of abnormal shoe wear pattern. On physical evaluation, the Veteran demonstrated active left knee extension from 0 to 90 degrees with pain beginning at 20 degrees without additional limitation of motion on repetitive use. He also demonstrated active and passive flexion from 20 to 90 degrees with pain beginning at 70 degrees and without additional limitation of motion on repetitive use. There was weakness in the left knee but the limitation was secondary to pain, and there was no change in range of motion with repetitive movements times three. Most recently on VA examination in February 2011, the Veteran reported pain intermittently at times and all day at other times, with the pain being worse in the morning and with weather changes, and walking on concrete. He indicated that his left knee no longer gives out on him anymore but when he stepped on the left knee wrong, he may almost fall. It was noted that there was left knee deformity, instability, pain, stiffness, weakness, incoordination, swelling, tenderness, locking once per month, repeated effusions, and severe inconsistent flare-ups lasting from minutes to hours. Precipitating movements include twisting, misplaced step when turning or walking, and alleviating factor was getting off the knee. Standing limitation was 30 minutes but he was able to stand two to two and half hours if he had to, and he was able to walk 1/4 mile. He did not wear a brace on the left knee, but indicated that he wore one on the right knee. The Veteran indicated that he could not walk or stand after a flare-up and had to sit down to alleviate pain. He denied giving way, episodes of dislocation or subluxation. On evaluation, the Veteran had an antalgic gait with evidence of abnormal weight bearing and abnormal shoe wear pattern with increased wear on the outside edge of the left shoe heel. There was no loss of bone or part of a bone, but there was crepitus, tenderness, pain at rest, guarding of movement, grinding, and patellar abnormality manifested as subpatellar tenderness. There were no bumps consistent with Osgood Schlatters disease, mass behind the knees, clicks or snaps, meniscus abnormality, abnormal tendons or bursae, or other knee abnormality. There was pain on range of motion testing, and flexion was from 0 to 95 degrees and extension limited by 10 degrees. On repetitive motion testing, there was objective evidence of pain with additional limitations after three repetition of range of motion (flexion was 0 to 85 degrees and extension was 85 to 10 degrees) with pain being the most important factor. There was no ankylosis, and there was a 15.5 cm linear vertical scar at the mid-line of the left knee that was non-tender, non-depressed, non-adherent, and well-healed. After examination of the Veteran and review of the claims folder, the examiner indicated that based on the Veteran's history of dishonest behavior that his true range of motion was more likely closer to what was documented by his orthopedist in December 2008 (i.e. 0 to 125 degrees), which was also supported by visits in February 2009 and May 2009 which showed range of motion of the left knee was well-maintained post-operatively. Additionally, the examiner indicated that the Veteran's range of motion following repetitive testing should be 0 to 115 degrees because the primary reason for the Veteran's decrease in range of motion was secondary to pain and not incoordination, weakness, or excess fatigability. Furthermore, the examiner noted that the Veteran's subjective reports of pain were out of proportion to the stated history. To support his assertion that the Veteran's range of motion was greater than demonstrated on examination that day, the examiner cited to the Veteran's fulltime employment as a truck driver, and indicated that if the Veteran had as much pain as he displayed during the evaluation, he would not be able to drive a truck full time bending the left knee at 90 degrees and getting in and out of the truck would require bending beyond 90 degrees. Based on the evidence of record, the Board does not find that an evaluation in excess of 10 percent is warranted prior to April 15, 2008; in excess of 30 percent evaluation from April 15, 2008, through September 25, 2008, and from November 1, 2009, to February 23, 2011; or in excess of 60 percent from February 24, 2011. Prior to April 15, 2008, the Veteran demonstrated nearly full range of motion of the left knee from 0 to 125 degrees. Motion from 0 to 140 degrees is considered normal for VA purposes. See 38 C.F.R. § 4.71a, Plate II (2012). The Veteran's limitation of flexion to 125 degrees is noncompensable. Likewise, he is not entitled to a compensable rating under Diagnostic Code 5261, as extension to 0 degrees is not compensable. Additionally, repetitive motion was within normal limits, and therefore a higher evaluation is not warranted under DeLuca v. Brown, 8 Vet. App. 202 (1995). Furthermore, the Veteran has not shown to have any other symptoms which would warrant an evaluation in excess of 10 percent prior to April 15, 2008. Beginning April 15, 2008, through September 25, 2008, and from November 1, 2009, to February 23, 2011, the Veteran demonstrated left knee extension from 0 to 90 degrees with pain beginning at 20 degrees, and flexion from 20 to 90 degrees with pain beginning at 70 degrees. He therefore does not meet the criteria for an evaluation in excess of 30 percent under Diagnostic Code 5260 and does not meet the criteria for a compensable evaluation under Diagnostic Code 5261. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). Accordingly, separate evaluations are not available under Diagnostic Codes 5260 and 5261. See VAOPGCPREC 9-2004. A separate evaluation is also not warranted under Diagnostic Code 5257 in light of the absence of evidence of even slight recurrent subluxation or lateral instability. Additionally, repetitive motion was within normal limits and therefore a higher evaluation is not warranted under DeLuca v. Brown, 8 Vet. App. 202 (1995). Furthermore, the Veteran has not shown to have any other symptoms which would warrant an evaluation in excess of 30 percent beginning April 15, 2008. Additionally, following his left knee replacement surgery in 2008, there was no evidence of chronic residuals consisting of severely painful motion or severe weakness in the affected extremity to warrant a 60 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). Beginning February 24, 2011, the Board concludes that a disability rating in excess of 60 percent for the Veteran's left knee disability is not warranted. The Veteran is receipt of the maximum disability evaluation available after the one year period following surgery and the evaluation contemplates his chronic residuals consisting of severely painful motion or severe weakness in the affected extremity. See 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). The Board observes that the rating criteria for evaluating the knee do not provide a higher evaluation than the currently assigned 60 percent evaluation. In sum, the Board concludes that the Veteran is not entitled to increased ratings for his left knee disability. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert. v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Other Considerations In reaching the above conclusion with respect to the Veteran's increased rating claims, the Board has not overlooked the Veteran's statements with regard to the severity of his left knee disability. The Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain; and the Board finds that the Veteran's reports have been credible. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board has considered the Veteran's testimony; however, the pertinent rating criteria contain diagnostic criteria that require medical expertise (such as measuring range of motion) to evaluate the Veteran's disability. The record does not reflect that the Veteran is competent to make such medical opinions. Accordingly, the objective medical findings and opinions provided by the Veteran's VA examination reports have been accorded greater probative weight. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The United States Court of Appeals for Veterans Claims (Court) has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the Veteran has not required any hospitalizations for his left knee disability, other than for which he received a 100 percent temporary evaluation. Additionally, the Board finds that the manifestations of his disability are not in excess of those contemplated by the schedular criteria. The service-connected left knee is manifested by pain and functional limitations. As discussed in the preceding section, these symptoms are fully contemplated by the rating criteria. In sum, there is no indication that the average industrial impairment from the disabilities would be in excess of those contemplated by the assigned rating. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service- connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that his disability renders him totally unemployable. The February 2011 VA examination report showed that the Veteran had done industrial maintenance since leaving service but had switched jobs in the last year due to his knee disability. He was then currently employed full-time as a truck driver and had not missed any work in the preceding year. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER Prior to April 15, 2008, entitlement to an evaluation in excess of 10 percent for post operative residuals, left partial medial meniscectomy, cartilage, is denied. From April 15, 2008, through September 25, 2008, and from November 1, 2009, to February 23, 2011, entitlement to an evaluation in excess of 30 percent for post operative residuals, left partial medial meniscectomy, cartilage, is denied. Beginning February 24, 2011, entitlement to an evaluation in excess of 60 percent for post operative residuals, left unicompartmental knee replacement, is denied. ____________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs