Citation Nr: 1301388 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 10-37 432 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial compensable rating for dermatitis/eczema. 2. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the right knee. 3. Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the left knee. ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active service from January 2001 to January 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2007 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Montgomery, Alabama. In a February 2012 rating action, the RO denied the Veteran's claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). There is no indication from the information of record that the Veteran filed a Notice of Disagreement. Accordingly, this issue is not before the Board for appellate consideration. FINDINGS OF FACT 1. Although the Veteran's service-connected dermatitis/eczema has been treated with topical skin creams, the Veteran has not had intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, at any time; the Veteran's dermatitis/eczema affects less than 5 percent of the entire body and less than 5 percent of the exposed area affected. 2. For the period of time from June 13, 2007 to February 25, 2010, and also since March 9, 2012, the Veteran's service-connected patellofemoral syndrome of the right knee has not been manifested by limitation of flexion to 60 degrees or less or limitation of extension to more than 5 degrees and there was/is no objective evidence of instability, swelling, recurrent subluxation, or dislocated semilunar cartilage with recurrent episodes of locking with effusion into the joint; the right knee disability has not been manifested by arthritis confirmed by x-ray. 3. For the period of time from June 13, 2007 to February 25, 2010, and also since March 9, 2012, the Veteran's service-connected patellofemoral syndrome of the left knee has not been manifested by limitation of flexion to 60 degrees or less or limitation of extension to more than 5 degrees and there was/is no objective evidence of instability, swelling, recurrent subluxation, or dislocated semilunar cartilage with recurrent episodes of locking with effusion into the joint; the left knee disability has not been manifested by arthritis confirmed by x-ray 4. For the period of time from February 26, 2010 to March 8, 2012, the Veteran's patellofemoral syndrome of the right knee was manifested by limitation of extension to 20 degrees, but not by extension limited to 30 degrees, flexion limited to 45 degrees, nonunion of the tibia and fibula or any type of ankylosis. 5. For the period of time from February 26, 2010 to March 8, 2012, the Veteran's patellofemoral syndrome of the left knee was manifested by limitation of extension to 20 degrees, but not by extension limited to 30 degrees, flexion limited to 45 degrees, nonunion of the tibia and fibula or any type of ankylosis. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for dermatitis/eczema are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.118, Diagnostic Code 7806 (2012). 2. The criteria for an initial rating in excess of 10 percent for patellofemoral syndrome of the right knee were not met for the period of time from June 13, 2007 to February 25, 2010, and are not met since March 9, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.59, 4.71a, Diagnostic Codes 5256-5263 (2012). 3. The criteria for an initial rating in excess of 10 percent for patellofemoral syndrome of the left knee were not met for the period of time from June 13, 2007 to February 25, 2010, and are not met since March 9, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.59, 4.71a, Diagnostic Codes 5256-5263 (2012). 4. The criteria for a rating of 30 percent for the Veteran's service-connected patellofemoral syndrome of the right knee have been met for the period of time from February 26, 2010 to March 8, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.59, 4.71a, Diagnostic Code 5261 (2012). 5. The criteria for a rating of 30 percent for the Veteran's service-connected patellofemoral syndrome of the left knee have been met for the period of time from February 26, 2010 to March 8, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.59, 4.71a, Diagnostic Code 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA also redefined the obligations of VA with respect to the duty to assist the veteran with the claim. Id. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the letters dated in June 2007, February 2010, and March 2010 that were sent to the Veteran adequately apprised him of the information and evidence needed to substantiate the claims. The RO thus complied with VCAA's notification requirements. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, on March 3, 2006, the United States Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Board finds that VA has met these duties with regard to the claims adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in June 2007, February 2010, and March 2010 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claims, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the aforementioned letters also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." Written notice was provided in June 2007, prior to the appealed from rating decision, along with the subsequent notice provided in February 2010 and March 2010, after the decision that is the subject of this appeal. With respect to any timing deficiency, the Board notes that the case was subsequently readjudicated in a March 2012 supplemental statement of the case (SSOC) and, as such, the Veteran has not been prejudiced thereby. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). During the pendency of this appeal, the Court issued a decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), which pertains to a greater degree of specificity with respect to notice of the criteria necessary for an increased rating. However, this decision was recently vacated by the United States Court of Appeals for the Federal Circuit (Federal Circuit). See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). Also, since the claims on appeal are downstream issues from that of service connection, Vazquez notice was never required. See VAOPGCPREC 8- 2003 (Dec. 22, 2003). The Board finds that the June 2007, February 2010, and March 2010 letters substantially satisfy the current notification requirements for the claims on appeal. As the Veteran has not indicated any prejudice caused by a content error and no such error is apparent, the Board finds no basis for finding prejudice against the Veteran's appeal of the issues adjudicated in this decision. Shinseki v. Sanders, 129, S. Ct. 1696 (2009) regarding the rule of prejudicial error. The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claims by VA. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence, and the Veteran received VA examinations in October 2007, February 2010, and March 2012, which were thorough in nature and adequate for the purposes of deciding these claims. The aforementioned VA examinations revealed findings that are adequate for rating the Veteran's dermatitis/eczema and bilateral knee disabilities. Thus, the Board finds that the medical evidence of record is sufficient to resolve this appeal; VA has no further duty to provide an examination or medical opinion. 38 C.F.R. §§ 3.326, 3.327. Based on the foregoing, it is the Board's determination that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard, supra. II. Pertinent Laws and Regulations Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. 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. 38 C.F.R. § 4.7. III. Dermatitis/Eczema A. Factual Background The Veteran's service treatment records show that he was treated on numerous occasions for a rash on the back of his neck. In June 2007, the Veteran filed a claim of entitlement to service connection for a skin disorder/rash. A VA examination was conducted in October 2007. At that time, the Veteran stated that during service, a rash erupted in his posterior neck area. Although he was given topical medications, the Veteran indicated that he continued to experience the rash. He also noted that there was itching and burning associated with the rash. The examiner reported that the Veteran described the skin eruptions as papular with surrounding erythremic dermatitis. At present, the Veteran was not taking any medication. Upon physical examination of the Veteran's posterior cervical area, he had an area of light erythema which measured 3 x 3 centimeters (cm). The dermatitis extended into the Veteran's hairline. There was a mild folliculitis noted in the hairline. The diagnosis was eczema dermatitis of the posterior cervical area. The examiner opined that it was at least as likely as not that the Veteran's dermatitis (eczema) was related to his military service. In a November 2007 rating action, the RO granted service connection for dermatitis/eczema. The RO assigned a noncompensable rating under Diagnostic Code 7806, effective from June 13, 2007, for the Veteran's service-connected dermatitis/eczema. In March 2012, the Veteran underwent a VA skin examination. At that time, the examiner stated that she had reviewed the Veteran's claims file. She noted that according to the Veteran, he continued to have "bumps back there" on his neck. Since his last VA examination, he had been given a topical treatment for his dermatitis/eczema. The examiner indicated that the Veteran's skin condition did not cause scarring or disfigurement of the head, face, or neck. In the past 12 months, the Veteran had not been treated with oral or topical medications. Upon the physical examination, the Veteran's service-connected skin disorder affected less than 5 percent of the entire body and less than 5 percent of the exposed area affected. The examiner noted that the Veteran's service-connected skin disorder did not have an impact on his ability to work. B. Analysis As the Veteran has taken issue with the initial rating assigned following the grant of service connection, separate ratings may be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). Thus, the Board must evaluate the relevant evidence since June 13, 2007. The Veteran's service-connected dermatitis/eczema has been assigned a noncompensable disability rating under Diagnostic Code 7806. Diagnostic Code 7806 directs that when dermatitis or eczema covers less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and no more than topical therapy is required during the past 12-month period, a 0 percent rating is assigned. A 10 percent rating is assigned when at least 5 percent, but less than 20 percent of the entire body is covered; or at least 5 percent, but less than 20 percent of exposed areas are affected; or intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs, are required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or for dermatitis or eczema that requires systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent disability rating is assigned for dermatitis or eczema, affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or for dermatitis or eczema that requires constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. In this case, the Veteran seeks a compensable rating for his service-connected dermatitis/eczema. He contends that his dermatitis/eczema causes itching and burning. In this regard, lay statements are considered to be competent evidence when describing symptoms of a disease or disability or an event. However, symptoms must be viewed in conjunction with the objective medical evidence of record. Upon review of the evidence, the Board finds that the overall disability picture does not support a higher compensable rating for the Veteran's dermatitis/eczema. In making this determination, the Board recognizes that the Veteran has used topical skin creams to treat his dermatitis/eczema. However, there is no evidence that he has ever been treated with intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs at any time during the appeal period. The Board also notes that there is no evidence to show that his dermatitis/eczema affects at least 5 percent of his entire body, or 5 percent for exposed areas, or that he has been provided any systemic therapy for any period of time during the appeal period. In the March 2012 VA examination report, the examiner specifically stated that the Veteran's service-connected skin disorder affected less than 5 percent of the entire body and less than 5 percent of the exposed area affected. Although the examiner indicated that the Veteran had acne which affected less than 40 percent of his face and neck, the Board notes that the Veteran is not service-connected for acne. Rather, he is only service-connected for dermatitis/eczema. Thus, a compensable initial rating is simply not warranted for the Veteran's dermatitis/eczema. 38 C.F.R. § 4.3. In summary, the Board finds that an initial compensable rating for dermatitis/eczema is not warranted at any time since the initial grant of service connection. See Fenderson, 12 Vet. App. at 125-26. Accordingly, the Board concludes that there is a preponderance of evidence against the claim for an initial compensable rating for dermatitis/eczema. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply; therefore, the claim for a higher initial evaluation must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Patellofemoral Syndrome of the Right and Left Knees A. Factual Background In June 2007, the Veteran filed a claim for service connection for bilateral knee disabilities. In October 2007, the Veteran underwent a VA examination. He stated that during service, he developed bilateral knee pain and was prescribed a brace and physical therapy. The Veteran indicated that after his discharge, he continued to experience bilateral knee pain. He noted that the pain was a 7 on a scale of 1 to 10, with an increase to a 9 during flare-ups. According to the Veteran, he had associated weakness, stiffness, swelling, redness, buckling, instability, and fatigability. He did not use a cane or brace. The Veteran denied any dislocation or subluxation. He also denied any history of arthritis of the knees. The Veteran reported that he was able to stand for 10 to 15 minutes and that he was not able to walk greater than 100 yards at one time. He noted that he had problems with heavy lifting, bending, stooping, and running. The examiner stated that a review of the Veteran's service treatment records showed that he was treated for bilateral patellofemoral syndrome and was prescribed medication. The physical examination of the Veteran's knees showed that there was no obvious warmth, redness, swelling, or effusion. Flexion was to 140 degrees on the left with minimal pain, and to 138 degrees on the right with minimal pain. Extension was to 0 degrees, bilaterally, with mild pain. The Veteran had an increase in pain but no decrease in range of motion with repetitive testing times 3. He had mild fatigue, weakness, and lack of endurance with repetitive testing times 3 of his bilateral knees. The Veteran had negative Lachman's test, negative McMurray's test, and varus valgus testing was negative, bilaterally. There was no misalignment to the knee. There was no evidence of genu varum or genu valgus. The Veteran had no significant gait abnormalities and he did not use a cane or brace. Leg strength was graded at 5/5. Patellar reflexes were within normal limits. X-rays of the Veteran's knees were reported to be normal. The diagnosis was bilateral knee patellofemoral syndrome. The examiner opined that it was at least as likely as not that the Veteran's bilateral knee condition was related to his military service. In a November 2007 rating action, the RO granted service connection for patellofemoral syndrome of the right and left knees. The RO assigned a 10 percent rating under Diagnostic Code 5260 for each knee, effective from June 13, 2007. On February 26, 2010, the Veteran underwent a VA examination which was conducted by A.C.P., M.D. According to Dr. P., the Veteran did not have arthritis of the knees; however, he had bilateral knee arthralgia. The Veteran stated that he was unable to stand for more than a few minutes. He was able to walk for more than a quarter of a mile but less than one mile. The Veteran did not use any assistive devices. He had pain in his knees and his knees felt stiff and would give way three to four times a week. There was no locking or effusion. The Veteran reported that he had weakness and lack of endurance. He stated that he worked full time at Walmart as a supervisor. In the last 12 month period, he had lost less than one week from work due to his bilateral knee condition. The physical examination showed that the Veteran's gait was antalgic. There was no instability of the knees. The Veteran had bilateral knee pain at rest and weakness. In regard to range of motion, right knee flexion was to 115 degrees and left knee flexion was to 110 degrees. However, Dr. P. reported that the Veteran's bilateral knee extension was not normal; extension of each knee was limited by 20 degrees. There was pain with range of motion and with repetitive motion. There were no additional limitations after three repetitions of range of motion. There was no joint ankylosis. A magnetic resonance imaging (MRI) of the right knee, dated in February 2010, was reported to be unremarkable. A February 2010 MRI of the left knee was reported to show small joint effusion with no acute internal derangement of the left knee. Following the physical examination and a review of the MRI reports, Dr. P. diagnosed the Veteran with bilateral patellofemoral syndrome. Dr. P. stated that the Veteran's service-connected bilateral knee disabilities had significant effects on his occupation. Specifically, the examiner indicated that the Veteran's bilateral knee disabilities caused decreased mobility, problems with lifting and carrying, difficulty reaching, weakness or fatigue, decreased strength, and pain of the lower extremities. In regard to the effects of the Veteran's bilateral knee disabilities on his usual daily activities, the examiner stated that there were severe effects in respect to shopping, traveling, and driving, and that they prevented the Veteran from exercise and participating in sports and recreation. There were moderate effects in regard to chores. There were no effects with respect to feeding, bathing, dressing, toileting, and grooming. VA Medical Center (VAMC) outpatient treatment records show that in July 2010, Dr. P. once again examined the Veteran. At that time, range of motion testing again showed that extension of each knee was limited by 20 degrees. On March 9, 2012, the Veteran underwent a VA examination. At that time, he stated that he had chronic pain in his knees and that sometimes his knees gave out. According to the Veteran, he was working at an automobile manufacturing plant. The physical examination of the Veteran's knees showed that flexion was to 140 degrees, bilaterally. Extension was to 0 degrees, bilaterally. The Veteran was able to perform repetitive-use testing with 3 repetitions. The Veteran did not have additional limitation in range of motion of the knees following repetitive-use testing. He did not have any functional loss and/or functional impairment of the knees. Muscle strength testing was 5/5, bilaterally. Lachman's test was normal and anterior drawer sign test was normal, both bilaterally. There was no varus/valgus instability. There was no evidence or history of recurrent patellar subluxation/dislocation. According to the examiner, degenerative or traumatic arthritis had not been documented. The examiner noted that MRI's of both knees, dated in 2010, showed intact ligaments, intact tendons, and normal cartilage, bilaterally. The examiner stated that the Veteran's bilateral knee disabilities did not impact his ability to work. The diagnosis was bilateral knee strain. B. Analysis As the Veteran has taken issue with the initial ratings assigned following the grant of service connection, separate ratings may be assigned for separate periods of time based on the facts found. See Fenderson, 12 Vet. App. at 119. Thus, the Board must evaluate the relevant evidence since June 13, 2007. The RO has assigned separate 10 percent evaluations under Diagnostic Code 5260 for the Veteran's bilateral knee disabilities. Diagnostic Code 6260 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. A 20 percent evaluation requires that flexion be limited to 30 degrees, and a 30 percent evaluation requires that flexion be limited to 15 degrees. 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, and to 10 degrees warrants a 10 percent evaluation. A 20 percent evaluation requires that extension be limited to 15 degrees, and a 30 percent evaluation requires that extension be limited to 20 degrees. A 40 percent evaluation requires that extension be limited to 30 degrees, and a 50 percent evaluation requires that extension be limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Separate ratings under Diagnostic Code 5260 and 5261 may be assigned for disability of the same joint. See VAOPGCPREC 9- 2004. Normal knee motion is from zero degrees to 140 degrees. See 38 C.F.R. § 4.71, Plate II (2012). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement and weakness. 38 C.F.R. §§ 4.44, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the diagnostic code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, 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 Veteran maintains that his current ratings are not high enough in light of the disability that his knees cause. He indicates that he has chronic pain in his knees that is aggravated by prolonged standing and walking. In this regard, lay statements are considered to be competent evidence when describing symptoms of a disease. However, symptoms must be viewed in conjunction with the objective medical evidence of record. The Board finds that staged ratings are appropriate in this case since it is an appeal of the initial rating and the evidence of record shows different medical findings for distinct time periods. Thus, for the period of time from June 13, 2007 to February 25, 2010, a rating in excess of 10 percent is not warranted for either knee disability. However, for the period of time from February 26, 2010 to March 8, 2012, a staged disability rating of 30 percent is warranted for each knee disability based on limitation of extension of each knee. Following that period, the evidence demonstrates that the Veteran's bilateral knee disabilities substantially improve, with no limitation of extension of either knee shown. Thus, on and after March 9, 2012, the 30 percent ratings for each knee are discontinued and the ratings return to the 10 percent ratings awarded by the RO in the first instance. Because the ratings return to the 10 percent ratings originally assigned by the RO, this is not a "reduction" in rating and is appropriate. O'Connell v. Nicholson, 21 Vet. App. 89 (2007). Rating in Excess of 10 Percent From June 13, 2007 to February 25, 2010 In the November 2007 rating action, the RO granted service connection for patellofemoral syndrome of the right and left knees and assigned separate 10 percent ratings under Diagnostic Code 5260 for each knee, effective from June 13, 2007. The RO noted that in the October 2007 VA examination, although the Veteran had full range of motion of the knees, he had pain on motion. Thus, the 10 percent disability ratings represented painful motion of each knee. For the period of time from June 13, 2007 to February 25, 2010, to warrant an increased evaluation under Diagnostic Code 5260 for limitation of flexion of the leg, there needs to be medical evidence of limitation of flexion that more nearly approximates 30 degrees than 45 degrees. However, in the October 2007 VA examination, flexion of the right leg was to 138 degrees and flexion of the left leg was to 140 degrees. Thus, an evaluation in excess of 10 percent is not warranted for the Veteran's right knee disability or left knee disability under Diagnostic Code 5260 for the period of time from June 13, 2007 to February 25, 2010. An increased evaluation is further warranted when extension of the leg is more nearly limited to 15 degrees than to 10 degrees. However, upon a review of the October 2007 VA examination report, the Veteran had full extension of both of his legs to 0 degrees. Thus, an evaluation in excess of 10 percent is not warranted for the Veteran's right knee disability or left knee disability under Diagnostic Code 5261 for the period of time from June 13, 2007 to February 25, 2010. As stated above, Diagnostic Code 5257 is used to rate recurrent subluxation or lateral instability. However, in this case, the competent medical evidence of record is negative for any evidence of instability or subluxation of either knee. In this regard, the Board recognizes that the Veteran maintains that his knees give way. In addition, in the October 2007 VA examination report, the examiner stated that the Veteran had mild fatigue, weakness, and lack of endurance with repetitive testing times 3 of his knees. However, the examiner also stated that Lachman's and McMurray's tests were negative, and varus valgus testing was negative, bilaterally. Moreover, there was no misalignment to the knee and there was no evidence of genu varum or genu valgus. In addition, the Veteran had no significant gait abnormalities and he did not use a cane or brace. Consequently, since there is no medical evidence of recurrent subluxation or lateral instability, a separate compensable evaluation is not warranted for either knee disability due to impairment of the knee. With respect to potential application of other criteria, the Board notes that there is no evidence of ankylosis, dislocation of the semilunar cartilage, or impairment of the tibia and fibula for evaluation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, or 5262 (2012). In addition, the Board further notes that because arthritis of the knees has not been shown by the medical evidence of record, separate evaluations are not warranted. See VAOPGCPREC 23- 97, 62 Fed. Reg. 63604 (1997). In the October 2007 VA examination report, the examiner stated that x-rays of the Veteran's knees were reported to be normal. The Board has further considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.40 and 4.45 would warrant higher ratings. See DeLuca, 8 Vet. App. at 202. However, higher ratings in excess of 10 percent for the Veteran's knees are not warranted with consideration of these provisions. The Veteran's complaints of discomfort and pain have been considered and have been taken into account in the assignment of the 10 percent evaluations for his service- connected right and left knee disabilities. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. In the October 2007 VA examination, the Veteran had an increase in pain with repetitive testing times three. However, he had no decrease in range of motion upon repetitive testing. Thus, although pain has been the primary problem experienced by the Veteran, the available medical evidence does not suggest that loss of function due to pain, weakness, etc. equate to limitation of flexion to 45 degrees or less or limitation of extension to 10 degrees or more. Although the Board is required to consider the effect of pain when making a rating determination, which has been done in this case, it is important to emphasize that the Rating Schedule does not provide a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194 (1997); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In light of the above, the Board finds that the preponderance of the evidence is against the Veteran's claims for initial ratings in excess of 10 percent for right and left knee disabilities for the period of time from June 13, 2007 to February 25, 2010. As the preponderance of the evidence is against this aspect of the appeal, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Rating in Excess of 10 Percent From February 26, 2010 to March 8, 2012 The Veteran is entitled to a 30 percent rating, but no greater, for his right knee disability for the period of time from February 26, 2010 to March 8, 2012. In addition, the Veteran is also entitled to a 30 percent rating, but no greater, for his left knee disability for the period of time from February 26, 2010 to March 8, 2012. A review of the evidence of record shows that at no point during the period on appeal was there any finding of flexion of either leg limited to 45 degrees, the minimum requirement for a compensable rating under Diagnostic Code 5260. On the other hand, the medical evidence of record does indicate that on the day of a VA examination conducted on February 26, 2010, the Veteran showed a worsening of symptomatology. Specifically, he showed limited range of motion with regard to extension. In the February 2010 VA examination report, Dr. P. stated that the Veteran's bilateral knee extension was not normal; extension of each knee was limited by 20 degrees. There was also pain with range of motion and with repetitive motion. In addition, VAMC outpatient treatment records reflect that in July 2010, Dr. P. once again examined the Veteran and extension of each knee was still limited by 20 degrees. As explained further below, a subsequent VA examination report, dated on March 9, 2012, shows substantial improvement with full extension to 0 degrees. In light of the above, beginning on February 26, 2010, the evidence of record showed a significant worsening of extension of the legs, with substantial improvement shown on March 9, 2012. Thus, for the period of time from February 26, 2010 to March 8, 2012, a staged rating of 30 percent is warranted for each knee based on limitation of extension. Further, it is important to note that this same evidence does not demonstrate that a rating in excess of 30 percent, from February 26, 2010 to March 8, 2012, is in order for either knee. The Board observes that while extension of each leg was limited to 20 degrees during the period of time from February 26, 2010 to March 8, 2012, there is no evidence showing that extension was limited beyond 20 degrees. In the February 2010 VA examination, although there was pain with range of motion, there were no additional limitations after three repetitions of range of motion. Thus, a rating in excess of 30 percent is not warranted under Diagnostic Code 5261 for either knee during the period of time from February 26, 2010 to March 8, 2012. See DeLuca, supra. With respect to potential application of other criteria, the Board notes that there is no evidence of ankylosis or impairment of the tibia and fibula for evaluation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262 (2012). Rating In Excess of 10 Percent On and After March 9, 2010 Although the Veteran showed limitation of extension at the time of his February 2010 VA examination, he showed substantial improvement during his March 9, 2012 VA examination. At that time, he had full range of motion of each leg. Specifically, extension was to 0 degrees, bilaterally. Thus, the Board finds that on and after March 9, 2012, the 30 percent ratings for each knee are discontinued and the ratings are returned to the 10 percent ratings awarded by the RO in the first instance. For the period of time on and after March 9, 2012, to warrant an increased evaluation under Diagnostic Code 5260 for limitation of flexion of the leg, there needs to be medical evidence of limitation of flexion that more nearly approximates 30 degrees than 45 degrees. However, in the March 2012 VA examination, flexion of both legs was to 140 degrees. Thus, an evaluation in excess of 10 percent is not warranted for the Veteran's right knee disability or left knee disability under Diagnostic Code 5260 on and after March 9, 2012. An increased evaluation is further warranted when extension of the leg is more nearly limited to 15 degrees than to 10 degrees. However, upon a review of the March 2012 VA examination report, the Veteran had full extension of both of his legs to 0 degrees. Thus, an evaluation in excess of 10 percent is not warranted for the Veteran's right knee disability or left knee disability under Diagnostic Code 5261 on and after March 9, 2012. With respect to Diagnostic Code 5257 and whether the Veteran experiences any recurrent subluxation or lateral instability, the competent medical evidence of record is negative for any evidence of instability or subluxation of either knee. The Board recognizes that the Veteran maintains that his knees give way. However, in the March 2012 VA examination, the examiner specifically stated that there was no varus/valgus instability. In addition, Lachman's test was negative and the anterior drawer sign test was normal. Moreover, the examiner stated that the Veteran did not have any functional loss and/or functional impairment of the knees. There was no evidence of recurrent patellar subluxation/dislocation. Consequently, since there is no medical evidence of recurrent subluxation or lateral instability, a separate compensable evaluation is not warranted for either knee disability due to impairment of the knee. With respect to potential application of other criteria, the Board notes that there is no evidence of ankylosis, dislocation of the semilunar cartilage, or impairment of the tibia and fibula for evaluation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, or 5262 (2012). In addition, the Board further notes that because arthritis of the knees has not been shown by the medical evidence of record, separate evaluations are not warranted. See VAOPGCPREC 23- 97, 62 Fed. Reg. 63604 (1997). In the March 2012 VA examination report, the examiner stated that degenerative or traumatic arthritis had not been documented. The Board has further considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.40 and 4.45 would warrant higher ratings. See DeLuca, 8 Vet. App. at 202. However, higher ratings in excess of 10 percent for the Veteran's knees are not warranted with consideration of these provisions. In the March 2012 VA examination, the Veteran was able to perform repetitive-use testing with three repetitions and he did not have additional limitation in range of motion of the knees following repetitive-use testing. In addition, he did not have any functional loss and/or functional impairment of the knees. Thus, although pain has been the primary problem experienced by the Veteran, the available medical evidence does not suggest that loss of function due to pain, weakness, etc. equate to limitation of flexion to 45 degrees or less or limitation of extension to 10 degrees or more. Therefore, increased evaluations for the bilateral knee disabilities are not warranted under DeLuca. In light of the above, the Board finds that the preponderance of the evidence is against the Veteran's claims for initial ratings in excess of 10 percent for right and left knee disabilities on and after March 9, 2012. As the preponderance of the evidence is against this aspect of the appeal, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 49. V. Extraschedular Considerations In exceptional cases, including when a disability causes marked interference with employment or requires frequent periods of hospitalization, a higher evaluation may be available on an extraschedular basis. See 38 C.F.R. § 3.321(b) (2012). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determined whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedular is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. The evidence does not present such an exceptional or unusual disability picture that available schedular evaluations are inadequate. The evidence does not show functional impacts which affect the Veteran's life in an exceptional or unusual way. The Board recognizes the Veteran's contention that his service-connected bilateral knee disabilities interfere with his ability to maintain employment. However, the Veteran has essentially been working throughout this appeal. In addition, the Board recognizes that in the February 2010 VA examination, the examiner stated that the Veteran's bilateral knee disabilities had significant effects on his occupation. However, the examiner also noted that according to the Veteran, in the last 12 month period, he had lost less than one week of work due to his bilateral knee disabilities. Moreover, in the March 2013 VA examination, the examiner stated that the Veteran's bilateral knee disabilities did not impact his ability to work. The Board also notes that there is no evidence of marked interference with employment or frequent periods of hospitalization due to the Veteran's service-connected dermatitis/eczema and/or his service-connected bilateral knee disabilities. Accordingly, the Board finds that referral for consideration of an extraschedular rating is not warranted. ORDER Entitlement to an initial compensable rating for dermatitis/eczema is denied. Entitlement to an initial rating in excess of 10 percent for the Veteran's service-connected patellofemoral syndrome of the right knee is denied for the period of time from June 13, 2007 to February 25, 2010, and since March 9, 2012. Entitlement to an initial rating in excess of 10 percent for the Veteran's service-connected patellofemoral syndrome of the left knee is denied for the period of time from June 13, 2007 to February 25, 2010, and since March 9, 2012. Entitlement to a staged rating of 30 percent for the Veteran's service-connected patellofemoral syndrome of the right knee is granted for the period of time from February 26, 2010 to March 8, 2012, to the extent warranted under pertinent laws and regulations. Entitlement to a staged rating of 30 percent for the Veteran's service-connected patellofemoral syndrome of the left knee is granted for the period of time from February 26, 2010 to March 8, 2012, to the extent warranted under pertinent laws and regulations. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs