Citation Nr: 1301820 Decision Date: 01/16/13 Archive Date: 01/23/13 DOCKET NO. 94-35 990 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for status post operative left knee injury. 2. Entitlement to an evaluation in excess of 10 percent for a chronic strain of the dorsal segment of the spine prior to September 26, 2003. 3. Entitlement to an evaluation in excess of 20 percent for a chronic strain of the dorsal segment of the spine for the period from September 26, 2003, to March 25, 2009. 4. Entitlement to an evaluation in excess of 40 percent for a chronic strain of the dorsal segment of the spine for the period from on or after March 25, 2009. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1977 to December 1980. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from January 1994 and February 1994 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The January 1994 rating decision denied an evaluation in excess of 10 percent for chronic strain of the dorsal spine and a compensable rating for left knee disability, status post meniscectomy. The Veteran appealed the decision to BVA, and the case was referred to the Board for appellate review. In June 1996, the Veteran appeared at the RO and testified at a hearing before a Veterans Law Judge at the Board. A transcript of that hearing has been associated with the claims file. In August 2012, the Board advised the Veteran that the Veterans Law Judge who conducted the June 1996 hearing is no longer employed by the Board and asked whether he wished to appear at another hearing. In August 2012, the Veteran responded that he did not wish for another hearing. Thus, the Board will proceed with the adjudication of his appeal. The case was previously before the Board in March 1997 at which time it was remanded for further evidentiary development. The record shows that, in accordance with the Veteran's wishes and the directives of the Board's remand, the RO made specific requests for additional service treatment records from Balboa Hospital and March Air Force Base, neither of which was able to provide any additional pertinent medical evidence. In a March 1998 rating decision, the RO assigned a 10 percent rating for the Veteran's service-connected left knee disability on the basis of degenerative arthritis with limitation of motion. Nevertheless, the Veteran continued his appeal for an increased evaluation. The case was then returned to the Board, and in an October 1998 decision, the Board denied the Veteran's claims. That decision was subsequently vacated and remanded by the United States Court of Appeals for Veterans Claims (Court) in an order dated in January 2001 that implemented a joint motion for remand filed by the appellant and the Secretary of VA to ensure compliance with the Veterans Claims Assistance Act of 2000 (VCAA), that had become law during the pendency of the Veteran's appeal before the Court. Following further development, the Board issued another decision in November 2001. The Veteran appealed that decision to the Court, and in December 2002, the Court issued an order granting the Appellee's Motion for Remand and to Stay Proceedings of the Court, and vacated and remanded those portions of the November 2001 Board decisions that were before it. The Court issued this order to allow the Board to address and remedy a failure to discuss the amended duty to notify under the VCAA. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. The Board notes that in May 2003 the Veteran submitted a Motion for Advancement on the Docket pursuant to 38 U.S.C.A. § 7107 and 38 C.F.R. § 20.900(c). In May 2003, a Veterans Law Judge at the Board issued a ruling denying the Veteran's motion finding that his situation did not meet any of the strict criteria set forth by law for granting such a motion. In August 2003 and August 2004, the Board remanded the issues of a rating in excess of 10 percent for a left knee disability and a rating in excess of 10 percent for chronic strain of the dorsal spine. Following further development, the Board issued a decision in June 2006, which denied the back and knee issues currently on appeal. The Veteran appealed those decisions to the Court, and in an April 2008 order, the Court vacated and remanded the case for proceedings consistent with a joint motion. The Board subsequently remanded the case for further development in December 2008. That development was completed, and the case has since been returned to the Board for appellate review. In an October 2009 RO decision, the RO granted an increased disability rating of 40 percent for the Veteran's dorsal spine disorder effective March 35, 2009. As a higher schedular evaluation for this disability is possible, the issue of entitlement to a rating in excess of 40 percent remains before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). The Board subsequently remanded the case for further development in February 2011. That development was completed, and the case has since been returned to the Board for appellate review. The Board notes that the February 2011 Board decision also denied the issues of entitlement to service connection for a circulatory disorder of the legs and feet; nonarticular rheumatism, fibrositis, and fibromyositis; residuals of an injury to the right ankle, right knee, and right thigh, to include cartilage damage and tendonitis; a low back disorder with arthritis; an upper back disorder and neck spasm; residuals of an injury to the right leg and hip with arthritis; an upper gastrointestinal bulb disorder; chronic prostatitis; residuals of a bladder injury; flat feet; a rupture and strain of the left testicle; residuals of a muscle strain and cartilage injury of the stomach, heart, and chest; a hiatal hernia; a left leg and groin disability, to include varicose veins; and a left shoulder disorder. The issues are therefore no longer before the Board, and this decision will be focused on the back and knee issues remanded by the February 2011 Board decision. The Board recognizes that the Veteran has submitted multiple letters since the February 2011 decision, however, all of these letters address the service connection issues and not the increased rating issues of the current appeal. Therefore, no waiver of original jurisdiction of the letters is necessary. FINDINGS OF FACT 1. A left knee disability is shown to be manifested by subjective complaints of pain, with degenerative changes on x-ray study; and without objective evidence of limitation of flexion or extension. 2. For the entire appeal period, the Veteran's dorsal spine disorder was manifested by subjective complaints of pain, limited forward flexion to 30 degrees, without objective evidence of neurological impairment or incapacitating episodes. CONCLUSIONS OF LAW 1. The criteria for the assignment of a disability rating in excess of 10 percent for the service-connected status post operative left knee injury have not been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2011). 2. For the time period prior to September 26, 2003, the criteria for a disability rating in excess of 10 percent for chronic strain of the dorsal segment of the spine have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5291 (effective before September 26, 2003). 3. For the time period from September 26, 2003 to March 25, 2009, the criteria for a disability rating of 40 percent for lumbar chronic strain of the dorsal segment of the spine have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2011). 4. For the time period from March 25, 2009, the criteria for a disability rating in excess of 40 percent for lumbar chronic strain of the dorsal segment of the spine have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2009); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the Veteran's claim for increased ratings for a low back and left knee disorders was received in February 2002. Thereafter, he was notified of the general provisions of the VCAA in correspondence dated in January 2005, April 2008, and February 2009. These letters notified the Veteran of VA's responsibilities in obtaining information to assist him in completing his claims, identified his duties in obtaining information and evidence to substantiate his claims, and provided other pertinent information regarding VCAA. Thereafter, the claims were reviewed and a supplemental statement of the case was issued in May 2012. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). The April 2008 letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has been made aware of the information and evidence necessary to substantiate his claims and has been provided opportunities to submit such evidence. A review of the claims file shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records and VA and private treatment records have been obtained and associated with his claims file. The Veteran was also afforded multiple VA examinations in to obtain an opinion on the nature and severity of the Veteran's low back and left knee disabilities. The Board finds that the examinations were adequate to allow proper adjudication of the issues on appeal. The examiners conducted complete examinations, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disability. Furthermore, the Veteran has been notified of the evidence and information necessary to substantiate his claims, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claims. Legal Criteria - General Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, 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. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Court has held that 'staged' ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background The Veteran was granted service connection for low back and left knee disorders in a February 1988 RO decision. VA outpatient treatment records dated in April 1991 show the Veteran was seen with complaints of spasms of the upper chest and back, with a choking feeling. Objective examination revealed mild tenderness over the dorsal spine and paravertebral muscles. The assessment was musculoskeletal pain. Thoracic spine x-rays conducted in May and August 1991 revealed minimal scoliosis with no significant bone change. From January to March 1992, the Veteran was seen at VA facilities on multiple occasions with complaints of back pain. In April 1992 the Veteran reported a sensation of numbness in his right lower extremity. It was noted that he was interested in pursuing disability. Motor conduction studies and electromyogram (EMG) revealed no evidence of lumbosacral radiculopathy at that time. On VA orthopedic consultation in June 1992 the Veteran complained of back pain without specific location, as well as left knee pain. With regard to the back, deep tendon reflexes were intact and muscle power was excellent and symmetrical. X-rays of the left knee and the lumbosacral spine were negative. X-rays of the dorsal spine disclosed minimal scoliosis with no paraspinal abnormalities in the soft tissue. The orthopedist's impression was no orthopedic conditions requiring treatment. VA outpatient treatment records dated in February 1993 to May 1994 reflect the Veteran was seen on multiple occasions for varying complaints to include arthritis. Records dated in December 1993 show he was given medication for compression fracture of the dorsal spine. Orthopedic evaluation of the lumbosacral spine was also conducted in May 1994 which indicated that deep tendon reflexes, range of motion, sensation, and muscle power were normal. The hips, pelvis and lumbosacral spine were shown to be grossly intact on x-rays conducted in May 1994. When the Veteran testified at his June 1994 personal hearing at the RO he described an injury in July 1978 in which a snow tire fell onto him, pinning his right ankle under his buttock and injuring his knee and lower back. Reportedly, he has experienced problems with those areas since the incident. At the time of the hearing the Veteran testified that the accident caused an injury to the L5 disc resulting in constant pain since that time. He further indicated that due to his disc problem his right knee gave way resulting in his left knee injury and surgery. The Veteran also described a subsequent injury in which a large slab of concrete, reportedly weighing more than 200 pounds, fell onto him causing injury to multiple areas of his body. With regard to his left knee the Veteran indicated that pain, swelling and wobbling were the problems. He asserted that his dorsal spine area occasionally locked up. He reported that during the first year after separation from service he lived with his grandparents and did not work, because he was convalescing. The Veteran's representative contended that because the Veteran basically went home to die there were no treatment records related to that period. The report of his July 1994 VA orthopedic examination reflects the Veteran's complaints of left knee pain and instability. The VA examiner recorded that the Veteran presented many other complaints, all of which were inconsistent with his physical examination, specifically expressing doubt that a herniated disc had ever been documented. The examiner included in the examination report, a photograph of the Veteran's right thigh, said to depict a small 2 centimeter scar, considered to be difficult to see at best. Physical examination revealed no swelling or deformities, or loss of motion in any joints, including the knees. On evaluation of the knees there also was no subluxation, instability, nonunion, or malunion. Examination of the musculature of the spine revealed tenderness to the posterior left cervical muscles including the elevated scapula and sub scapular muscles, with no other abnormalities. The Veteran claimed pain on all range of motion of the spine, although it did not appear to the examiner that the Veteran was in pain. Upper and lower extremity neurological examination was normal for sensory/vibratory reflexes and strengths. X-rays of the left knee appeared normal and thoracic spine x-rays revealed mild scoliosis. The assessment was left knee post meniscectomy for meniscal injury, full range of motion, stable knee; chronic thoracic strain/sprain; and chronic lumbar back pain syndrome. The Veteran was seen in January 1995 with multiple complaints to include pain in the back. X-rays of the left shoulder, left ribs and chest, conducted in January 1995 were normal studies. The assessment at that time was chronic pain syndrome. In February 1995, the Veteran testified at a second personal hearing at the RO. At that time he asserted that he had been treated for arthritis during service. The Veteran also reported that he was employed by the postal service, but indicated he was frequently unable to work a full day, with resulting reduction in his annual income. With regard to his upper back he related that the discs were rubbing the nerves and he believed there was 'grit' between them. He also expressed the view that his nerves were compressed and affecting the function of his arm and as well as his internal organs. Medical records dated in February 1995 to March 1995 demonstrate the Veteran was admitted to a VA Medical Center (VAMC) and underwent multiple procedures and laboratory work- up. His course of hospitalization was uneventful and he had multiple complaints during his admission. Also noted was a history of thoracic films indicating normal T-spine. An x-ray report of the knees revealed mild degenerative osteoarthritis. An in depth discussion was conducted about the issue of how much anxiety was contributing to his issue and the Veteran adamantly did not want to pursue this path as a possible cause of his symptoms. The diagnoses listed included lumbar disc disease. When the Veteran testified at his June 1996 personal hearing before the Board, he related that at the time of his physical examination on separation from service he gave a written description of many additional symptoms and disorders which are not reflected in the examination report. He urged that the document be located and also asked that records be sought from Balboa Hospital and March Air Force Base. The Veteran expressed his opinion that if the first doctor who saw him after his worst injury in service had written down what the Veteran told him, rather than telling him that he could not put it down, the Veteran felt he would be in better shape at the time of the hearing. With regard to his service-connected left knee disorder the Veteran complained of pain and grinding, as well as giving way, hyperextending and swelling on prolonged use. At the time of hearing he reportedly had nearly full range of motion, stopping short of full extension, but with full flexion. The first post service treatment the Veteran reported was in approximately 1983 when he was treated by an osteopath for symptoms referable to the neck and back. He also related that he had sustained post service injuries while working for a railroad. In approximately 1986 the Veteran reportedly sustained an injury to the L5 area, as well as his right hip, knee and ankle. During a subsequent on-the-job accident he reportedly injured his dorsal spine and the L5 area. At the time of the hearing the Veteran was employed as a postmaster. A January 1997 VA report shows the Veteran was referred to the anesthesia service for complaint of constant near total body pain, with both sharp and dull components, which interfered with his sleep. A review of recent diagnostic studies indicated that x-rays of the cervical and thoracic spines had been normal. On physical examination the Veteran was diffusely tender to palpation with no trigger points in all of the following areas: left shoulder, left scapula, left chest wall, bilateral costal margins, posterior neck, sternum, thoracic spinous processes, and lumbar spinous processes. The back had no obvious deformity. Examination of the lower extremities revealed no obvious deformity, full range of motion of all joints, no tenderness and no atrophy. Motor and sensory examinations were also normal. The impression was chronic total body pain worsening since injury in the Air Force in 1978. On VA examination conducted in October 1997 the Veteran gave a history of injuries in service, focusing on three separate incidents. The first occurred in 1977 or 1978 when a tire from a snowplow flipped onto his lap, reportedly resulting in an L5 disc syndrome, with partial herniation at the level of L3 and some tailbone pain. The second incident related by the Veteran involved his left knee injury which resulted in a left lateral meniscectomy. Following the surgery the Veteran reportedly continued in active service out of a sense of duty, despite pain in the left knee, as well as the right hip, knee and ankle. The most important episode of injury reportedly occurred between February 1978 and June 1978. The Veteran stated that he had some memory impairment regarding the incident, which involved the lifting of a concrete slab that reportedly was leaned against the Veteran cutting into him, although it did not land on him per se. The Veteran attributed multiple injuries to the period when he was straining to hold onto the slab and keep it from falling on his distal extremities, and posturing himself to minimize further damage. He believed that much of the weight of the slab was balanced on his right thigh and he had an indentation in his muscles from the incident. He did not recall how he extricated himself from underneath the rock, but believed he blacked out from the strain. The Veteran also stated that his knee gave way and he developed varicose veins as a result. According to the Veteran diagnoses were reportedly made over the next one and one half years and attributed to the strain included T1, T5, and T6 nerve root compressions and T8, and T9 malalignment and L5 disc syndrome. His complaints included tingling and numbness, with his legs feeling cold at times. He stated that it was difficult for him to go up or down stairs. Objective examination showed that he walked with a slight limp which was considered inconspicuous. He stated that chronic pain precipitated the limp. Dorsalis pedis pulses, posterior tibial pulses and radial pulses were two plus and equal. When he walked on his heels in normal manner he felt a pulling sensation in his back. The Veteran declined to squat. With regard to his lumbosacral region he stated that with lateral bending he felt pain bilaterally, greater on the right side. He could bend to 12 degrees bilaterally. He began experiencing pain on forward flexion at 30 degrees and extension became painful at 10 degrees. The Veteran stated he had chronic persistent pain with acute exacerbations by certain maneuvers. No complaints or findings of pain localized to the thoracic spine were reported or identified. Deep tendon reflexes were not assessed in the patellar region because the Veteran stated he was unable to tolerate the pain produced by a reflex hammer. The examiner indicated that with his knees the Veteran forced flexion to 140 degrees although his comfort level was limited 100 degrees. On the left he flexed to 90 degrees. He had full extension bilaterally. There was a healed incision lateral to the patella on the left knee. Mid-thigh measurements were 57 centimeters on the right and 59 centimeters on the left. Neurologic evaluation disclosed that cranial nerves II through XII were grossly intact, with no gross motor or sensory deficits, although he had intermittent sensory loss. No paralysis was noted on examination. Minimal degenerative changes were noted per x-ray evaluation of the left knee. Lumbosacral x-rays were normal. An MRI of the thoracic spine showed a normal study and no change from a prior examination in March 1990. On MRI of the lumbar spine, vertebral alignment was normal, bony structures and vertebral discs were normal. There were no disc herniations, bony spinal canal, normal diameter, or intrathecal abnormalities evident. MRI of the left knee disclosed that the lateral joint compartment was stressed and narrowed. The medial meniscus was normal, and the collateral and cruciate ligaments were intact with no abnormal thickening or signal visible. Patellofemoral articulation was unremarkable, with no burning or soft tissue signal visible. The impression of the lumbar and left knee MRI's was normal lumbar spine and post lateral meniscectomy changes of the left knee with appropriate narrowing of the lateral joint space. The October 1997 VA examiner's diagnoses included normal lumbar spine; post lateral meniscectomy changes of the left knee, with narrowing of the lateral joint space, per MRI, September 1997. Following thorough review of the medical record the examiner commented that some of the Veteran's complaints may be well explained by the prior injuries and the well documented left knee surgery. With regard to the Veteran's February 1996 letter stating that he had seven compressed disks, and a similar statement that he had 7, 8, and 9 malalignment, the examiner was unsure where the assertion came from, but noted that at hearing the Veteran had said a doctor had indicated the malalignment. When asked where the x-ray was the Veteran had suggested that it must have been lifted from his file. However, the October 1997 VA examiner indicated a review of the record did not suggest that the reports of any recommended x-rays were missing. The VA examiner felt that many of the Veteran's previous examiners had likely suggested possible etiologies of complaints, pending formal evaluation by the radiologist, and the interpretation by the radiologist did not match the presumptive diagnosis by the referring examiner. In such instances she believed that the worse of the hypotheses were quoted later. The Veteran was considered to have numerous complaints with an element of truth, but the data had been misconstrued and the Veteran had become quite frustrated in the feeling that he had legitimate diagnoses that were being ignored, which may not always be the case. In an addendum to the examination report dated in November 1997 the examiner related additional assessments were left knee x-rays with minimal degenerative change. The Veteran's claims file also contains various VA outpatient treatment notes dated from December 1998 to September 2000. The Veteran also underwent several VA spine CT scans in January 2000. A CTT scan of the Veteran's lumbosacral spine revealed osteopenia, but no acute abnormality. A CTT scan of the lumbosacral spine without contrast also revealed no evidence of disc protrusion or spinal canal stenosis, but mild bilateral facet hypertrophy at L5-S1. The remainder of these outpatient treatment notes reflect continuing complaints of all-over body pain and arthralgias. Examinations resulted in numerous diagnoses of somatization disorder. The Veteran's claims file also contains an examination report dated in April 2001 by R. L. Short, D.O., C.I.M.E. Following a recitation of the Veteran's report of medical history, a review of some of the Veteran's service and post-service medical records, and a physical examination, the examiner assessed the following disorders: chronic lumbar strain; previous left lateral meniscectomy involving the left knee; osteoarthritis of left knee; and persistent musculoskeletal pain with psychogenic overlay. The examiner further opined that, based upon the Veteran's history and physical examination, the Veteran had received significant injuries involving the lumbar spine and left knee. He also continued to experience chronic musculoskeletal pain with psychogenic overlay. The examiner also indicated that the Veteran had not worked since being fired in October 2000, and it was most likely that the Veteran would pursue options for medical disability and/or retirement rather than pursuing active rehabilitation. VA outpatient notes dated from 2000 to July 2005 show that the Veteran has received treatment for various ailments. The impressions have included chronic multiple joint pains status post remote crush injury, with significant somatization component; chronic pain syndrome (multifactorial), probably a component of fibromyalgia as well as somatization; and degenerative joint disease of the shoulders, knees, and hips. In December 2002 and April 2003, the Veteran appeared for VA examinations to address questions regarding the presence of any low back disorder with arthritis. At the time of the April 2003 VA orthopedic examination, the examiner reviewed X-rays taken of the lumbar spine in December 2002, as well as an MRI; a bone scan from November 2002; and x-rays of the hip, pelvis, and knees in October 2002. The results were as follows: the spine films were normal; the knee radiographs had very mild degenerative changes in the patellofemoral compartment; and the bone scan only showed some mild accumulation in the region of the left acetabulum, which would be consistent with some degenerative arthrosis. Physical examination revealed full range of motion of the knees and knee stable ligamentously. The diagnosis was multiple somatic complaints. A private x-ray report of the lumbar spine dated in May 2004 showed degenerative changes at the L5-S1 joints, but was otherwise negative. VA x-ray reports dated in June 2006 revealed slight degenerative spurring of the left knee and thoracic spine. During a July 2007 VA joints examination, the Veteran reported he was able to walk more than a quarter of a mile but less than a mile. He complained of giving way, pain, stiffness, weakness, and episodes of dislocation several times a week, locking episodes several times a week, and weekly severe flare-ups. Upon physical examination he had extension to zero degrees and flexion to 140 degrees without additional limitation of motion on repetitive use. The examiner reviewed the claims file and noted that when compared to previous x-ray findings and previously orthopedic examinations, disability is very minimal. During a July 2007 VA spine examination, the Veteran complained of fatigue, decreased motion, stiffness, weakness, spasms, and constant moderate pain. The Veteran reported weekly severe flare-ups due to weather and climbing stairs. During a flare-up he is unable to do daily chores or activities. Upon physical examination, the examiner noted pain with motion and weakness of the thoracic sacrospinalis. Motor examination was normal. There were no findings of thoracolumbar spine ankylosis. Range of motion findings included flexion 30 degrees with pain at zero degrees, extension to zero degrees with pain at zero degrees, lateral flexion to the right to 10 degrees with pain at zero degrees, lateral flexion to the left to 5 degrees with pain at zero degrees, lateral rotation to the right to 10 degrees with pain at zero degrees, lateral rotation to the left with pain at zero degrees. The examiner noted no degenerative joint disease of the lumbar spine with normal x-ray test. The examiner noted that the Veteran's limitation was limited due to complaints out of proportion to findings. He did not do repetitive motion with joint or with spine claiming severe pain although these were only minimal range of motion done passively. The examiner found that range of motion of the left knee and spines are grossly exaggerated by the Veteran. During a March 2009 VA examination, the examiner reported range of motion findings including flexion to 130 and extension to zero. There was no additional limitation of motion after three repetitions. An x-ray report found minimal retropatellar spurring of the left knee. The diagnosis was left knee menisectomy with mild degenerative arthritis. The examiner noted that the Veteran was purposely resisted the flexion of his knee using muscle strength. He is presently a veteran representative and the examiner suspected that he knows that a decreased range of motion will be awarded a higher degree of disability. During a March 2009 spine examination, the Veteran complained of constant severe pain with decreased motion, spasms, and stiffness. The Veteran reported no flare-ups of spinal disorders. There are also no incapacitating episodes of spine disease. The eternal reported he is able to walk more than a quarter mile but less than a mile. The examiner noted he appeared not to be in distress when getting up form a chair or walking. Upon examination, the examiner found no spasm, atrophy, guarding, pain or weakness, but did note tenderness. Detailed motor and sensory examinations were normal. Range of motion findings included flexion to 30 degrees and extension to 10 degrees. He also had left lateral flexion to 25 degrees, left lateral rotation to30 degrees, right lateral flexion to 25 degrees, and right lateral rotation to 30 degrees. The examiner noted no objective evidence of pain on active range of motion. There was also no additional limitation with repetitive motion. X-ray studies of the lumbar and thoracic spine found no acute bony injury and no significant change. The examiner found normal lumbar spine. The examiner noted that the Veteran had a totally normal lumbar spine series, which was interested in light of the fact that he had marked decrease in the range of motion of his lumbar spine. The examiner noted that the Veteran was factitiously limiting his range of motion. During an October 2009 VA examination, the Veteran complained of constant pain in the left knee aggravated by walking, standing and exercise. He also complained of giving way, weakness, incoordination, decreased speed of joint motion, locking episodes several times a week, tenderness and weekly moderate flare-ups. Upon physical examination, the examiner noted crepitation, clicks or snaps, grinding, and meniscus surgically absent without any other knee abnormalities. The examiner found range of motion measurements with active motion from zero to 140 degrees with objective evidence of pain with active motion. There was no additional limitation with repetitive motion or joint ankylosis. With regard to the spine, the Veteran complained of worsened back pain that is aggravated by prolonged standing, walking, and exercise. The Veteran complained of urinary urgency and frequency, nocturia, erectile dysfunction, numbness, paresthesias, weakness, falls and unsteadiness. The examiner noted that the etiology of these symptoms were not unrelated to the Veteran's claimed disability. The Veteran also complained of fatigue, decreased motion, stiffness, weakness, spasms, and pain hours per day radiating to the low thighs. He also reported flare-ups moderately and weekly for hours. There were no incapacitating episodes of spine disease. The Veteran refused spinal examination. An EMG study found evidence suggestive but not definitively diagnostic of chronic L5 and S1 radiculopathties in the let lower extremity. VA progress notes dated through May 2012 indicate ongoing complaints of back and knee pain. Back Disorder Legal Criteria During the pendency of the Veteran's appeal, substantive changes were made to that portion of the Rating Schedule that addresses evaluation of the spine. In 2002, the evaluation criteria for Diagnostic Code (DC) 5293, for intervertebral disc syndrome, were amended. See 67 Fed. Reg. 54,345-349 (Aug. 22, 2002) (codified at 38 C.F.R. § 4.71a, DC 5293). The amendment was effective on September 23, 2002. In 2003, further amendments were made for evaluating disabilities of the spine. See 68 Fed. Reg. 51,454-458 (Aug. 27, 2003) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243). An omission was then corrected by reinserting two missing notes. See 69 Fed. Reg. 32,449 (June 10, 2004). The amendment and correction were made effective from September 26, 2003. Where a law or regulation changes after a claim has been filed, but before the administrative appeal process has been concluded, the version most favorable to an appellant applies. See e.g., VAOPGCPREC 7-2003. The effective-date rule established by 38 U.S.C.A. § 5110(g), however, prohibits the application of any liberalizing rule to a claim prior to the effective date of such law or regulation. The veteran does get the benefit of having both the old regulation and the new regulation considered for the period after the change was made. See Rhodan v. West, 12 Vet. App. 55 (1998), appeal dismissed, No. 99-7041 (Fed. Cir. Oct. 28, 1999) (unpublished opinion) (VA may not apply revised schedular criteria to a claim prior to the effective date of the pertinent amended regulations). Under the old version of Diagnostic Code 5293, a 10 percent evaluation required mild intervertebral disc syndrome. A 20 percent required moderate intervertebral disc syndrome with recurring attacks. A 40 percent evaluation required severe intervertebral disc syndrome, with recurring attacks, with intermittent relief. A 60 percent evaluation required pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy (i.e., with characteristic pain and demonstrable muscle spasm and an absent ankle jerk or other neurological findings appropriate to the site of the diseased disc) and little intermittent relief. 38 C.F.R. § 4.71a, DC 5293 (prior to Sept. 23, 2002). Under the new version of Diagnostic Code 5293, intervertebral disc syndrome is evaluated (preoperatively or postoperatively) either on the total duration of incapacitating episodes over the past 12 months or by combining, under 38 C.F.R. § 4.25, separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. Incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months warrant a 40 percent evaluation, and incapacitating episodes having a total duration of at least six weeks during the past 12 months warrant a 60 percent evaluation. 38 C.F.R. § 4.71a, DC 5293 (effective on and after Sept. 23, 2002). Further, under Note (1) for purposes of evaluations under the current Diagnostic Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurologic manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Id. Under Note (2), when evaluating on the basis of chronic manifestations, VA is to evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes, and evaluate neurologic disabilities separately using evaluation criteria for the most appropriate neurologic diagnostic code or codes. Id. Under Note (3), if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is evaluated on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. Id. Under the old version of Diagnostic Code 5291, moderate or severe limitation of motion of the dorsal spine warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5291 (prior to Sept. 26, 2003). Under Diagnostic Code 5292, severe limitation of motion of the lumbar spine warrants a 40 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (prior to Sept. 26, 2003). Under Diagnostic Code 5295, a 40 percent evaluation requires severe lumbosacral strain manifested by listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of the joint space. A 40 percent evaluation is also warranted if only some of these manifestations are present if there is also abnormal mobility on forced motion. 38 C.F.R. § 4.71a, DC 5295 (prior to Sept. 26, 2003). Under the amended regulations effective September 26, 2003, the evaluation criteria for rating disabilities of the spine were revised by establishing a general rating formula that applies to all diseases and injuries of the spine. The amendment made editorial changes, not representing any substantive change, to the adopted evaluation criteria for intervertebral disc syndrome to make them compatible with the new general rating formula. The seven Diagnostic Codes 5286 through 5292 that involved findings of ankylosis or limitation of motion of the spine were deleted. The amended regulations added degenerative arthritis of the spine, DC 5242, which will ordinarily be evaluated under the general rating formula for diseases and injuries of the spine except when x-ray findings, as discussed under DC 5003, are the sole basis of its evaluation. Under the amended regulations, new diagnostic codes were assigned for conditions already in the Rating Schedule, which included DC 5237 for lumbosacral strain and DC 5243 for intervertebral disc syndrome. The General Rating Formula for Diseases and Injuries of the Spine provide that: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the general rating formula provides that unfavorable ankylosis of the entire spine warrants a 100 percent evaluation. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent evaluation. Unfavorable ankylosis of the entire cervical spine, or forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine warrants a 40 percent evaluation. Forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine warrants a 30 percent evaluation. Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or combined range of motion of the cervical spine limited to not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis warrants a 20 percent evaluation. Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height warrants a 10 percent evaluation. The notes to the General Rating Formula are: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also diagnostic code 5003); 5243 Intervertebral disc syndrome Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under Sec. 4.25. In addition, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides: Incapacitating episodes having a total duration of at least 6 weeks during the past 12 months warrant a 60 percent evaluation Incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months warrant a 40 percent evaluation Incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months warrant a 20 percent evaluation Incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months warrant a 10 percent evaluation. Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. See 68 Fed. Reg. 51,454-458 (Aug. 27, 2003); 69 Fed. Reg. 32,449 (June 10, 2004). 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Where the limitation of motion of the specific joint or joints involved is noncompensable, under the applicable diagnostic codes, a maximum rating of 10 percent is warranted where arthritis is shown by x-ray and where limitation of motion is objectively confirmed by evidence of swelling, muscle spasm, or painful motion. In the absence of limitation of motion, but with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is warranted. A 10 percent rating is warranted when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2011). Prior to September 26, 2003, ankylosis (complete bony fixation) of the dorsal spine at a favorable angle warrants a 20 percent evaluation. Ankylosis of the dorsal spine at an unfavorable angle warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5288. Prior to September 26, 2003, ankylosis of the lumbar spine at a favorable angle warrants a 40 percent evaluation. Ankylosis of the lumbar spine at an unfavorable angle warrants a 50 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5289. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2011). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In exceptional cases where the schedular evaluations are found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be approved provided the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2011). Analysis As noted above, during the pendency of the Veteran's claim and appeal, changes were made to that portion of the Rating Schedule that addresses evaluation of disorders of the spine, effective September 23, 2002, and September 26, 2003. Because the Veteran's claim was filed before the regulatory changes occurred, he is entitled to consideration of both the old and revised regulations. If a revised version of the regulation is more favorable, the retroactive reach of that regulation can be no earlier than the effective date of that change, and the Board must apply only the earlier version(s) of the regulation for the period prior to the effective date of the change. The Veteran was originally assigned a 10 percent disability rating for the low back disability in a rating decision in February 2008. A January 1994 decision confirmed this disability rating. The Veteran appealed this rating decision. In subsequent decisions, the RO increased the Veteran's disability rating to 20 percent effective in September 26, 2003, to March 25, 2009, and 40 percent thereafter. The Veteran continued his appeal claiming that his condition was more severe. Clearly, the Veteran is competent to allege that he is worse, and that he has functional impairment. However, the Board must also consider the evidence created by competent professionals in deciding the appeal. In reaching its decision, the Board has considered the complete history of the disability in question as well as the current clinical manifestations and the effect the disability may have on the earning capacity of the veteran. 38 C. F. R. §§ 4.1, 4.2, 4.41 (2010). The history of back complaints has been reviewed and the functional impairment which can be attributed to pain or weakness has been taken into account. As detailed above, during the course of the Veteran's appeal, regulations had undergone significant changes as to how the Veteran's lumbar disability, characterized as chronic strain of the dorsal segment of the spine, is evaluated. Prior to September 26, 2003 In this case, the Veteran's disability was originally rated under the pre-September 23, 2002 criteria which combined orthopedic and neurological disabilities. The Veteran was assigned a 10 percent disability rating Diagnostic Code 5291 for moderate or severe limitation of motion of the dorsal spine. Based on the above discussed evidence, an increased rating in excess of 10 percent disabling for service-connected chronic strain of the dorsal segment of the spine is not warranted for the period prior to September 26, 2003. During this time period, the Veteran's dorsal spine disorder was manifested by continued complaints of pain with findings of limitation of motion. During an October 1997 VA examination, the Veteran reported experiencing pain on forward flexion at 30 degrees, and extension became painful at 10 degrees. Upon neurological examination, there were no gross motor or sensory deficits although he had intermittent sensory loss. Lumbosacral x-rays were normal. A 10 percent disability is warranted for moderate or severe limitation of motion of the dorsal spine. Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Part 4 (2002), to include other potentially applicable diagnostic codes whether or not they were raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The evidence of record for that period does not show a diagnosis of intervertebral disc syndrome, lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position; or lumbosacral strain that was severe, with listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, and narrowing or irregularity of the joint space, to warrant a rating in excess of 10 percent disabling under the regulations previously in effect during the appeals period. See 38 C.F.R. § 4.71a, Diagnostic Code 5003-5295 (1996-2002). For this time period there are no other rating criteria that would afford the Veteran a higher rating. From September 26, 2003 As noted, on September 23, 2002, new regulations went into effect. With these new regulations, it became possible to evaluate intervertebral disc syndrome based upon both orthopedic and neurological manifestations. The Veteran's back disability has been evaluated under both the pre-September 23, 2002 and post-September 23, 2002 regulations, and the new regulations favor the Veteran. Prior to September 26, 2003, under diagnostic code 5291 for moderate or severe limitation of motion of the dorsal spine, the rating schedule provides no more than a 10 percent evaluation unless there is demonstrable deformity of a vertebra from fracture, something the evidence does not show. However, under post-September 26, 2003 General Rating Formula, disability ratings are based on limitation of motion by degrees of loss of motion. The Board finds the aforementioned evidence reflect findings that would warrant a rating of 40 percent, but no higher, under the schedular criteria of the General Rating Formula. In VA examinations dated in October 1997, July 2007, and March 2009, the Veteran had consistent limitation of flexion to 30 degrees which is within the range for a 40 percent rating. Under Diagnostic Code 5237, a 40 percent rating is in order, as flexion of the thoracolumbar spine limited to 30 degrees or less. The General Rating Formula also directs that neurological manifestations of should be rated separately from orthopedic manifestations. The Board notes that although the Veteran has consistently complained of pain and radiation related to this service-connected back disorder, there are no objective manifestations of neurological deficit that would result in separate disability ratings. In fact, the March 2009 VA examiner found detailed motor and sensory examinations were normal. Though the October 2009 VA examiner noted an EMG test which was suggestive of chronic L5-S1 radiculopathies, he stated there was no definitive diagnostic finding, therefore, no diagnosis was made. The Board also finds that there is no basis for the assignment of any higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca. There were no findings of incoordination, or lack of endurance of the thoracolumbar spine during this time period. The Veteran complained of weakness, though there were no objective findings of weakness during the appeals period. Consequently, the assignment of rating in excess of 40 percent for chronic strain of the dorsal segment of the spine is not warranted during this time period. While competent medical evidence during this time period does show limited range of motion, objective medical findings do not indicate that the Veteran's range of motion was akin to ankylosis warranting a higher evaluation. As noted above, under provisions for rating intervertebral disc syndrome, effective September 23, 2002 under Diagnostic Code 5293, and effective September 26, 2003, under Diagnostic Code 5243, ratings are based on incapacitating episodes or orthopedic and neurologic impairment. There have been no complaints of incapacitating episodes during any of the many VA examinations or VA treatment reports. Therefore, for the time period from September 26, 2003, the Veteran's chronic strain of the dorsal segment of the spine is most favorably rated under the post-September 26, 2003, Diagnostic Code 5237 which warranted a 40 percent evaluation. Left Knee Disorder Analysis A rating action in February 1988 granted service connection for a left knee injury and assigned a 10 percent disability rating under Diagnostic Codes 5257 for recurrent subluxation or lateral instability. Diagnostic Code 5257 provides ratings for impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated as 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated as 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated as 30 percent disabling. 38 C.F.R. § 4.71a. The Board also points out that, in a precedent opinion, the VA General Counsel held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). Diagnostic Codes 5260 and 5261 govern the rating criteria with regard to limitation of motion of the knee. Under Diagnostic Code 5260, limitation of flexion of the knee warrants a zero percent rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and a 30 percent rating when limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg warrants a zero percent rating when extension is limited to 5 degrees; a 10 percent rating when extension is limited to 10 degrees; a 20 percent rating when limited to 15 degrees; 30 percent when limited to 20 degrees; 40 percent when limited to 30 degrees; and 50 percent when limited to 45 degrees. The regulations define normal range of motion for the leg as zero degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate I. Following a review of the evidence pertinent to the Veteran's left knee disability noted above, particularly the July 1994, October 1997, July 2007, March 2009, and October 2009 VA examination reports, the Board finds that the evidence does not support the assignment of a disability rating in excess of 10 percent for the left knee disability for instability or subluxation. Although the Veteran has complained of his left knee giving out, there have been no objective findings during this time of instability. Given that neither subluxation nor lateral instability has been objectively demonstrated on any examination, a disability rating in excess of 10 percent under Diagnostic Code 5257 is not warranted for the left knee. Although the Veteran has complained of decreased range of motion, the Board finds the Veteran's left knee disorder does not warrant a separate disability rating for limitation of flexion or extension. In an October 1997 VA examination, the examiner noted the Veteran flexed to 90 degrees with full extension. Though this represents a limitation of flexion, the Board finds this examination to represent a flare up, and not a full picture of the Veteran's left knee disability. The Board notes that in VA examinations dated prior to the October 1997 VA examination, including July 1994 VA examination and January 1997 reports show full range of motion. VA examination reports dated after October 1997, including those dated in April 2003, July 2007, and October 2009, also showed no limitation of flexion. The only other report which showed limitation of flexion was in a March 2009 VA examination, and the examiner noted that the Veteran purposely resisted flexion of his knee using muscle strength, therefore, rendering the examination unreliable. Finally, as the Veteran does not have ankylosis of the knee, a rating under Diagnostic Code 5256 would not be appropriate. Neither does he have impairment of the tibia and fibula such that a rating under Diagnostic Code 5262 would be appropriate. In conclusion, the Board has considered all of the applicable evidence relating to the Veteran's left knee disabilities, and has considered all applicable Diagnostic Codes, and the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, the holding in DeLuca v Brown, 6 Vet. App. 321 (1993), and VAOPGCPREC 23-97. The Board recognizes that the Veteran has manifested considerable subjective complaints that may appear to have much greater impact on her level of function than recognized by the schedular ratings assigned herein. The Board, however, is restricted to an assessment of the objective manifestations of a disability that can be measured against the rating schedule. The preponderance of the evidence is against the assignment of higher rating than outlined above for the Veteran's left knee disorder; there is no doubt to be resolved; and a rating higher than 10 percent is not warranted for the left knee. Fenderson v. West, 12 Vet. App. 119, 126 (1999). For All Issues and Time Periods The Board acknowledges the Veteran and his representative's contentions that his back and left knee are more severely disabling. While the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and is within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet.App. 465, 469-70 (1994). The Veteran is not a licensed medical practitioner and is not competent to offer opinions on questions of medical causation or diagnosis. See Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Finally, the Board has also considered whether referral for extraschedular consideration is suggested by the record. In Thun v. Shinseki, F.3d 1366 (Fed. Cir. 2009), the Court articulated 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 is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate the 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 the Veteran's disability picture requires the assignment of an extraschedular rating. In the case at hand, there is no objective evidence that the disability picture presented is exceptional or that schedular criteria are inadequate. In this case, the Board finds there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization related to his low back disability that would take the Veteran's case outside the norm so as to warrant the assignment of an extraschedular rating during the appeal period. While the Board notes that the Veteran complained that his low back disability interfered with his employment, there is simply no objective evidence showing that the low back disability has resulted in marked interference with employment (i.e., beyond that contemplated in the assigned rating). Consequently, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). (ORDERS ON NEXT PAGE) ORDER Entitlement to a compensable evaluation prior to November 14, 1997 and an evaluation in excess of 10 percent for status post operative left knee injury is denied. Entitlement to an evaluation in excess of 10 percent for a chronic strain of the dorsal segment of the spine prior to September 26, 2003, is denied. Entitlement to an evaluation of 40 percent for a chronic strain of the dorsal segment of the spine for the period from September 26, 2003, to March 25, 2009 is allowed. Entitlement to an evaluation in excess of 40 percent for a chronic strain of the dorsal segment of the spine for the period from on or after March 25, 2009, is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs