Citation Nr: 1302999 Decision Date: 01/28/13 Archive Date: 02/05/13 DOCKET NO. 06-03 342 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for sinusitis. 2. Entitlement to an increased (compensable) rating for an allergic disorder, originally claimed as allergic pharyngitis. 3. Entitlement to an increased rating in excess of 10 percent for right knee arthritis. 4. Entitlement to an increased rating for lumbar spondylosis in excess of 10 percent prior to November 13, 2009, and in excess of 20 percent from November 13, 2009. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran (Appellant or Claimant) had active duty service from November 1988 to June 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2004 and November 2005 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston Texas. In March 2012, the Board remanded this matter for additional development, including obtaining the Veteran's Social Security records and affording the Veteran a VA examination. The Board finds that there has been substantial compliance with its May 2008 remand directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998) FINDINGS OF FACT 1. The Veteran sustained an in-service injury to the maxillary sinuses in February 1993. 2. Symptoms of sinusitis were chronic in service. 3. Symptoms of sinusitis were continuous since service. 4. The Veteran has a current sinusitis disability. 5. During the entire rating period, the Veteran's allergic disorder has not been manifested by greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side and has not been manifested by laryngitis or granulomatous rhinitis. 6. During the entire rating period, the Veteran's service-connected right knee disability manifested pain on motion, but did not manifest flexion limited to 30 degrees, extension limited to 15 degrees, or a combination of extension limited to 10 degrees with flexion limited to 45 degrees, recurrent subluxation or lateral instability, right knee ankylosis, impairment of the tibia and fibula, or genu recurvatum. 7. For the period prior to November 13, 2009, the Veteran's service-connected lumbar spine disability did not manifest forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 8. For the period from November 13, 2009, the Veteran's service-connected lumbar spine disability did not manifest forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for sinusitis have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.380 (2012). 2. The criteria for a compensable rating for allergic pharyngitis have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. § 4.97, Diagnostic Codes 6522, 6523, 6524 (2012). 3. The criteria for a rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256, 5260, 5261 (2012). 4. Prior to November 13, 2009, the criteria for a rating in excess of 10 percent for a lumbar spine disability were not met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5239 (2012). 5. From November 13, 2009, the criteria for a rating in excess of 20 percent for a lumbar spine disability are not met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5239 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102 , 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. A September 2003 letter provided the Veteran with notice of the evidence required to substantiate the claim for service connection for sinusitis. An October 2008 letter provided the Veteran with notice of the evidence necessary to substantiate the claim for service connection for sinusitis and the claims for increased ratings for a right knee disability, back disability and allergic disability. This letter informed the Veteran of how disability ratings and effective dates are assigned. In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). While a fully compliant VCAA notice was provided after the initial adjudication of the claims on appeal, the provision of the fully compliant notice letter in October 2008, followed by a subsequent readjudication in a supplemental statement of the case in a statement of the case in November 2009 and a supplemental statement of the case in January 2010, cured the timing of the notice. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording the Veteran VA examinations. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). VA examinations for the claimed sinus disability and allergic disability were conducted in September 2003, November 2009, and April 2012. The Veteran had VA examinations for the right knee and back disabilities in September 2003, October 2005, April 2009, and November 2009. The examinations considered all the pertinent evidence of record, including the Veteran's statements and the claims file. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's statements. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Service Connection for Sinusitis Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a) (2012). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for disease that is diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). The U.S. Court of Appeals for Veterans Claims has held that, in order to prevail on the issue of service connection, generally, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Diseases of allergic etiology, including skin allergies and allergic rhinitis, may not be disposed of routinely for compensation purposes as constitutional or developmental abnormalities. Service connection must be determined on the evidence as to existence prior to enlistment and, if so existent, a comparative study must be made of its severity at enlistment and subsequently. Increase in the degree of disability during service may not be disposed of routinely as natural progress or as due to the inherent nature of the disease. Seasonal and other acute allergic manifestations subsiding on the absence of or removal of the allergen are generally to be regarded as acute diseases, healing without residuals. The determination as to service incurrence or aggravation must be on the whole evidentiary showing. 38 C.F.R. § 3.380. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the U.S. Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that 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. The Veteran contends that she was treated for sinusitis during service in 1991 and has had continuous symptoms of sinusitis since service. She contends that she has had post-service treatment for sinusitis since 2003. The Veteran also asserts that sinusitis is somehow related to the service-connected upper respiratory disability and/or the service-connected migraine headaches. After a review of all of the evidence, the Board finds that the Veteran sustained an in-service injury to the maxillary sinuses when assaulted in February 1993. In February 1993, the Veteran was examined after an assault, and left orbital series x-rays were obtained. The radiologic report showed that the examination failed to demonstrate any evidence of acute fracture; however, both maxillary sinuses, especially the left were cloudy. The report noted that this most likely represented mucosal thickening from inflammatory changes, but the possibility of a nondisplaced fracture could not be excluded. The Board next finds that symptoms of sinusitis were chronic during service. Subsequent to the February 1993 injury, the Veteran subsequently reported sinus complaints during service. A July 1993 entry in the service treatment records reflects that the Veteran complained of sinus congestion and headache. On examination, the sinuses were noted to be nontender, although the assessment was rhinorrhea. Service treatment records show that in January 1994 and in April 1994 the Veteran reported a history of sinusitis, which reflects back on symptoms of sinusitis during service. The Board finds that symptoms of sinusitis have been continuous since service. In written statements, as well as her testimony at a RO hearing in September 2009, the Veteran reported that sinusitis began in service in 1991. A report of VA examination dated in November 2009 shows that the Veteran reported a history of sinusitis during service from 1991 and since service. Given the Veteran's competent and credible report of symptoms since service, which is consistent with the in-service findings and history of chronic sinus symptoms, the Board finds that a continuity of sinusitis symptomatology since service is shown. The Veteran is competent to report sinusitis symptoms she had in service. The Board finds the Veteran credible in the reporting of sinus symptoms during service and since service separation. The Board finds that the evidence is at least in equipoise with regard to whether the Veteran has a current diagnosis of sinusitis. Service treatment records show a history of injury to the face in February 1993 and subsequent findings of inflammatory changes of the maxillary sinuses. VA examinations have provided different opinions regarding a current diagnosis of sinusitis. The October 2003 VA examination found that sinusitis was not present, while the November 2009 VA examination diagnosed sinusitis. The April 2012 VA examination found that the Veteran did not have chronic sinusitis; however, the basis of that diagnosis is questionable because the same April 2012 examination report indicates that a CT scan showed mucosal thickening of the maxillary sinuses. Consistent with a current diagnosis of sinusitis is the Veteran's competent and credible testimony of chronic sinusitis symptoms during service and continuous sinusitis symptoms since service, including current symptoms. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran has a current disability of sinusitis. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves). On the question of relationship of currently diagnosed sinusitis to service, the Veteran's lay statements regarding sinusitis symptoms in service and since service supported a later diagnosis of sinusitis upon VA examination in November 2009. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (stating that lay evidence can be competent and sufficient to establish a diagnosis of a condition when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). In light of the documented injury in service, as well as the in-service chronic complaints of sinusitis and the Veteran's credible report of continuous sinusitis since service, the Board finds that the currently diagnosed sinusitis is related to service on the basis of chronic and continuous symptoms that manifested in a current diagnosis. See 38 C.F.R. § 3.303(b) (with chronic disease in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected). In this case, the Veteran has related observations of experiencing the same sinus symptoms since service that later formed the diagnosis of sinusitis. See Rhodes v. Brown, 4 Vet. App. 124, 126-27 (1993) (lay witnesses testimony of post-service continuous symptoms of numbness and tingling may be sufficient to substantiate a claim of service connection); Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (lay statements are competent on in-service symptoms and post-service symptoms that later formed the basis of diagnosis); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997) (continuity of post-service symptoms is "a substitute way of showing" in-service incurrence and medical nexus). For these reasons, and with resolution of reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for sinusitis are met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Disability Ratings - Law and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Increased Rating for an Allergic Disorder Service connection for allergic pharyngitis has been in effect since December 1994. A non-compensable rating was assigned. The Veteran filed a claim for an increased rating in June 2003. The Veteran asserts that pharyngitis causes itchy eyes, itchy throat, and post-nasal drip. The rating code does not contain a specific provision for pharyngitis. This disability is rated by analogy to allergic or vasomotor rhinitis under Diagnostic Code 6522. Diagnostic Code 6522 provides that a 10 percent rating is assignable for allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side. A 30 percent evaluation is assignable for allergic or vasomotor rhinitis with polyps. 38 C.F.R. § 4.97, Diagnostic Code 6522 (2012). Upon VA examination in September 2003, the Veteran reported frontal headaches. She reported that she had had headaches since 1991, which occurred two to three times a month, with the headaches being occipital and frontal at the same time, with pain around the eyes and behind the eyes. The Veteran reported that the headaches usually lasted all day. The examiner diagnosed migraine headaches and no known allergy or sinusitis. The Veteran had a VA examination in April 2009. Examination of the nose revealed mild swelling involving the middle and inferior turbinates, although there was no evidence of significant nasal obstruction present. There were no nasal polyps present. There was no mucopus in the nose or nasopharynx. Examination of the nose and mouth was unremarkable. The mucosa and the pharynx were completely unremarkable, and there was no abnormality noted in the pharynx. Examination of the neck was unremarkable. The VA examiner diagnosed mild allergic rhinitis. Upon VA examination in April 2012, the examiner noted in various statements a history of allergic rhinitis. The examiner indicated that the Veteran has rhinitis. The examiner stated that the Veteran did not have greater than 50 percent nasal obstruction on both sides due to rhinitis. There was not complete obstruction on one side due to rhinitis. There was not permanent hypertrophy of the nasal turbinates. There were no nasal polyps. The Veteran did not have any granulomatous conditions. The examiner indicated that the Veteran did not have chronic laryngitis. The Veteran did not have 50 percent nasal obstruction of the nasal passages due to traumatic septal deviation. The Veteran did not have a benign or malignant neoplasm related to any diagnosis. The examiner opined that the Veteran exhibits signs and symptoms of mild allergic rhinitis. In statements in support of her claim, the Veteran has noted that her allergic disorder symptoms include pressure over her eyes, facial pressure, itchy and watery eyes, lightheadedness, weakness, triggering of migraine headaches, runny nose, post-nasal drip and sneezing. The Board may not consider symptoms of sinusitis or headaches in rating the service-connected allergic disability because to do so would constitute impermissible pyramiding, that is, the rating of the same symptom under different diagnoses. 38 C.F.R. § 4.14 (rating of the "same disability" or the "same manifestation" under various diagnoses is to be avoided). In Esteban v. Brown, 6 Vet. App. 259 (1994), the Court held that, for purposes of determining whether an appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology of any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. In this case, the VA examinations and the Veteran's statements reflect the Veteran's report of symptoms such as runny nose, itchy eyes, and pressure in the face with weather changes. These symptoms are applicable to the appropriate rating for the separate disability of service-connected sinusitis, which considers such symptoms as sinusitis episodes with headaches and pain, but they are not pertinent to the appropriate rating for an allergic disorder. The VA examinations and the Veterans' statements also reflect her report of headaches. Service connection is in effect for migraine headaches; therefore, headaches may not also be considered when rating the service-connected allergic disorder, as the rating of the same disability (headaches) under various diagnoses is to be avoided. 38 C.F.R. § 4.14. The Board finds that, based on all the evidence, the Veteran's allergic disorder does not meet or more nearly approximate the criteria for a compensable rating for any period. The Veteran does not have greater than 50 percent obstruction of nasal passages on both sides or complete obstruction on one side. The Veteran's allergic disorder is not manifested by granulomatous infection. There is no laryngitis associated with the Veteran's disability. Accordingly, there is no basis for a compensable rating under Diagnostic Codes 6516, 6522, 6523 or 6524. For these reasons, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable rating for an allergic disorder for any period. As there is a preponderance of the evidence against the claim for an increase rating, reasonable doubt may not be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Rating Right Knee Arthritis A 10 percent rating is assigned for the Veteran's service-connected right knee arthritis, pursuant to Diagnostic Code 5003, since November 2004. The Diagnostic Codes (DCs) relevant to this case are 5003, 5010, 5260 and 5261. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings is to be evaluated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, an evaluation of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups. A 20 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a , DC 5003. DC 5256 provides that ratings of 30 to 60 percent are assignable for ankylosis of the knee. 38 C.F.R. § 4.71a. Diagnostic Code 5260 pertains to limitation of flexion. A 0 percent evaluation is assignable when flexion is limited to 60 degrees. A 10 percent evaluation is assignable when flexion is limited to 45 degrees. A 20 percent evaluation is assignable where flexion is limited to 30 degrees, and an evaluation of 30 percent is assignable when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261 applies to limitation of extension of the leg. A 0 percent evaluation is assignable for extension limited to 5 degrees. A 10 percent evaluation is assignable for extension limited to 10 degrees. A 20 percent evaluation is assignable for extension limited to 15 degrees. A 30 percent evaluation is assignable for extension limited to 20 degrees. A 40 percent evaluation is assignable for extension limited to 30 degrees, and a 50 percent evaluation is assignable when extension is limited to 50 degrees. See 38 C.F.R. § 4.71a. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). In VAOPGCPREC 23-97, the VA General Counsel interpreted that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating is based upon additional disability. VAOPGCPREC 23-97. Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98. The General Counsel has also directed that separate ratings also are available if a particular knee condition causes both the limitation of extension and limitation of flexion of the same joint. Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04. Upon VA examination in September 2003, the Veteran complained of pain and swelling of the right knee without any distinct catalyst activity or motion and with an occasional "buckling" but without give way causing falls. She reported retropatellar pain on ascending more than descending stairs and occasionally with kneeling more than squatting. She denied any exacerbation of her pain by walking on straight flat surfaces but did note an increase with inclines. She denied episodes of locking. Examination of the knees in September 2003 showed obscuration of normal landmark architecture but without clear evidence of effusion or erythema or warmth. She was tender to the right in the peripatellar region and to the patella tendon. She had extension of the right knee to 5 degrees. Flexion was to 100 degrees. There was no evidence of instability on varus-valgus stress testing in extension or 30 degrees neither of flexion nor on Lachman and Drawer testing. Patellofemoral compression test was positive on the right. She was noted to have painless retropatellar crepitus bilaterally on both active and passive range of motion and especially between 30 and 60 degrees of flexion. McMurray test was negative bilaterally. The examiner indicated that there was no objective evidence that function was additionally limited by pain, fatigue, weakness, incoordination or lack of endurance. Upon VA examination in October 2005, the Veteran reported swelling of the knee, giving out and pain in the joints. She reported that her functional impairment was that she was unable to climb stairs or walk long distances. The Drawer test of the right knee was within normal limits. McMurray's test was within normal limits. Flexion of the right knee was to 100 degrees, with pain at 100 degrees. The report noted that the joint function was additionally limited by pain and lack of endurance after repetitive use. The examiner stated that he was unable to make a determination without resorting to speculation on whether pain, fatigue, weakness, lack of endurance and incoordination additionally limited the joint function in degrees. A VA outpatient treatment record dated in November 2005 noted a long history of knee pain and intermittent swelling. The Veteran complained of 5/10 pain around the knee cap with stairs, kneeling and squatting. She denied locking and instability. Examination of the right knee in November 2005 showed range of motion of -8 to 140 degrees. There was tenderness over the patella tendon and in the medial and lateral joint spaces. The knee was stable to ligamentous stress, and there was no effusion. Upon VA examination in April 2009, the Veteran reported constant knee pain. She reported that the pain were an ache and grinding type pain. The Veteran reported that it interfered with her daily activities such as walking a mile and a half and standing for 30 minutes or longer. Examination of the right knee in April 2009 showed no deformity, no swelling and no palpable tenderness. Extension of the right knee was 0 degrees. Flexion was 105 degrees. There was no laxity or instability. Active range of motion did not produce weakness, incoordination or fatigue bilaterally. There was no additional loss with range of motion with repetitive motion three times bilaterally. The Veteran had a normal gait. A report of VA examination dated in November 2009 reflects that the Veteran reported pain, weakness, stiffness, swelling, heat, instability, giving way, locking, fatigability and lack of endurance of the right knee. She reported flare-ups of her knee condition, including increased pain, which was severe three to five times per week. The Veteran had flexion of the right knee to 60 degrees and extension to 0 degrees. Varus/ valgus of medial collateral ligaments and lateral collateral ligaments were both normal. Anterior cruciate ligaments and posterior cruciate ligaments were normal. McMurray's test of the right knee was negative. In statements in support of her claim, the Veteran has reported that her knee disability impacts such activities as driving, walking for long periods and mobility. She reported that she has continuous swelling, stiffness, and aching. The Board finds that, based on all the evidence, the Veteran's right knee arthritis does not more nearly approximate the criteria for a rating in excess of 10 percent for any period. During the entire rating period, the Veteran's service-connected right knee arthritis disability manifested pain on motion, but did not manifest flexion limited to 30 degrees, extension limited to 15 degrees, recurrent subluxation or lateral instability, right knee ankylosis, impairment of the tibia and fibula, or genu recurvatum. As the evidence shows that the Veteran's right knee arthritis has been manifested by flexion of 60 degrees or greater and full extension of 0 degrees during the appeal period, a higher rating is not assignable under the criteria for Diagnostic Codes 5260 or 5261 based upon limitation of extension or limitation of flexion. Likewise, as the evidence does not show a combination of extension limited to 10 degrees with flexion limited to 45 degrees, separate compensable ratings for limitation of extension (Diagnostic Code 6261) and limitation of flexion (Diagnostic Code 6260) are not warranted. See VAOPGCPREC 9-04. The Board has considered whether a higher rating is warranted based upon additional limitation of motion due to orthopedic factors, such as pain, guarding of movement, and fatigability. See DeLuca, supra; 38 C.F.R. §§ 4.45, 4.59. The September 2003 VA examination showed that there was no objective evidence that function was additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance. The October 2005 examination report noted that knee pain occurred at the end of range of motion of 100 degrees flexion. The report indicated that the joint function was additionally limited by pain and lack of endurance after repetitive use, but the examiner was unable to make a determination without resorting to speculation on whether pain, fatigue, weakness, lack of endurance, and incoordination additionally limited the joint function in degrees. The April 2009 VA examination indicated that active range of motion did not produce weakness, incoordination, or fatigue bilaterally, and there was no additional loss with range of motion with repetitive motion three times bilaterally. Even with consideration of additional limitation of motion and function due to pain, weakness, and stiffness, as indicated above, the weight of the evidence shows that the Veteran's right knee disability does not more nearly approximate the criteria for a rating in excess of 10 percent for limitation of flexion or extension. In addition, the evidence also does not establish loss of either flexion or extension to a compensable degree; thus, assignment of separate 10 percent evaluations for limitation of flexion and extension of the right knee is not warranted. VAOPGCPREC 9-2004. Diagnostic Code 5257 governs recurrent subluxation or lateral instability. A 10 percent evaluation is assignable for slight recurrent subluxation or lateral instability. A 20 percent evaluation is assignable for moderate recurrent subluxation or lateral instability. A 30 percent evaluation is provided for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257 (2012). The Veteran has alleged that she has instability of the right knee. In a lay statement dated in September 2010, the Veteran reported that she has buckling of the knee. The Veteran reported giving way of the knee at the November 2009 VA examination. The Veteran's report of instability is outweighed by the VA examination findings in September 2003, October 2005, April 2009 and November 2009 VA examinations, which all indicated that there was no instability of the knee. The Board finds that the weight of the evidence is against a finding of instability of the knee, given the lack of any objective evidence of instability. Accordingly, the Board finds that a separate compensable rating is not assignable for instability under Diagnostic Code 5257. A higher rating than 10 percent is not warranted under Diagnostic Code 5256, as the evidence does not show ankylosis of the knee. A higher rating is also not warranted under either Diagnostic Codes 5262 or 5263, as the evidence does not show impairment of the tibia and fibula or genu recurvatum. As there is a preponderance of the evidence against the claim for an increase rating in excess of 10 percent for right knee arthritis, the claim must be denied, and there remains no reasonable doubt to resolve in the Veteran's favor. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. §§ 4.3, 4.7. Increased Rating for a Back Disability prior to November 13, 2009 A December 1994 rating decision granted service connection for lumbosacral strain and assigned a 0 percent rating. A 10 percent rating was assigned from June 2003. A claim for an increased rating was received in November 2004. Lumbosacral strain is rated according to the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion for the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. There are several notes following the General Rating Formula criteria, which provide the following: First, associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateroflexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateroflexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurological 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 the regulation. 38 C.F.R. § 4.71a. The Formula for Rating Intervertebral Disc Syndrome based upon Incapacitating Episodes provides that a 20 percent rating is assignable with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assignable with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is assignable with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). In a September 2009 statement, the Veteran has indicated that her back disability has required three emergency room visits. She reported that she is not able to sit or stand for prolonged periods and cannot walk. The Veteran has reported that she uses a wheelchair. She also reported that she cannot perform daily job functions and daily chores. The Veteran had a VA examination in September 2003. The Veteran complained of recurring transverse lumbar pain and "spasm" (by description) which she associated with sitting for more than one hour and standing more than 35 minutes. She denied any exacerbation of her back or discomfort by walking or stair climbing. She denied any exacerbation by coughing or sneezing and did not associate her back pain with bowel or bladder changes. She reported periodic flare-ups of discomfort associated with those activities, approximately two times per week and lasting approximately a day and a half. She reported that she lost one day from work and school in the last year, but she had not had physician prescribed bedrest. Active range of motion in September 2003 showed forward flexion to 105 degrees and extension to 25 degrees. Lateral bending was zero to 20 degrees bilaterally, and rotation was 0 to 25 degrees to the left and zero to 30 to the right. There was no evidence of discomfort at extremes of motion. The Veteran had a VA examination in October 2005. The Veteran reported pain in the upper, middle and lower back. The pain was elicited by physical activity. It was relieved by rest, medication, a heating pad and sea salt baths. The Veteran reported that this condition did not cause incapacitation. She reported that this condition did not result in lost time from work. Examination in October 2005 revealed complaints of radiating pain up to the shoulders. Muscle spasm was absent. No tenderness was noted. There was a negative straight leg raising on the right and negative straight leg raising on the left. There was no ankylosis of the spine. The Veteran had flexion of the thoracolumbar spine to 90 degrees with pain at 90 degrees. Extension of the thoracolumbar spine was 30 degrees, with pain at 30 degrees. The Veteran had right and left lateral flexion to 30 degrees, with pain at 30 degrees. The Veteran had right and left lateral rotation to 30 degrees, with pain at 30 degrees. The VA examiner in October 2005 noted that the joint function of the spine was additionally limited by pain, fatigue, weakness, lack of endurance and incoordination. Pain had the major functional impact. The examiner indicated that he was unable to make a determination without resorting to speculation on whether pain, weakness, fatigue, lack of endurance and incoordination additionally limit the joint function in degrees. The VA examiner stated that there were no signs of intervertebral disc syndrome with chronic and permanent nerve involvement. Upon VA examination in April 2009, the Veteran complained of sharp back pains. The pains were usually sharp pains that radiated down her back, not down her legs. There was no leg numbness. She reported that sitting for one and a half hours aggravated her back. She reported that standing for 45 minutes or longer aggravated her back, but walking did not. On examination in April 2009, curvature of the lumbar spine was normal. The Veteran was nontender on palpation, with no deformities and no swelling. She had forward flexion to 85 degrees, with pain to the right and left of the lumbar spine in the musculature. The Veteran had extension to 25 degrees with pain in the same area. She had lateral flexion and lateral rotation to 25 degrees, both right and left, with pains in the same area. Pinprick was normal. She had normal strength of the lower extremities. Foot drop was negative bilaterally. Active range of motion did not produce weakness, fatigue or incoordination. There was no additional loss of range of motion with repetitive movement times three. A VA outpatient treatment record dated in June 2009 reflects that the Veteran complained of back pain. She reported that she was moving in the previous week and awoke with acute right back pain radiating from the right thigh to the knee. Examination revealed moderate spasm in the lumbar area. The Veteran had negative straight leg raising on the left and positive straight leg raising on the right. The Veteran had pain with range of motion in all directions, more so with mild flexion. A physician diagnosed acute lumbar strain/ spasm, possible discopathy. The physician prescribed bed rest for two days. After a review of all of the evidence, the Board finds that the criteria for a rating in excess of 10 percent for a back disability are not more nearly approximated at any time during the period prior to November 13, 2009. In this case, the Board finds that the criteria for an increased rating for lumbosacral strain were not met during the time period prior to November 13, 2009. For a 20 percent rating under the General Rating Formula for Diseases and Injuries of the spine, the evidence must show forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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. In this case, during the entire period prior to November 13, 2009, the Veteran had forward flexion greater than 60 degrees. She had forward flexion to 105 degrees in September 2003, 90 degrees in October 2005 and 85 degrees in April 2009. Even with consideration of the DeLuca factors, this does not more nearly approximate the criteria for an increased rating. The examination reports did not indicate that there was muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. There was a finding of muscle spasm in June 2009; however, there is no indication that muscle spasm resulted in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, as required for a 20 percent disability rating. There were no findings or evidence of ankylosis. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202 . The Veteran has reported functional impairments such as problems walking or sitting for a prolonged period and difficulty performing daily chores. The evidence does not show additional functional loss due to pain or weakness, fatigability, incoordination, or pain on movement that would warrant a rating in excess of 10 percent under the General Rating Formula. Upon VA examination in 2003, flexion of the thoracolumbar spine was 105 degrees without pain. The October 2005 VA examination noted that pain started at the end of the range of motion of 90 degrees. There was no additional loss of range of motion with repetition. The examiner indicated that he was unable to make a determination without resorting to speculation on whether pain, weakness, fatigue, lack of endurance and incoordination additionally limit the joint function in degrees. In April 2009, the Veteran had flexion of the thoracolumbar spine to 85 degrees. The VA examiner noted that the Veteran had pain but did not specify at what point pain began. The Board has considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in). The range of motion findings during this period do not more nearly approximate the criteria for a rating in excess of 10 percent, even when painful motion is considered. The Board acknowledges the Veteran's report in June 2009 that she has pain in all ranges of motion. The Veteran also asserts that her back pain is of the severity that it is equivalent to ankylosis. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance, in order to constitute functional loss. Id. at 11; see also 38 C.F.R. § 4.40. The evidence indicated in this decision does not show such additional functional loss or limitation of motion of the thoracolumbar spine due to such factors as pain to more nearly approximated the criteria for a higher disability rating based on limitation of motion. The Board has considered whether a higher rating is warranted under the criteria pertaining to intervertebral disc syndrome. Although the Veteran has reported pain radiating down her right leg and to her shoulders, there is no diagnosis of intervetebral disc syndrome. The Veteran had prescribed bedrest for two days in June 2009. As the incapacitating episode of back pain was less than 2 weeks in duration, it does not meet the criteria for a higher rating based upon the Formula for Rating Intervertebral Disc Syndrome Based upon Incapacitating Episodes. There is also no diagnosis of neurological impairment associated with the Veteran's service-connected back disability; therefore, a separate rating on the basis of associated neurological abnormalities is also not appropriate. For these reasons, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 10 percent for a back disability for the period prior to November 13, 2009. As there is a preponderance of the evidence against the claim for an increase rating for this period, this aspect of the claim must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Increased Rating for a Back Disability from November 13, 2009 Upon VA examination in November 2009, the Veteran reported back pain. She reported numbness and tingling traveling down the right leg. She reported that the pain occurred three to four times a week. She reported that she could walk for 15 to 20 minutes or close to one mile. She reported that her walk was unsteady and that she had fallen. The November 2009 VA examiner indicated that ankylosis was not present. The Veteran had forward flexion to 90 degrees, extension to 30 degrees, left lateral flexion to 30 degrees, right lateral flexion to 30 degrees and left and right lateral rotation to 30 degrees. The VA examiner indicated that there was no muscle spasm present. The examiner indicated that there was no additional loss of range of motion with repetition. The examiner noted that there was pain after range of motion. There was no fatigue, weakness, lack of endurance, or incoordination. Lower extremity motor and sensory function were normal. There was no bowel or bladder dysfunction. The Veteran reported that she did not know how many days at a time her back condition required bedrest. In a December 2010 statement, the Veteran indicated that she has periods of immobility which require a wheelchair. She indicated that she is unable to stand, sit or walk for long periods and cannot drive long distances. She indicated that she is unable to sleep comfortably and cannot perform chores. After a review of all of the evidence, the Board finds that the criteria for a rating in excess of 20 percent for a back disability are not more nearly approximated for the period. In order to warrant a rating in excess of 20 percent, the evidence must show forward flexion of the thoracolumbar spine or 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The Veteran has had flexion of the thoracolumbar spine greater than 30 degrees throughout the appeal period. There have been no findings of ankylosis. The Board has considered the additional functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint in determining that a rating in excess of 20 percent is not warranted for the rating period from November 13, 2009. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, supra. The evidence for this time period did not show that the Veteran had additional limitation of motion due to pain. The November 2009 VA examination report showed that the Veteran had pain after range of motion but no additional loss of range of motion with repetition and no other limiting factors. In November 2009, the Veteran reported numbness and tingling in the right leg. There is no diagnosis of intervetebral disc syndrome and no diagnosis of neurological impairment associated with the Veteran's service-connected back disability. There were no incapacitating episodes noted during this period. Therefore, a rating in accordance with the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not appropriate; and, a separate rating on the basis of associated neurological abnormalities is also not appropriate. For these reasons, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 20 percent for a back disability for the rating period from November 13, 2009. As there is a preponderance of the evidence against the claim for an increase rating for this period, this aspect of the appeal must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the Board finds that the schedular rating criteria contemplate the Veteran's allergic disorder, knee, and back disabilities. The criteria pertaining to the Veteran's allergic disorder contemplates the symptomatology, including whether there is nasal obstruction or granulomatous infection due to the disability. The rating criteria pertaining to the Veteran's service-connected right knee disability consider the range of motion of the knee, whether there is subluxation or instability and whether ankylosis is present. The rating criteria for the knee and back disabilities also consider limitation of motion of the knee and back, including due to pain and other orthopedic factors. 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. The rating criteria pertaining to the back disability include both forward flexion and combined ranges of motion, whether there is ankylosis, and whether there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The criteria also consider whether there are incapacitating episodes due to intervertebral disc syndrome. Because the schedular rating criteria are adequate to rate the Veteran's disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER Service connection for sinusitis is granted. A compensable rating for an allergic disorder is denied. A rating in excess of 10 percent for right knee arthritis is denied. A rating in excess of 10 percent for a back disability prior to November 13, 2009 and in excess of 20 percent from November 13, 2009 is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs