Citation Nr: 1304380 Decision Date: 02/07/13 Archive Date: 02/19/13 DOCKET NO. 09-33 714 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased rating for a left knee disability, currently rated as 10 percent disabling. 2. Entitlement to an increased rating for a right knee disability, currently rated as 10 percent disabling. 3. Entitlement to an increased rating for lumbar strain, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. C. Dale, Counsel INTRODUCTION The Veteran had active duty service from February 1995 to January 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) in St. Petersburg, Florida. In her August 2009 substantive appeal, the Veteran requested a hearing. She withdrew her request in January 2010. The Veteran also perfected an appeal for service connection for migraines and an increased rating for scar, lateral aspect of the right breast. In February 2009, the RO awarded service connection and granted the maximum schedular rating for the scar. As this rating action results in a full grant of the benefits sought, these issues are no longer on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). A review of the Virtual VA paperless claims processing system does not show any pertinent records that are not already associated with the claims folder. FINDINGS OF FACT 1. The left knee patellofemoral syndrome is manifested by limitation of flexion to 130 degrees and normal extension without subluxation or instability. 2. The right knee patellofemoral syndrome is manifested by limitation of flexion to 130 degrees and normal extension without subluxation or instability. 3. The lumbar spine has not been manifested by forward flexion to 60 degrees, combined range of motion of 120 degrees or less, or muscle spasm and guarding severe enough to result in an abnormal gait or abnormal spinal contour. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5014, 5257, 5260, 5261 (2012). 2. The criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5014, 5257, 5260, 5261 (2012). 3. The criteria for a rating in excess of 10 percent for lumbar strain are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5014, 5237 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The United States Court of Appeals for Veteran Claims' (Court's) decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. This decision has since been replaced by Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the Court continued to recognize that typically a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In December 2007, a VCAA letter was issued to the Veteran with regard to her increased rating claims. It notified her of what information and evidence is needed to substantiate her claims for an increased rating, what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA, and what evidence is necessary to support a disability rating and effective date. The Board acknowledges a decision from the Court that provided additional guidance on the content of the notice that is required under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) in claims involving increase compensation benefits. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The Board points out that the U.S. Court of Appeals for the Federal Circuit reversed the Court's holding in Vazquez, to the extent the Court imposed a requirement that VA notify a Veteran of alternative diagnostic codes or potential "daily life" evidence. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In April 2009, the Veteran was issued a Vazquez letter, thus this constitutes proper notice. The duty to notify has been met. The Board also finds that VA has complied with all assistance provisions of VCAA. The evidence of record contains the Veteran's service treatment records and post-service treatment records. There is otherwise no indication of relevant, outstanding records which would support the Veteran's claims. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran underwent VA examinations in March 2009 pertaining to her claims. In August 2009, she reported that her service connected disabilities had increased in severity. Her statement is facially vague as to the nature and extent of increased symptomatology. There is no record of hospital or even outpatient treatment since the March 2009 VA examination reflecting ongoing, much less increased complaints regarding the knees and back. It would seem logical if disability increased significantly, the Veteran would have sought treatment. The Board does not find the claim of increased severity since the March 2009 VA examination to be convincing. Madden v. Brown, 125 F. 3d 1447, 1481 (Fed. Cir. 1997); (Holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence."); see Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Another VA examination is not warranted based upon the Veteran's August 2009 statements. For the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues on appeal. General laws and regulations Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (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 claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Board must consider a Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. 38 C.F.R. §§ 4.40, 4.45; see Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court interpreted these regulations in DeLuca v. Brown, 8 Vet. App. 202 (1995), and held that all complaints of pain, fatigability, etc., shall be considered when put forth by a veteran. In accordance, the Veteran's reports of pain will be considered in conjunction with the Board's review of the limitation of motion diagnostic codes. See also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). (i) Bilateral knee disability The Veteran is currently in receipt of a 10 percent disability rating for each knee, diagnosed as patellofemoral syndrome, and rated pursuant to Diagnostic Code (DC) 5260-5014. 38 C.F.R. § 4.71a, DC 5260-5014. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27 (2012). Here, the use of DCs 5260-5014 reflects that there is no diagnostic code specifically applicable to the Veteran's knee disability, and that this disability is rated by analogy to osteomalacia under DC 5014. See 38 C.F.R. § 4.20 (2012) (allowing for rating of unlisted condition by analogy to closely related disease or injury). For purposes of this decision, the normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Ratings for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, DC 5260. Ratings for limitation of extension of the knee are assigned as follows: extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, DC 5261. The Veteran's bilateral knee disability is rated as osteomalacia. For rating purposes, osteomalacia is rated as degenerative arthritis. Painful motion of a major joint or groups caused by degenerative arthritis, where the arthritis is established by X-ray, is also deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even though there is no actual limitation of motion. See 38 C.F.R. §§ 4.40, 4.59, 4.71a, DCs 5003, 5014; VAOPGCPREC 09-98 (August 14, 1998), citing Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). In addition to the limitation of motion diagnostic criteria, the rating schedule also includes ratings for subluxation or lateral instability of the knee. A 10 percent rating applies for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under DCs 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August 1998). Moreover, the General Counsel also held more recently that separate ratings under 38 C.F.R. § 4.71a, DC 5260 (limitation of flexion of the leg) and under DC 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 2004). For historical purposes, the Veteran was noted to have bilateral knee patellofemoral syndrome in 1997. She had pain and swelling in both knees. Private medical records, dated in January 2007, show that the Veteran sought medical attention for bilateral knee pain. It was exacerbated by activity. Clinical examination showed right knee inferior tenderness and left knee lateral and inferior tenderness. The examiner assessed joint pain and referred the Veteran to a physical therapy provider. The Veteran visited a private physical therapy clinic in March 2007. Her symptoms remained the same. Clinical examination showed both knees to have full extension and flexion. For both knees, McMurray's test was negative, but patellar mobility was hyper and tenderness was moderate. The examiner assessed bilateral patella tendonitis with tracking dysfunction and commented that the Veteran's rehabilitation potential was excellent. He recommended a physical therapy course of three times per week for a month, in addition to home exercises. In her April 2008 notice of disagreement, the Veteran stated that she was greatly restricted in performing many activities due to knee pain. She believed the physical therapy had not been beneficial. She left her job as a computer technician due to back and knee pain. In January 2009, the Veteran had an initial consultation with the VA primary care clinic. She complained about migraines and back pain. Clinical examination showed her joints to have a full range of motion without pain. The examiner did not provide a diagnosis for either knee. The Veteran had a VA knee examination in March 2009. She continued to have bilateral knee pain. Specifically, she endorsed having pain, stiffness, and decreased speed of motion. She denied giving way, instability, weakness, incoordination, subluxation, locking episodes, or effusion. She described having moderate flare-ups approximately once a week that lasted for one to two days. It was precipitated by increased activity. She was able to stand for up to 25 minutes and could walk up to a mile. Clinical examination reflected that she had a normal gait. The examiner found crepitus, tenderness, and guarding of both knees. However, instability was not observed, nor was any patellar or meniscus abnormalities. Left knee flexion was to 140 degrees with pain and right knee flexion was to 135 degrees with pain. There was objective evidence of pain following both initial and repetitive motions. However, there was not additional limitation of motion due to pain after three repetitions. Ankylosis was not present. Right knee flexion active motion was to 130 degrees limited by pain and left knee flexion active motion was to 135 degrees limited by pain. Extension active motion was to -5 limited by pain. The examiner continued the patellofemoral syndrome diagnosis for both knees. In May 2009, the Veteran reported that she had significant limitations in physical activities due to knee pain. She stated that knee pain interrupted her sleep. She made similar assertions in her August 2009 substantive appeal. The Veteran contends that increased ratings are warranted for her knee disabilities. The available clinical findings show minimal limitation in range of motion for both knees. See March 2009 VA examination report; January and March 2007 private medical records. These clinical findings do not approximate the criteria for compensable ratings under either DCs 5060 or 5261. VAOGCPREC 9-2004 (September 2004); 38 C.F.R. §§ 4.59, 4.71a, DCs 5003, 5260, and 5261. For DCs 5260 and 5261, the Board has considered 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206 -07. However, an increased rating for complaints about pain, excess fatigability, decreased functional ability, etc. is not warranted. As detailed, on examination in March 2009, with regard to both knees, pain was the major functional impact. Likewise, pain had an effect on functional impairment. Her functional impairment due to pain and weakness has been considered in the 10 percent disability rating for each knee. While acknowledging the effects on her daily activities reflected in the VA examination report of record, there is no basis for a higher rating based on additional functional loss due to pain, weakness, impaired endurance, fatigue, incoordination, or flare-ups. A separate rating is not warranted pursuant to Diagnostic Code 5257 as the VA examinations and treatment records do not reflect any symptoms of instability or subluxation. See March 2009 VA examination report; January and March 2007 private medical records; VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August 1998); 38 C.F.R. § 4.71a, DC 5257. In summary, a rating in excess of 10 percent or an additional separate rating is denied for both knees. 38 C.F.R. §§ 3.102, 4.40, 4.71a, DCs 5257, 5260, 5261. (ii) Low back disability The Veteran is currently in receipt of a 10 percent disability rating for lumbar strain pursuant to DC 5237-5014. 38 C.F.R. § 4.71a, DC 5237-5014. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27 (2012). Here, the use of DCs 5237-5014 reflects that there is no diagnostic code specifically applicable to the Veteran's back disability, and that this disability is rated by analogy to osteomalacia under DC 5014. See 38 C.F.R. § 4.20 (2012) (allowing for rating of unlisted condition by analogy to closely related disease or injury). The service connected lumbar strain is covered by The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). The General Rating Formula holds that for DCs 5235 to 5243 (unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome based on incapacitating episode) the following rating criteria: 40 percent rating: unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. 20 percent rating: 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 the combined range of motion of the cervical spine 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. 10 percent rating: forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 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. 38 C.F.R. § 4.71a, General Rating Formula, DCs 5235 to 5243. The General Rating Formula also include the following provisions: 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 DC 5003) 5243 Intervertebral disc syndrome. The Veteran is considered to have osteomalacia of the lumbar spine. Osteomalacia is rated as degenerative arthritis. Painful motion of a major joint or groups caused by degenerative arthritis, where the arthritis is established by X-ray, is also deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even though there is no actual limitation of motion. See 38 C.F.R. §§ 4.40, 4.59, 4.71a, DCs 5003, 5014; VAOPGCPREC 09-98 (August 14, 1998), citing Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). For historical purposes, the Veteran had back pain beginning in 1995. She described having occasional lumbar muscle spasms and was diagnosed with muscular low back pain. Private medical records, dated in March 2006 and January 2007, reflect that the Veteran sought medical attention for muscle spasms in her lumbar spine. She described pain radiating up her back, but denied any additional symptoms. In February 2008, she presented with similar low back symptoms. Clinical examination confirmed paravertebral muscle spasm and left lumbosacral tenderness. Flexion finger to ground was 6 inches and straight leg raising test was positive at 60 degrees, bilaterally. In her April 2008 notice of disagreement, the Veteran reported having constant back spasms that greatly impaired movement. She consistently used muscle relaxers and pain relief medications. She stated that she left her job due to knee and back pain. In January 2009, the Veteran had an initial consultation with the VA primary care clinic. She complained about migraines and back pain. It did not radiate. It was precipitated by physical activity. Clinical examination did not show tenderness upon palpation for the lumbar spine. The examiner observed her gait to be coordinated and smooth. Range of motion of the lumbar spine was within normal limits without pain. The examiner assessed lumbar muscle spasm controlled by current medication. The Veteran was afforded a March 2009 VA spine examination. She reported initially injuring her back in service while lifting a can of paint. She denied any associated neurological symptoms. She endorsed having low back stiffness, weakness, spasms, and pain. She described it as near constant and precipitated by activity. Upon clinical examination, the examiner observed a normal posture and gait. He did not find any abnormal spinal curvature. He noted bilateral spasm, right sided guarding, pain with motion, and tenderness. However, he commented that the spasm and guarding was not severe enough to be productive of an abnormal gait or spinal contour. Neurological examination was normal. Forward flexion was to 70 degrees and extension was full. Lateral flexion was to 25 degrees bilaterally. Rotation was to 30 degrees bilaterally. There was objective evidence of pain following both initial and repetitive motions. However, there was not additional limitation of motion due to pain after three repetitions. During active motion against gravity testing, forward flexion was to 60 degrees with pain beginning and ending at 70 degrees. Extension was to 25 degrees with pain beginning and ending 30 degrees. Bilateral lateral flexion was to 20 degrees with pain beginning and ending at 25 degrees. Bilateral lateral rotation was to 25 degrees with pain beginning and ending at 30 degrees. The examiner cited facial grimacing as evidence of pain. He continued the lumbar strain diagnosis. The objective findings on clinical examination show the low back to have more nearly approximated the assigned 10 percent rating, even taking into consideration functional loss due to pain. 38 C.F.R. § 4.59. Although she has painful motion, she has demonstrated forward flexion to 70 degrees, albeit with pain. Her muscle spasms are not demonstrated to result in an abnormal gait or spinal contour. Her combined range of thoracolumbar motion is well over 120 degrees. In short, the record does not show that her back disability approximates the criteria for a 20 percent rating under DC 5237. 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5237. For DC 5237, the Board has considered 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206 -07. However, an increased rating for complaints about pain, excess fatigability, decreased functional ability, etc. is not warranted. As detailed, on examination in March 2009, with regard to her lumbar spine, pain was the major functional impact. Likewise, pain had an effect on functional impairment. Her functional impairment due to pain and weakness has been considered in the 10 percent disability rating for lumbar strain. While acknowledging the effects on her daily activities reflected in the VA examination report of record, there is no basis for a higher rating based on additional functional loss due to pain, weakness, impaired endurance, fatigue, incoordination, or flare-ups. The Veteran does not have intervertebral disc syndrome or associated neurological manifestations of lumbar strain. Hence, ratings based upon incapacitating episodes or neurological manifestations are not for current consideration. 38 C.F.R. § 4.71a, DC 5237, Note 1, DC 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. As with the knees, there is no convincing evidence of flare-ups reflecting significantly increased disability. Treatment records do not reflect a spike in symptoms warranting an increased rating. Extraschedular considerations The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board finds that the severity of the Veteran's service-connected bilateral knee and low back disabilities are fully contemplated by the rating criteria. They are productive of pain, tenderness, and reduced motion. There is nothing exceptional about them. The degree of disability exhibited is contemplated by the rating schedule. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. 38 C.F.R. § 4.16(b); Thun v. Peake, 22 Vet. App. 111 (2008). Total disability based upon individual unemployability (TDIU) A request for a TDIU whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. In this instance, the record shows that the Veteran was gainfully employed for part of the claims period. It is unclear if she is currently employed. In April 2008, the Veteran reported that she left her job due to bilateral knee and back pain. However, subsequent clinical findings and examiner's comments from the March 2009 VA examination do not show that these disabilities are of a severity as to wholly preclude employment as a bank computer technician. In light of the inconsistency with the additional evidence of record, the Board does not consider her April 2008 assertion of unemployability credible. Madden, 125 F. 3d at 1481; Cartwright, 2 Vet. App. at 25. TDIU is not further consideration. ORDER A rating in excess of 10 percent for a left knee disability is denied. A rating in excess of 10 percent for a right knee disability is denied. A rating in excess of 10 percent for a low back disability is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs