Citation Nr: 1305152 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 05-19 207 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a rating in excess of 10 percent for degenerative joint disease (DJD) of the lumbar spine prior to April 14, 2011, and in excess of 20 percent thereafter. 2. Entitlement to a rating in excess of 10 percent for DJD of the right hip. 3. Entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome and chondromalacia. 4. Entitlement to a compensable rating for status post right knee arthroscopy prior to February 4, 2005, and in excess of 10 percent thereafter. (The issue of entitlement to service connection for sensory peripheral neuropathy in the lower extremities, to include as secondary to a service-connected low back disability, will be addressed in a separate Board decision). REPRESENTATION Veteran represented by: Kathy A. Lieberman, Attorney ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran had active service from June 1979 to June 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. In a May 2008 decision, the Board, inter alia, denied service connection for DJD of the lumbar spine, DJD of the right hip, left knee patellofemoral syndrome and chondromalacia, and status post right knee arthroscopy. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a January 2009 Joint Motion for Partial Remand, the Court vacated the Board's decision in February 2009 and remanded the case for compliance with the terms of the Joint Motion. In September 2009, the Board remanded the claims to the RO, via the Appeals Management Center in Washington, DC, to obtain VA medical center treatment records and to afford the Veteran appropriate VA examinations. The requested treatment records have been associated with the claims file, and in April 2011, the requested VA examinations were performed. As such, the Board finds that there has been substantial compliance with the requirements articulated in the Board's prior remand instructions. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). During the course of the appeal, in July 2005, the RO increased the disability evaluation for the Veteran's right knee disability to 10 percent disabling, effective February 4, 2005. In January 2012, the RO increased the disability evaluation for the Veteran's lumbar spine disability to 20 percent disabling, effective April 14, 2011. However, inasmuch as higher ratings are available for these disabilities, and the Veteran is presumed to seek the maximum available benefit for a disability, the claims for higher ratings remain viable on appeal. Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). In reviewing the Veteran's appeal for increased ratings, the Board has not overlooked the recent holding of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that claims for higher evaluations also include a claim for a total rating based on individual unemployability (TDIU) when the appellant claims he is unable to work due to a service connected disability). However, the Board notes that in an April 2008 statement, the Veteran specifically stated that he did not want to establish TDIU as an issue. As such, the Board finds that Rice is not applicable to the current appeal because the Veteran has specifically indicated that he does not want TDIU to be an issue. See Rice, 22 Vet. App. 447, citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). Therefore, the Board finds that the current decision need not consider whether the Veteran meets the criteria for entitlement to TDIU. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claims. A review of the documents in the electronic file to date reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal that the Board is adjudicating in this decision. The Board notes that a separate decision is being issued with respect to claim of entitlement to service connection for peripheral neuropathy of the lower extremities. This separate decision is necessary because the Veteran has separate legal representation concerning that issue. The issue of entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome and chondromalacia is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. Throughout the period of appeal, the Veteran's service-connected DJD of the lumbar spine has been manifested primarily by pain and forward flexion of 60 degrees or less, but the limitation of motion did not more nearly approximate severe, the intervertebral disc syndrome did not more nearly approximate severe than moderate, and neither loss of lateral spine motion, listing of the whole spine to the opposite side, positive Goldthwaite's sign, abnormal mobility on forced motion, nor ankylosis was present. 2. Throughout the period of appeal, the Veteran's DJD of the right hip has been manifested by limitation of motion; limitation of flexion that more nearly approximated limitation to 30 degrees than limitation to 45 degrees was not shown, nor has limitation of abduction motion beyond 10 degrees been shown. 3. Throughout the period of appeal, the Veteran's status post right knee arthroscopy has been manifested by flexion to 104 degrees and extension to 11 degrees; ankylosis, moderate recurrent subluxation or lateral instability, dislocated semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum were not shown. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 20 percent, but no higher, for service-connected DJD of the lumbar spine have been met throughout the appeal period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5292, 5294, 5295 (2003); 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.40, 4.45, Diagnostic Codes 5235-5243 (2012). 2. The criteria for a disability rating in excess of 10 percent for DJD of the right hip have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5252, 5253 (2012). 3. The criteria for a disability rating of 10 percent, but not higher, for status post right knee arthroscopy has been met throughout the appeal period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.68, 4.71a, Diagnostic Codes 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist In correspondence dated in March 2001 and July 2005, and September 2005, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claims; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The July 2005 and September 2005 letters informed the Veteran that in order to establish a higher rating, the evidence would need to show that his disabilities had increased in severity. He was informed of the type of evidence that could be submitted to support his claims. Additionally, a March 2006 letter notified the Veteran of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claims were subsequently readjudicated in an April 2012 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (noting that VA cured its failure to afford statutory notice to the claimant prior to an initial rating decision by issuing a notification letter after the decision, readjudicating the claim, and notifying the claimant of such readjudication in the statement of the case). Specifically as the claims related to the spine and right hip, the Board notes that since the claims are appeals of initial ratings, fully satisfactory notice was delivered after they were adjudicated. However, the RO subsequently readjudicated the claims based on all the evidence in various supplemental statements of the case issued, most recently issued in April 2012. The Veteran was able to participate effectively in the processing of his claims. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claims would have been different had complete notice been provided at an earlier time. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records have been associated with the claims file. All identified and available treatment records have been secured. As the Board will discuss in detail in its analysis below, the Veteran was provided with multiple VA examinations throughout the appeal period. The reports of these examinations reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, and provided sufficient findings to evaluate the Veteran's disabilities. Additionally, the Veteran has not stated nor is there evidence indicating that there has been a material change in the severity of any of his disabilities decided herein since he was last examined in April 2011. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). The Board concludes that the examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 CF.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has declined the opportunity to present testimony before a Veterans Law Judge. Therefore, the duties to notify and assist have been met. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). An appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2012). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2012). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2012). For the purpose of rating disability from arthritis, the spine is considered a major joint. 38 C.F.R. § 4.45 (2012). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2012). Traumatic arthritis is rated using Diagnostic Code 5010, which directs that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Diagnostic Code 5003 (2012). 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2012). It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). Lumbar Spine The regulations for rating disabilities of the spine were twice revised during the pendency of the Veteran's appeal, effective September 23, 2002, and effective September 26, 2003. 67 Fed. Reg. 54345 (Aug. 22, 2002); 68 Fed. Reg. 51454 (Aug. 27, 2003). VA's Office of General Counsel has determined that the amended rating criteria can be applied only for periods from and after the effective date of the regulatory change. The Board can apply only the prior regulation to rate the Veteran's disability for periods preceding the effective date of the regulatory change. VAOPGCPREC 3-00 (Apr. 10, 2000), 65 Fed. Reg. 33422 (2000). The Board has evaluated the Veteran's back disorder under multiple diagnostic codes to determine if there is any basis to increase the assigned rating. Such evaluations involve consideration of the level of impairment of a veteran's ability to engage in ordinary activities, to include employment, as well as an assessment of the effect of pain on those activities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2012). Prior to September 26, 2003, a 10 percent rating was warranted for slight limitation of motion of the lumbar spine, 20 percent rating was warranted for moderate limitation of motion of the lumbar spine, and a 40 percent rating was warranted for severe limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2002). Prior to September 26, 2003, a 10 percent rating was warranted for lumbosacral strain with characteristic pain on motion. A 20 percent rating was warranted for lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position. A 40 percent rating was warranted for lumbosacral strain that was severe, with listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, and narrowing or irregularity of the joint space; a 40 percent evaluation was also warranted when only some of those symptoms were present if there was also abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2002). Prior to September 23, 2002, intervertebral disc syndrome warranted a 10 percent rating when it was mild. It warranted a 20 percent rating when it was moderate, with recurrent attacks. A 40 percent rating was warranted for severe intervertebral disc syndrome, with recurring attacks with intermittent relief. A 60 percent rating was warranted when the intervertebral disc syndrome was pronounced, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, intermittent relief. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2001). Since Diagnostic Code 5293 contemplates limitation of motion, a separate rating for limitation of motion cannot be warranted. VAOPGCPREC 36-97 (Dec. 12, 1997), 63 Fed. Reg. 31262 (1998). Effective September 23, 2002, the rating criteria for evaluation of intervertebral disc syndrome were amended to evaluate the disorder either on the total duration of incapacitating episodes resulting from intervertebral disc syndrome over the past 12 months, or by combining under 38 C.F.R. § 4.25 separate evaluations of its chronic orthopedic and neurological manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. A 10 percent rating was warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A rating of 20 percent was warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A rating of 40 percent was warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of least four weeks but less than six weeks during the past 12 months. Finally, a rating of 60 percent was warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least six weeks during the past 12 months. This regulation was again slightly revised in September 2003. Effective September 26, 2003, the regulations for rating disabilities of the spine were revised, and the diagnostic codes were reclassified. These reclassified diagnostic codes include 5237 (lumbosacral strain) and 5243 (intervertebral disc syndrome). 68 Fed. Reg. 51454 (Aug. 27, 2003). The code for intervertebral disc syndrome (DIAGNOSTIC CODE 5243), permits evaluation under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Codes 5237, 5242, 5243 (2012). The September 2003 regulation revisions set forth a General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease as follows: Unfavorable ankylosis of the entire spine (100 percent); Unfavorable ankylosis of the entire thoracolumbar spine (50 percent); Unfavorable ankylosis of the entire cervical spine, or forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine (40 percent); For forward flexion of the cervical spine to 15 degrees or less, or favorable ankylosis of the entire cervical spine (30 percent); For forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or 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 (20 percent); For forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height (10 percent). 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, 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. Normal combined range of motion of the thoracolumbar spine is 240 degrees. Normal ranges of motion for each component of spinal motion provided are the maximum usable for calculating the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2 (2012). It has not been contended or shown in this case that the Veteran has demonstrable deformity of a vertebral body (Diagnostic Code 5285), complete bony fixation of the spine (Diagnostic Code 5286), or ankylosis of the lumbar spine (Diagnostic Code 5289). Accordingly, the diagnostic codes pertaining to these disabilities are not applicable in the instant case. The evidence includes an August 2000 letter from R.A., M.D., reflecting that the Veteran experienced pain in his low back. Dr. A. observed lumbosacral myositis with multiple tender points and sacroiliitis. Dr. A. noted that an X-ray revealed a straightening of the spine secondary to muscle spasms and marginal osteophytes at L3-L5 interiorly. The assessment given was osteoarthritis and sacroiliitis. On VA compensation and pension examination in March 2001, the Veteran reported a low back pain that was described as mild. He mentioned that when he walked a lot the pain became moderate to severe. No fecal or urinary incontinence was reported. The Veteran related that he had good pain control while taking Relafen. It was noted that during the previous year there were no visits to the emergency room due to low back pain, although he had been treated twice by a rheumatologist. Flare-ups were reported after walking a lot, and going up and down stairs. The Veteran alleviated his flare-ups with medications and bedrest. He reported three episodes of severe pain during the previous year. The examiner noted that the Veteran did not need to use crutches, braces, or a cane to walk. On evaluation, the Veteran demonstrated forward flexion of the lumbar spine to 60 degrees, backward extension, to 15 degrees, lateral flexion to 35 degrees bilaterally, and rotation to 35 degrees bilaterally. The examiner found no objective evidence of painful motion on all movements of the lumbar spine, although there was a mild lumbar paravertebral muscle spasm and mild tenderness to palpation on the lumbar area. The examiner further found no postural abnormalities or fixed deformities of the back. It was noted that the Veteran had a normal gait. The examiner further noted that the Veteran was observed going to check in at the clinic walking quickly and without problems, but when the Veteran entered the examiner's office, he limped. In an October 2001 letter, Dr. A. reported that the Veteran experienced tightness in his lower back with irradiation of pain to the legs. Dr. A. indicated that the Veteran walked with a limp and had lumbosacral myositis. A private MRI taken in April 2004 revealed mild diffuse disc bulges with early degenerative changes without evidence of stenosis or neural foramina narrowing. A July 2004 letter from Dr. A. reflects that the Veteran experienced low back pain. Lumbosacral myositis was observed. A private MRI taken in March 2005 revealed degenerative disc changes at L5-S1 with bulging of the annulus fibroses. On VA examination in March 2005, the Veteran reported experiencing pain in his lumbosacral area that had an intensity of a 6 on a 0 (low) to 10 (high) pain scale. He took Ultracet for mild relief. He reported weekly flare-ups that rated a 9 on the same pain scale. He relieved his flare-ups with medications and hot showers. No numbness, bladder complaints, or erectile dysfunction was reported. The Veteran used a one-point cane to walk. Forward flexion of the thoracolumbar spine was to 70 degrees with pain from 30 to 70 degrees. Extension was to 30 degrees with pain from 20 to 30 degrees. Lateral flexion was to 30 degrees bilaterally with pain from 20 to 30 degrees. Lateral rotation was to 30 degrees bilaterally with pain from 20 to 30 degrees. Repetitive motion produced pain but no weakness, lack of endurance, or fatigue. The examiner found no evidence of reversed lordosis, abnormal kyphosis, or scoliosis. No ankylosis was observed. Sensory examination was intact for both lower extremities. The examiner further noted that the Veteran denied being hospitalized during the previous year due to lumbosacral pain. On VA examination in January 2010, the Veteran reported experiencing weakness and difficulty walking. He reported that he had not received any current treatment or physical therapy. He took Naproxen and Tramadol twice a day. The examiner noted a history of leg or foot weakness, numbness, and unsteadiness, but no urinary incontinence, nocturia, or erectile dysfunction. The Veteran reported experiencing constant moderate daily pain that radiated to his lower extremities. The Veteran stated that he experienced weekly flare-ups that would last for hours. The Veteran reported experiencing two weeks of incapacitating episodes over the prior 12 months. The examiner indicated that the Veteran's posture was normal. No gibbous, kyphosis, lumbar lordosis, scoliosis, or ankylosis was observed. The examiner noted lumbar flattening, spasm, tenderness, and pain with motion. The examiner opined that the muscle spasm and tenderness was severe enough to be responsible for an abnormal gait or abnormal spinal contour. No atrophy, guarding, or weakness was objectively observed. Sensory examination was normal to pain and light touch. Forward flexion of the thoracolumbar spine was to 60 degrees. Left lateral flexion was to 15 degrees. Right lateral flexion was to 10 degrees. Left lateral rotation was to 25 degrees. Right lateral rotation was to 15 degrees. No additional limitations were noted after multiple repetitions. The examiner reviewed the electrodiagnostic tests and said there was no evidence of radiculopathy or neuropathy. On VA examination in April 2011, the Veteran reported that he used a brace. He said that he was treated with Tramadol, Meloxicam, and Flexeril. There was no history of urinary incontinence, urgency, or retention requiring catheterization. The Veteran stated that he experienced urinary frequency, erectile dysfunction, and numbness. The examiner observed that the Veteran's posture was normal, although the Veteran walked with an antalgic gait. The examiner wrote that the Veteran did not use an assistive device to walk that day. Although there was lumbar flattening, the examiner found no kyphosis, gibbous, lumbar lordosis, reverse lordosis, scoliosis, or ankylosis. Spasm, guarding, pain, and tenderness were present. The examiner felt that the muscle spasm and tenderness were severe enough to be responsible for an abnormal gait or abnormal spinal contour. On evaluation, forward flexion of the thoracolumbar spine was to 53 degrees, extension was to 21 degrees, left lateral flexion was to 21 degrees, and left lateral rotation, right lateral flexion, and right lateral rotation were to 20 degrees each. Pain was elicited on all ranges of motion. After repetitive motion, forward flexion was to 47 degrees, extension was to 17 degrees, left lateral flexion and rotation were each to 18 degrees, right lateral flexion was to 21 degrees, and right lateral rotation was to 20 degrees. Sensory examination was normal to vibration, position sense, pain or pinprick, and light touch. An electrodiagnostic study revealed no evidence of active lumbar radiculopathy. Based on the evidence of record, the Board finds that a rating of 20 percent, but no higher, is warranted throughout the entire period of appeal. Under the old schedular criteria of Diagnostic Code 5292, a higher rating of 20 percent was warranted for moderate limitation of motion of the lumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5292. On VA examination in March 2001, the Veteran demonstrated forward flexion of the lumbar spine to 60 degrees, backward extension, to 15 degrees, lateral flexion to 35 degrees bilaterally, and rotation to 35 degrees bilaterally. At the March 2005 VA examination, he was shown to have forward flexion of the thoracolumbar spine to 70 degrees, extension to 30 degrees, lateral flexion to 30 degrees bilaterally, and lateral rotation to 30 degrees bilaterally. In January 2010, the Veteran demonstrated forward flexion of the thoracolumbar spine to 60 degrees, left lateral flexion to 15 degrees, right lateral flexion to 10 degrees, left lateral rotation to 25 degrees, right lateral rotation to 15 degrees. Most recently, in April 2011, range of motion was forward flexion of the thoracolumbar spine to 53 degrees, extension to 21 degrees, left lateral flexion to 21 degrees, and left lateral rotation, right lateral flexion, and right lateral rotation to 20 degrees each. Based upon the ranges of motion recorded at the above examinations, the Board finds that the Veteran's range of motion warrants a higher rating of 20 percent, but not more, as he has demonstrated no more than moderate limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2002). Under the more specific numerical criteria found under the revised spinal regulations, the Veteran's lumbar spine disability fails to satisfy the requirements for a rating in excess of 20 percent. According to the new regulations, his ranges of motion do not meet the requirements for a higher rating of 40 percent: forward flexion of the thoracolumbar spine to 30 degrees or less. Nor has he demonstrated favorable ankylosis of the entire thoracolumbar spine. See 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). Thus, the new schedular criteria of Diagnostic Code 5237 cannot serve as a basis for a rating in excess of 20 percent. When rated under the diagnostic code for lumbosacral strain, the Veteran's low back disability fails to satisfy the qualitative criteria for a rating higher than 20 percent under the old version, as well as under the new version. Compare 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2002) with 38 C.F.R. § 4.71a, Diagnostic Code 5237, General Rating Formula for Diseases and Injuries of the Spine (2012). Under the old schedular criteria of Diagnostic Code 5295, a higher rating of a 40 percent rating was warranted for lumbosacral strain that was severe, with listing of the whole spine to the opposite side, a positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, and narrowing or irregularity of the joint space; or when only some of those symptoms were present if there was also abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2002). However, based on the evidence cited above, there is no indication that the Veteran meets any of the criteria set forth for a higher rating of 40 percent under the old criteria of Diagnostic Code 5295. Under the new schedular criteria, the Veteran does not meet the criteria for a higher rating of 40 percent, as discussed immediately above. In evaluating whether Diagnostic Code 5293, the code pertaining to intervertebral disc syndrome, would entitle the Veteran to a higher rating, the Board notes that none of the findings outline above demonstrate severe intervertebral disc syndrome, with recurring attacks with intermittent relief. The Veteran's description of the severity and duration of his symptoms is noted, but the medical evidence shows that his low back disability was only moderately disabling. As previously discussed, with pain, he still demonstrated lumbar motion to 47 degrees, and the VA examination reports show that the service-connected low back disability was primarily productive of only pain. The Veteran is, thus, not entitled to a rating in excess of 20 percent for his low back disability under the criteria of Diagnostic Code 5293, as in effect prior to September 23, 2002. The rating criteria for limitation of motion and lumbosacral strain did not change between September 23, 2002 and September 26, 2003. However, as noted above, the code relating to IDS was amended, effective September 23, 2002. After September 23, 2002, and prior to September 26, 2003, IDS could be rated either on the basis of the total duration of incapacitating episodes over the past 12 months or by combining under 38 C.F.R. § 4.25 separate evaluations of its chronic orthopedic and neurological manifestations, along with evaluations for all other disabilities, whichever method results in the higher evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2003 and 2004). Under this code, a rating of 20 percent was warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months incapacitating episodes were defined as requiring bed rest prescribed by a physician and treatment by a physician. Although the Veteran has asserted that he had to take weeks off from work due to back pain, the record does not contain prescriptions for bedrest from a physician for this time period. As noted above, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes defines an incapacitating episode as 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 (emphasis added). As such, there is no basis to assign a rating in excess of the current 20 percent rating under this version of this diagnostic code. A September 2003 revision to the IDS code stated that IDS (pre-operatively or post-operatively) is to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under §4.25. For purposes of evaluation under Diagnostic Code 5243, "[c]hronic orthopedic and neurological manifestations" means orthopedic and neurological signs and symptoms resulting from IDS that are present constantly, or nearly so. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1 (2003-04). Orthopedic disabilities are rated using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Similarly, neurological disabilities are rated separately using criteria for the most appropriate neurological diagnostic code or codes. Id., at Note 2. It has been determined in this case that there is no evidence of incapacitating episodes as defined under Diagnostic Code 5293 or the General Rating Formula for Diseases and Injuries of the Spine (in effect from September 23, 2002 to September 26, 2003, and from September 26, 2003 through the present, respectively). Therefore, it is necessary to determine whether the Veteran may be entitled to a higher rating if chronic orthopedic and neurological manifestations are evaluated separately and combined with all other disabilities. Turning first to the orthopedic manifestations, the Board refers to the range of motion set forth above. Taken together, these ranges of motion do not warrant a rating in excess of a 20 percent evaluation under the general rating formula. The requirements for a higher rating under the general rating formula - forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine - are not demonstrated. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120 (2012). Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123 (2012). Diagnostic Code 8520 provides the rating criteria for paralysis of the sciatic nerve, and therefore neuritis and neuralgia of that nerve. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Disability ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis which is mild, moderate or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Diagnostic Code 8620 refers to neuritis of the sciatic nerve, and DC 8720 refers to neuralgia of the sciatic nerve. The question before the Board, then, is whether the Veteran is entitled to a separate rating for his neurological manifestations. The Board acknowledges that the Veteran has complained of pain radiating into his lower extremities; however, the medical evidence of record has consistently shown no neurological abnormality was present attributable to the service-connected low back disorder. Accordingly, the Board finds that the Veteran is not entitled to a separate rating for neurological manifestations. Consideration has been given to the provisions of 38 C.F.R. §§ 4.40 and 4.45. The relevant evidence includes the March 2005 examination report, which showed that repetitive motion produced pain but no weakness, lack of endurance, or fatigue. On range of motion testing in January 2010, the Veteran did not demonstrate additional limitation after multiple repetitions. In April 2011, on repetitive testing, the Veteran's range of motion decreased: forward flexion was to 47 degrees (from 53 degrees), extension was to 17 degrees (from 21 degrees), left lateral flexion was to 18 degrees (from 21 degrees), left lateral rotation was to 18 degrees (from 20 degrees), right lateral flexion was to 21 degrees (from 20 degrees), and right lateral rotation was to 20 degrees (from 20 degrees). Additionally, there was pain elicited on all ranges of motion. Although the Board is required to consider the effect of pain when making a rating determination, which has been done in this case, it is important to emphasize that the rating schedule does not provide a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). Additionally, taking into account the additional loss of motion noted in April 2011, the Board finds that such loss of range of motion is insufficient to warrant a higher evaluation which contemplates limitation of flexion of the knee to 30 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2011). Thus, even when considering the Veteran's complaints of pain and the additional loss of range of motion as noted herein, the criteria for a higher rating based on the Veteran's range of motion for the spine (forward flexion of the thoracolumbar spine is 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine) are not approximated and a higher evaluation is not warranted on this basis. In sum, the Board further finds that, since the effective date of service connection, the Veteran's lumbar spine disability was 20 percent disabling. Fenderson, supra. Right Hip The Veteran's right hip disorder is rated at 10 percent effective October 18, 2000 (the initial effective date of service connection), under Diagnostic Codes 5252-5253. Limitation of hip motion is rated under Diagnostic Codes 5251, 5252, and 5253 (and 5250 if there is ankylosis, 5254 if there is flail joint of the hips and 5255 if there is impairment of the femur, none of which are shown here). Under Diagnostic Code 5251 (for limitation of thigh extension), a maximum 10 percent rating is warranted where extension is limited to 5 degrees. 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5252 (for limitation of flexion), a 10 percent rating is warranted where limitation is to 45 degrees; a 20 percent rating is warranted where the limitation is to 30 degrees, a 30 percent rating is warranted where the limitation is to 20 degrees; and a 40 percent rating is warranted where the limitation is to 10 degrees. 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5253 (for thigh impairment), a 10 percent rating is warranted when there is limitation of rotation of the thigh, cannot toe-out more than 15 degrees in the affected leg, or where there is limitation of abduction to the point that the legs cannot be crossed. A maximum 20 percent evaluation is warranted where there is limitation of abduction, motion lost beyond 10 degrees. 38 C.F.R. § 4.71a (2012). For purposes of VA compensation, normal range of flexion of the hip is from 0 degrees to 125 degrees, and normal abduction is from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II (2012). An August 2000 letter from R.A., M.D., reflects that the Veteran had pain in his right hip. On VA joints examination in March 2001, the Veteran complained of a moderate posterior right hip pain. He stated that the pain radiated, and his pain was precipitated by walking and sitting for more than 30 minutes. The examiner found no constitutional symptoms for inflammatory arthritis. Flexion of the right hip was to 80 degrees. At one point, the examiner indicated that extension was to 5 degrees; however, at another point, the examiner remarked that extension was to minus 10 degrees. Internal and external rotation were each to 20 degrees. Abduction was to 30 degrees. Adduction was to 20 degrees. The examiner noted that there was no objective evidence of painful motion. No ankylosis was observed, and the Veteran walked with a normal gait. An October 2001 letter from R.A., M.D., reflects that the Veteran had osteoarthritis of the right hip joint with post traumatic soft tissue calcification. A July 2004 letter from Dr. A. reflects that the Veteran experienced hip pain. An X-ray of the right hip performed at a VA facility in February 2005 revealed a prominent right hip spur. On VA joint examination in February 2005, the Veteran complained of pain in his right hip. He reported that he was treated with Ultracet and Skelaxin. It was noted that the Veteran used a one-point cane for ambulation. Right hip flexion was from 0 to 100 degrees, with pain from 60 to 100 degrees. Right hip extension was from 0 to 30 degrees, with pain from 10 to 30 degrees. Adduction was from 0 to 20 degrees, with pain from 10 to 20 degrees. Abduction was from 0 to 45 degrees, with pain from 30 to 45 degrees. External rotation was from 0 to 60 degrees, with pain from 40 to 60 degrees. Internal rotation was from 0 to 40 degrees, with pain from 10 to 40 degrees. The examiner found no ankylosis or leg length discrepancy. On VA joint examination in October 2005, the Veteran reported experiencing pain that rated a 6 on a 0 (low) to 10 (high) pain scale. He said he experienced flare-ups that rated a 9 on the same scale every week. Right hip flexion was to 125 degrees with pain at 115 degrees. Extension was to 30 degrees with pain at 20 degrees. Adduction was to 25 degrees with pain at 15 degrees. Abduction was to 45 degrees with pain at 35 degrees. External rotation was to 40 degrees with pain at 30 degrees. The examiner found that the hip area did not show any evidence of edema, effusion, or redness. No ankylosis or leg length discrepancy was found. On VA joint examination in April 2011, the Veteran reported that he treated his pain with Tramadol, Meloxicam, and Flexeril. The examiner found no instability, deformity, or giving way of the right hip. Pain, stiffness, and weakness were noted. The Veteran reported experiencing severe daily flare-ups that lasted for an unspecified number of minutes. Right hip flexion was to 105 degrees. Extension was to 15 degrees. Abduction was to 33 degrees. The examiner found objective evidence of pain but no additional limitations on the ranges of motion after repetitive movement. Additionally, the Veteran was observed to be able to cross his right leg over his left, and he could move his toes out to an angle greater than 15 degrees. Diagnostic Code 5252 provides a 20 percent rating for flexion limited to 30 degrees. In this case, even after consideration of pain and flare-ups, the Veteran's right hip flexion is too great to warrant a 20 percent rating. The Veteran's lowest recorded flexion, even with consideration of pain, is 60 degrees. The Board recognizes that the March 2001 VA examiner indicated that extension of the right hip was to 5 degrees; however, at another point, the examiner remarked that extension was to minus 10 degrees. As these findings are contradictory, they are not adequate for rating purposes. Adequate extension ranges of motion were recorded in each of the other VA examination reports of record. See 38 C.F.R. 4.71a, Diagnostic Code § 5251 (2012). Each of them reflect that there was no compensable limitation or extension. Additionally, there is no evidence of ankylosis, flail joint, impairment of the femur, fracture, or malunion, as such, no alternative rating codes pertaining to the hip are available. See 38 C.F.R. 4.71a, Diagnostic Codes §§ 5250, 5254, 5255 (2012). Additionally, the Veteran has not demonstrated limitation of abduction of motion lost beyond degrees to warrant a 20 percent evaluation under Diagnostic 5253. Consequently, a rating in excess of 10 percent is not warranted. In light of all the evidence, a disability rating in excess of 10 percent is not warranted for the right hip disability. Right Knee The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOGCPREC 23-97 (July 1, 1997); VAOGCPREC 9-98 (August 14, 1998). The VA General Counsel has also held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 17, 2004). Knee impairment with recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight; a 20 percent evaluation if it is moderate; or a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). Limitation of flexion of the knee warrants a noncompensable rating if flexion is limited to 60 degrees; a 10 percent rating if flexion is limited to 45 degrees; and a 20 percent rating if flexion is limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Limitation of extension of the knee warrants a noncompensable rating if extension is limited to five degrees; a 10 percent rating if extension is limited to 10 degrees; and a 20 percent rating if extension is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2012). The removal of semilunar cartilage warrants a 10 percent rating if it is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2012). On VA examination in October 1998, the Veteran reported experiencing moderate pain in his right knee. He said that the pain would occasionally radiate to his ankle and lower back. It was noted that the Veteran did not need to use crutches, a brace, a cane, or corrective shoes to walk. The examiner specified that there were no episodes of dislocation or recurrent subluxation. Flexion of the right knee was to 140 degrees. Extension was to 0 degrees. The examiner found no painful motion of the right knee. No ankylosis was present. An X-ray yielded normal findings. An August 2000 letter from R.A., M.D., reflects that the Veteran had pain in his right knee. Dr. A. observed crepitus in the right knee, and there was mediolateral laxity of a mild degree. On VA examination in March 2001, the Veteran reported experiencing pain around his right knee joint that he described as severe. It was noted that the Veteran did not need to use crutches, a brace, a cane, or corrective shoes to walk. The examiner specified that there were no episodes of dislocation or recurrent subluxation of the right knee. Flexion of the right knee was to 110 degrees. Extension was to minus 10 degrees. The examiner noted that while the Veteran was sitting on the office stretcher, he bent to a greater extent, and while testing for manual muscle strength, the Veteran extended completely with a pain-free expression on his face. The examiner indicated that there was no objective evidence of painful motion. There was no objective evidence of edema, effusion, weakness, redness, or heat. The examiner specified that instability could not be checked well, as the Veteran was putting resistance towards examination and manipulation upon valgus and varus stress. Visually, there was no dislocation. No ankylosis was observed. The examiner remarked that the Veteran walked with a normal gait. In an October 2001 letter, R.A., M.D., wrote that the Veteran had multiple episodes of pain in his knees, and his knees would give out frequently. He indicated that the Veteran walked with a limp. He specified that the Veteran had mediolateral laxity of the right knee and small effusion. In a July 2004 letter, Dr. A. recorded the Veteran's sensations of buckling and instability of the knee. Dr. Z. indicated that the Veteran had a right knee medio lateral laxity, knee effusion, and Bakers cyst. On VA examination in February 2005, the Veteran complained of left knee pain that rated a 7 on a 0 (low) to 10 (high) basis. He said that his pain was accompanied by weakness, stiffness, swelling, fatigability, and a lack of endurance. He reported flare-ups that rated a 10 on the same pain scale. It was noted that the Veteran used a one-point cane for ambulation. The examiner found no episodes of dislocation or recurrent subluxation. Right knee forward flexion was to 120 degrees with pain at 100 degrees. Extension was to 0 degrees with pain in the last 10 degrees. The examiner specified that the instability tests for varus-valgus and anterior-posterior cruciate ligaments were negative for the right knee. On VA examination in April 2011, it was noted that the Veteran experienced giving way, pain, stiffness, weakness, and crepitation in his right knee. He reported episodes of locking on a weekly basis. No deformity, instability, or incoordination were noted. Daily episodes of dislocation or subluxation were reported. The Veteran reported weekly, severe flare-ups. He used a cane and walked with an antalgic gate. The examiner found subpatellar tenderness. The examiner did not objectively observe instability. No dislocation or abnormal tendons were observed. Right knee flexion was to 104 degrees. Extension was limited by 11 degrees. There was objective evidence of pain following repetitive motion. No ankylosis was present. Based on the Veteran's subjective complaints of pain and giving way throughout the appeal period, the Board finds that his disability is commensurate with mild instability to warrant a rating of 10 percent, but no higher, throughout the entire period of appeal for the Veteran's right knee disability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). However, a higher evaluation is not warranted as he has not demonstrated moderate instability. As reviewed above, none of the records reveal findings of ankylosis, dislocation, impairment of the tibia and fibula, or genu recurvatum. Although the August 2000 and October 2001 letters from Dr. A. contain the Veteran's self-report that his right knee would give out frequently, these reports do not appear to objectively confirm the Veteran's self-report through independent observations or actual testing of the right knee. Significantly, the October 1998, March 2001, February 2005, and April 2011 VA examiners indicated that there was no laxity or subluxation. The Board finds that the VA examination reports all outweigh the Veteran's self-report of instability, as the VA report was prepared by an objective medical professional with no personal interest in the claim. The Board further finds that the VA examination reports outweigh the letters from Dr. A., as it appears that the VA examiners actually conducted laxity testing. Concerning the Veteran's statements, the Board recognizes that that personal interest may affect the credibility of the evidence. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). As such, a separate compensable rating is not warranted at any time throughout the period of appeal for instability or subluxation. Additionally, the Veteran is noted to have extension limited at most to 11 degrees and flexion to at least 104 degrees, albeit with painful motion. As such, a 10 percent disability rating under Diagnostic Code 5261, for limitation of extension of the leg, appears to be consistent with DeLuca, 38 C.F.R. § 4.40, 4.45, and 4.59 (recognizing the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint). However, the evidence reflects that no higher rating is assignable, even when functional loss due to pain, weakness and other factors is considered. Consequently, neither a rating higher than 10 percent nor a separate compensable rating for the right knee disability is warranted under available under any of the applicable rating codes for the entire period on appeal. In sum, the Board finds that the Veteran's right knee was 20 percent disabling throughout the entire period on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Other Considerations In reaching the above determinations, the Board has considered the Veteran's statements regarding the severity of his disorder. However, whether the Veteran's disability has worsened sufficiently to meet the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on both the Veteran's complaints coupled with the medical evidence. Here, although the Veteran believes he meets the criteria for higher disability ratings, his complaints and the medical findings do not meet the schedular requirements for the higher ratings, as explained and discussed above. The Board concludes that the medical evidence, prepared by a skilled professional, is more probative of the degree of disability. 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 scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. There is no evidence in the medical records of an exceptional or unusual clinical picture. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. (CONTINUED ON NEXT PAGE) ORDER A rating of 20 percent, but no higher, for degenerative joint disease (DJD) of the lumbar spine is granted throughout the period on appeal, subject to the criteria applicable to the payment of monetary benefits. A rating in excess of 10 percent for DJD of the right hip is denied. A rating of 10 percent, but no higher, for status post right knee arthroscopy is granted throughout the period on appeal, subject to the criteria applicable to the payment of monetary benefits. REMAND In April 2012, the Veteran submitted a claim for a temporary total evaluation based on the need for convalescence. He indicated that he had just undergone surgery on his service-connected left knee. With his claim, he submitted a medical record which reflects that he underwent left knee arthroscopic surgery on March 21, 2012. In Green (Victor) v. Derwinski, 1 Vet. App. 121, 124 (1991), the Court held that the duty to assist may include "the conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." In consideration of the Veteran's recent left knee surgery, the Board finds that the Veteran should be afforded a new VA examination in connection with his claim for a higher rating. In addition, on remand, the Veteran should be requested to identify any outstanding records. Also, as the record reflects that the Veteran has continued to receive treatment at the VA Medical Center (VAM), any ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (noting that VA medical records are in constructive possession of the agency and must be obtained if pertinent). Accordingly, the case is REMANDED for the following actions: 1. The AMC/RO must ascertain if the Veteran has received any VA, non-VA, or other medical treatment for his left knee disability that is not evidenced by the current record. Provide the Veteran with authorization forms for the release of any identified outstanding private treatment records. Any such records must be obtained and associated with the claims folder. All efforts to obtain the additional evidence must be documented in the claims files. If VA is unable to secure these records, VA must notify the Veteran and (a) identify the specific records VA is unable to obtain; (b) briefly explain the efforts that VA made to obtain those records; (c) describe any further action to be taken by VA with respect to the claim; and (d) notify him that he is ultimately responsible for providing the evidence. 38 U.S.C.A. § 5103A(b)(2) (West 2002); 38 C.F.R. § 3.159(e)(1) (2012). 2. Obtain all outstanding VA treatment records. All efforts to obtain the additional evidence must be documented in the claims folder. If the search for such records has negative results, documentation to that effect should be included in the claims files. 3. Arrange for the Veteran to undergo a VA examination to determine the severity of his service-connected left knee disorder. The claims folders must be thoroughly reviewed by the examiner in connection with the examination, and a complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. The examiner should describe all pertinent symptomatology associated with the Veteran's left knee disorder and should provide the following information: a. The examiner should specifically state range of motion findings using a goniometer, and indicate on the examination report that a goniometer was used; b. The examiner should comment on whether this disability exhibits weakened movement, excess fatigability, incoordination, or pain on use attributable to the service-connected right knee (if feasible, these determinations should be expressed in terms of the degree of additional range of motion loss due to these symptoms); c. The examiner should discuss whether pain significantly limits functional ability during flare-ups or following repeated use (these determinations should also, if feasible, be portrayed in terms of the degree of additional range of motion loss due to pain on use or during flare-ups); and d. The examiner should opine should describe the severity of the Veteran's subluxation or lateral instability of the left knee. 3. Upon receipt of the VA reviewer's report, the RO or the AMC should conduct a review to verify that all requested opinions have been offered. If information is deemed lacking, the RO or the AMC should refer the report to the VA reviewer for corrections or additions. 4. Then, the RO or the AMC should readjudicate the Veteran's claim (to include his claim for a convalescent period following his March 2012 left knee surgery and consideration of 38 C.F.R. §§ 3.321(b) and 4.16(b)). If any benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period of time for response. The case should then be returned to the Board for further consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ LANA K. JENG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs