Citation Nr: 1306065 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 07-19 609 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee (previously diagnosed as internal derangement with limitation of motion). 2. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee (previously diagnosed as internal derangement with limitation of motion). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran served on active duty from July 1994 to August 1997. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In October 2009, the Veteran testified at a videoconference hearing. A transcript of that hearing is of record. The Board remanded the case for further development in March 2010 and March 2012. The Board remands directed additional development regarding the appeal for an increased rating that included a request to obtain outstanding private treatment records and for VA examinations to address the service-connected left and right knee disabilities. This was accomplished, and the Board concludes that it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). FINDINGS OF FACT 1. For the entire rating period, right knee degenerative joint disease has been manifested by chronic pain and painful motion with at least 100 degrees flexion and full extension to 0 degrees without additional limitations due to pain. There was no additional limitation to range of motion in degrees on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. Objective testing for anterior/posterior and medial/lateral instability shows that the knee was stable. 2. For the entire rating period, left knee degenerative joint disease has been manifested by chronic pain and painful motion with at least 100 degrees flexion and full extension to 0 degrees without additional limitations due to pain. There was no additional limitation to range of motion in degrees on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. Objective testing for anterior/posterior and medial/lateral instability shows that the knee was stable. CONCLUSIONS OF LAW 1. For the entire rating period, the criteria for an increased evaluation in excess of 10 percent for right knee degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012). 2. For the entire rating period, the criteria for an increased evaluation in excess of 10 percent for left knee degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). VA has met its duty to notify and assist the Veteran. In September 2005, May 2006 and November 2007 letters, VA informed the Veteran of the evidence necessary to substantiate his claim, evidence VA would reasonably seek to obtain, and information and evidence for which the Veteran was responsible. May 2006 and November 2007 letters provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The May 2006 and November 2007 notice letters were not sent prior to the initial rating decision. Despite the inadequate timing of this notice, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The RO cured any VCAA notice deficiency by issuing the corrective notice in May 2006 and November 2007, and the RO readjudicated the case in later supplemental statements of the case (SSOC). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). There is no indication that any notice deficiency reasonably affects the outcome of this case. VA and private treatment records, VA examinations, and lay statements and testimony have been associated with the claims file. The Board notes specifically that the Veteran was afforded VA examinations in November 2005, July 2007, December 2010, and June 2012. 38 C.F.R. § 3.159(c)(4) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As set forth in greater detail below, the Board finds that, cumulatively, the examinations obtained in this case are adequate as they are predicated on a review of the claims folder and medical records contained therein; contain a description of the history of the disability at issue; document and consider the Veteran's complaints and symptoms; and contain a discussion of the functional effects of the Veteran's service-connected disability on occupational and daily activities. The Board finds that the most recent June 2012 VA examination substantially complied with March 2010 and March 2012 Board remand orders which directed, in pertinent part, that the examiner should comment on the diagnosis of right chronic medial meniscus tear and chondromalecia of the patella and specifically determine whether MRI findings and subsequent diagnoses were a part of the Veteran's service-connected knee disabilities. In that regard, the June 2012 VA examiner identified the Veteran's diagnosed meniscal tears, which were stated to affect both knees, during the examination. The examiner identified all current bilateral knee symptoms in the Veteran's reported history. The examiner addressed all relevant rating criteria in evaluating the Veteran's bilateral knee disability. The examiner also provided an evaluation for the diagnosed meniscal knee conditions in accordance with the relevant rating criteria under Diagnostic Codes 5258 and 5259. In an October 2012 opinion, provided in an e-mail correspondence, the examiner opined that the historical information given for the Veteran in June 2012 was consistent with his physical and x-ray findings. Based on a review of the June 2012 examination and October 2012 opinion, the Board finds that the VA examiner adequately addressed the significance of the Veteran's meniscal tears and all other knee pathology in evaluating the service-connected knee disabilities, and because the examiner declined to distinguish symptoms and impairment attributable to the Veteran's service-connected knee disabilities from those attributable to any other knee diagnoses, all of the Veteran's knee symptoms and associated impairment have been considered by the Board in evaluating his service-connected disabilities. See 38 C.F.R. § 3.102 (2012); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so.) Accordingly the Board finds that the June 2012 VA examination and October 2012 opinion substantially comply with the March 2010 and March 2012 Board remand orders, and the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. See 38 C.F.R. § 3.159(c)(4); Dyment, 13 Vet. App. at 146; Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claim, and to respond to VA notices. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012). Disability Rating Law Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The United States Court of Appeals for Veterans Claims (Court or CAVC) has also held that 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 relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether staged ratings are for consideration in this case; however, the Board finds that the Veteran's bilateral knee disabilities have not increased in severity over the course of the appeal, and as such, a staged rating is not warranted. The Board notes that while a Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2012). Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45 (2012). With any form of arthritis, painful motion is an important factor of disability; therefore, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2012). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2012). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent evaluation is assigned with x-ray evidence of involvement of two or more major joints; a 20 percent rating is assigned with x- ray evidence of involvement of two or more major joints with occasional incapacitating exacerbations. Id. Ankylosis of the knee is evaluated under Diagnostic Code 5256. A 60 percent evaluation is assigned for extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more; a 50 percent evaluation is assigned for flexion between 20 and 45 degrees; a 40 percent evaluation is assigned for flexion between 10 and 20 degrees; and a 30 percent evaluation is assigned for a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256 (2012). Other impairment of the knee is assigned a 30 percent evaluation for severe recurrent subluxation or lateral instability; a 20 percent evaluation for moderate recurrent subluxation or lateral instability; and a 10 percent evaluation for slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). A 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2012). A 10 percent evaluation is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2012). Under Diagnostic Code 5260, limitation of flexion of the leg is noncompensable where flexion is limited to 60 degrees. A 10 percent evaluation is warranted where flexion is limited to 45 degrees; a 20 percent evaluation is warranted where flexion is limited to 30 degrees; and a 30 percent evaluation is warranted where flexion is limited to 15 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Limitation of extension of the leg is noncompensable where extension is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees; a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). VA's Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA's General Counsel stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 (July 1, 1997). In VAOPGCPREC 9-98, VA's General Counsel reiterated that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, the General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Increased Rating Analysis The Veteran is currently in receipt of separate 10 percent ratings for service-connected degenerative joint disease of the left and right knees under Diagnostic Code 5010-5260. See 38 C.F.R. § 4.27 (2012) (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). The Board finds that for the entire rating period, degenerative joint disease of both the right and left knees has been manifested by chronic pain and painful motion with at least 100 degrees flexion and full extension to 0 degrees without additional limitations due to pain. There was no additional limitation to range of motion in degrees on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. Objective testing for anterior/posterior and medial/lateral instability shows that both knees were stable. The Board finds that for the entire rating period, an evaluation in excess of 10 percent is not warranted for degenerative arthritis of the right knee under Diagnostic Codes 5260 or 5261. VA examinations and VA authorized examinations of record show that the Veteran has had at least 100 degrees flexion in the right knee with consideration of limitations shown on repetitive use, and examinations consistently report full extension in the right knee to 0 degrees without additional limitations. A November 2005 VA examination reflects 0 degrees extension to 135 degrees flexion in the bilateral knees. Pain was noted to be present at 30 degrees of extension in the right knee. There was pain with range of motion testing, but no fatigue, weakness, lack of endurance, or loss of range of motion on repetitive use. A July 2007 VA examination reflects 0 degrees extension to 100 degrees flexion with pain and weakness noted on repetitive use. A December 2010 VA examination reflects 0 degrees extension to 140 degrees flexion in the bilateral knees with pain noted with repeat motion. The examiner stated, however, that this was unusual given the Veteran's normal physical examination, and the Veteran was noted to ambulate without apparent discomfort. The Veteran's most recent June 2012 VA examination reflects 0 degrees extension and 140 degrees flexion in the bilateral knees with pain starting 120 degrees flexion and no additional pain noted on extension. Additionally, the Veteran did not have additional loss in range of motion with repetitive use testing. Even with consideration of painful motion on repetitive use, the Veteran was able to complete 0 degrees extension and 140 degrees flexion in both knees. For these reasons, the Board finds that for the entire appeals period, the Veteran has had painful motion in the bilateral knees, but has had at least 0 degrees extension and at least 100 degrees flexion in the bilateral knees even with consideration of his limitations due to pain. Under Diagnostic Code 5260, a 10 percent evaluation is warranted where flexion is limited to 45 degrees, and under Diagnostic Code 5261, a 10 percent evaluation is warranted where extension is limited to 10 degrees. See 38 C.F.R. § 4.71a. The Veteran does not exhibit a compensable degree of limitation of flexion or limitation of extension in the right knee under Diagnostic Code 5260 or 5261. The Veteran's 10 percent evaluations in this case, was assigned based on the presence of painful motion in the right and left knees, to include consideration of his functional loss due to pain or painful motion where limitation of motion would otherwise be noncompensable. See Lichenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also 38 C.F.R. §§ 4.40, 4.45 (2012); DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). Even with consideration of the Veteran's functional loss, his disability does not approximate limitation of flexion to 30 degrees, or limitation of extension to 10 degrees to warrant a higher 20 percent rating under Diagnostic Code 5260 or a separate compensable rating under Diagnostic Code 5261. See 38 C.F.R. § 4.71a. The Board finds, therefore, that an evaluation in excess of 10 percent is not warranted under Diagnostic Code 5260 or 5261. The Board has considered whether compensable evaluation is warranted under other applicable provisions of the Diagnostic Code. The evidence of record does not reflect ankylosis of the right knee to warrant an evaluation under Diagnostic Codes 5256. See 38 C.F.R. § 4.71a. As noted above, the Veteran is shown to have active motion in the both knee joints without ankylosis as shown on VA examinations of record. The Board finds that the Veteran does not have recurrent subluxation or lateral instability of either the right or left knee sufficient to warrant a compensable evaluation Diagnostic Code 5257. See 38 C.F.R. § 4.71a. While the Veteran reported unsteadiness in the knees during a November 2005 VA examination, and instability during the July 2007 VA examination, there was no instability on physical examination in November 2005, and there was no laxity shown in the lateral and medial collateral ligaments, and the anterior cruciate ligaments were intact during the July 2007 VA examination. A January 2008 private treatment report shows that the Veteran reported occasional giving way, catching, and locking of the knee; however, the knee was stable to varus and valgus stress testing and the Veteran had a negative anterior drawer test. The Veteran denied instability in the knees during more recent VA examinations. A December 2010 VA examination shows that there was no laxity shown in the lateral and medial collateral ligaments, and the anterior cruciate ligaments were intact. While the Veteran reported use of a knee brace during a June 2012 VA examination, this was stated to be for the management of pain, and not for subluxation or instability of the knee. Objective testing for anterior/posterior and medial/lateral instability in June 2012 shows that the knees were stable. While the Veteran had some reports of instability or giving way of the knees, objective testing conducted throughout the course of the rating period consistently shows that the knees were stable without evidence of recurrent subluxation. For these reasons, the Board finds that for the entire rating period, the Veteran's disability is not manifested by recurrent subluxation or lateral stability in the right or left knee, and a separate evaluation is not warranted under Diagnostic Code 5257. 38 C.F.R. §§ 4.3, 4.7, 4.71a. While the Veteran has had evidence of chronic meniscal tears in both knees, there is no evidence of removal of semilunar cartilage or dislocated semilunar cartilage to warrant an evaluation under Diagnostic Codes 5258 or 5259. See 38 C.F.R. § 4.71a. A January 2008 MRI reflects a meniscal tear in the right knee, but does not reflect removal or dislocated semilunar cartilage. During VA examinations conducted during the rating period, to include the most recent June 2012 VA examination, the Veteran reported that he has never had surgery to the knees. While the Veteran has been diagnosed with medial meniscus tears bilaterally, he has not had evidence of dislocated semilunar cartilage at any time during the course of the appeal. Additionally, the Board finds that chronic meniscal tears do not result in additional symptoms outside of what has already been considered in evaluating the Veteran's bilateral knee disability. Symptoms of pain, swelling, and limitation of motion due to pain have already been considered in assigning the Veteran's current ratings under Diagnostic Code 5010-5060. For these reasons the Board finds that a separate evaluation is not warranted under Diagnostic Codes 5258 or 5259. Finally, the Veteran does not have evidence of nonunion or malunion of the tibia or fibula shown at any time during the rating period to warrant a rating under Diagnostic Code 5259. See 38 C.F.R. § 4.71a. In reaching the above conclusions, the Board has not overlooked the Veteran's lay statements with regard to the severity of his bilateral knee disability. The Board finds that the Veteran is competent to report his symptomatology and his occupational impairments due to such, and the Board finds that the Veteran has been consistent in his complaints, and finds that his statements are credible. The Veteran's statements have been considered by VA examiners in their evaluation of the Veteran, and by the Board. During his Board hearing, the Veteran described limitations to his employment, which involved climbing ladders, climbing incline belts, and driving a D9 Dozer which required the use of both legs. The Veteran was limited in his current position due to his knees. A June 2012 VA examiner also noted that the Veteran's disability made the Veteran's job as a heavy equipment operator more difficult due to his pain. The Board finds that the Veteran is shown to have limitations to his more physical employment due to his knees. However, the Board finds that identified symptoms of pain and swelling in the knees, and functional limitations due such are adequately addressed by the Veteran's assigned evaluations under Diagnostic Code 5010-5260. While the Veteran has reported symptoms of perceived instability at times, the Board has accorded greater probative weight to the medical evidence in this case, which shows, based on objective testing for stability, that the Veteran does not have recurrent subluxation or instability in the knees. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's bilateral knee disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Codes 5010, 5003, 5260, and 5261, specifically provide for disability ratings based on limitation of motion, including due to pain and other orthopedic factors. See 38 C.F.R. §§ 4.21, 4.40, 4.45, 4.59 (2012); see also DeLuca. In this case, considering the lay and medical evidence, the Veteran's bilateral knee disability has been manifested by pain and painful motion with at least 100 degrees flexion and full extension to 0 degrees without additional limitations due to pain and these symptoms are contemplated by the schedular rating criteria. The Board has additionally considered ratings under alternate schedular rating criteria as discussed above. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). Additionally, the Board has considered the Veteran's functional limitations noted during VA examinations, to include limitations to walking, prolonged sitting, climbing ladders, and operating heavy equipment to include a D9 Dozer. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155 (2012). "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2012). In this case, the functional limitations imposed by the Veteran's disability are specifically contemplated by the criteria discussed above, including the effect of the Veteran's knee pain and associated limitations on his occupation and daily life. In the absence of exceptional factors associated with the left and right knee disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER For the entire rating period, an increased rating for degenerative joint disease of the right knee (previously diagnosed as internal derangement with limitation of motion, in excess of 10 percent, is denied. For the entire rating period, an increased rating for degenerative joint disease of the left knee (previously diagnosed as internal derangement with limitation of motion, in excess of 10 percent, is denied. ____________________________________________ THOMAS JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs