Citation Nr: 1306987 Decision Date: 02/28/13 Archive Date: 03/01/13 DOCKET NO. 03-07 319 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to an evaluation in excess of 20 percent for left knee internal derangement. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Y. Hawkins, Counsel INTRODUCTION The Veteran served on active duty from November 1990 to November 1993. This matter comes before the Board of Veterans' Appeals ("Board") on appeal from a February 2002 rating decision that denied an increased rating for the Veteran's left knee internal derangement, which was evaluated at 20 percent. In June 2004, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge at the Pittsburgh RO. A transcript of the hearing has been associated with the Veteran's claims folder. The Board has previously considered this claim. In a November 2005 decision, the Board denied the Veteran's claim for an increased disability rating. The Veteran subsequently appealed the decision to the Unites States Court of Appeals for Veterans Claims ("Court"). Thereafter, while the case was pending before the Court, the VA Office of General Counsel and the appellant's attorney (hereinafter known as "the parties") filed a Joint Motion for Remand ("Joint Motion"), requesting that the Court vacate the decision. Thereafter, in September 2008, the Board remanded the case to conduct the development requested in the Joint Motion. The Veteran's claim was subsequently denied in a May 2009 Board decision, which the Veteran appealed to the Court. In a July 2010 memorandum decision, the Court vacated the May 2009 Board decision and remanded the matter to the Board for proceedings consistent with the memorandum decision. In February 2011, the Board remanded the claim to the agency of original jurisdiction ("AOJ") for additional development of the claim. The Board again remanded the claim to the AOJ in February 2012 and May 2012 for further development of the claim. The claims folder has been returned to the Board for further appellate proceedings. FINDING OF FACT Throughout the period on appeal, the Veteran's left knee internal derangement has not been manifested by severe recurrent subluxation or instability, and has not been productive of limitation of flexion to 15 degrees, or limitation of extension to 20 degrees. CONCLUSION OF LAW The criteria for a disability rating in excess of 20 percent for left knee internal derangement have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 ("VCAA") With respect to the Veteran's claim decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A.) Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) ("Pelegrini II"), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Element (4), however, the requirement of requesting that the claimant provide any evidence in his or her possession that pertains to the claim, was eliminated by the VA Secretary ("Secretary") during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini, effective May 30, 2008). The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Of particular importance, in Dingess/Hartman, the Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection is awarded. The United States Court of Appeals for the Federal Circuit ("Federal Circuit") has held that any error in a VCAA notice should be presumed prejudicial. The claimant bears the burden of demonstrating such error. VA then bears the burden of rebutting the presumption, by showing that the essential fairness of the adjudication has not been affected because, for example, actual knowledge by the claimant cured the notice defect, a reasonable person would have understood what was needed, or the benefits sought cannot be granted as a matter of law. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). In addition, both the Court and the Federal Circuit have held that VA can provide additional necessary notice subsequent to the initial AOJ adjudication, and then go back and readjudicate the claim, such that the essential fairness of the adjudication, as a whole, is unaffected because the appellant is still provided a meaningful opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (where the Federal Circuit Court held that a Statement of the Case ("SOC") or Supplemental Statement of the Case ("SSOC") can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC). In this case, the Board recognizes that the initial April 1999 notice letter provided to the Veteran was issued prior to VCAA, and thus, did not provide her with the prescribed notice of the evidence necessary to substantiate her claim. Nonetheless, the Board observes that the February 2002 rating decision provided the Veteran with the specific criteria necessary for an increased disability evaluation. Thereafter, the Veteran's claim was readjudicated in a February 2003 SOC. In a letter dated March 2005, the Veteran was advised that she should submit evidence showing that her left knee disability had increased in severity and what VA would do to assist her in obtaining evidence, including the types of evidence, both lay and medical, that could be submitted in support of a claim for an increased rating. The Veteran has also shown actual knowledge of the evidence needed to show that her left knee disability had increased in severity. During her June 2004 hearing before the Board, as well as at each of her VA examinations, the Veteran was questioned as to the severity of her knee disorder and what impact the condition had on her activities of daily living and occupation. The claim has since been readjudicated multiple times, and the Veteran was also afforded an October 2008 letter, which provided her with appropriate notice per Dingess/Hartman, supra. Accordingly, and as the Veteran has pointed to no prejudice resulting from the timing of the VCAA notice, the Board finds any failure in the content or timing of the notice is not prejudicial. B.) Duty to Assist The Board concludes that VA's duty to assist has been satisfied. The claims folder contains the Veteran's service and post-service treatment records, and several VA examination reports, that will be discussed in greater detail below. In addition, the claims folder contains the Veteran's statements in support of her claim. The Veteran has not referenced any outstanding records that she wanted VA to obtain or that she felt were relevant to her claim that have not already been obtained and added to the record. Review of the examination reports shows that, although the January 2002 VA examination was found by the Court to be inadequate for rating purposes because the claims folder had not been available to the VA examiner, the subsequent examination reports demonstrate that the examiners reviewed the complete claims folder, elicited from the Veteran her history of left knee symptomatology and its effect on her daily functioning and occupation, and provided the clinical results of the evaluations. Accordingly, the Board finds that the VA examination reports performed during the course of this appeal, taken as a whole, are adequate upon which to base a decision in this case. In short, the Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above finds that the development of the claim has been has been consistent with the provisions of the VCAA. The Veteran has been provided with every opportunity to submit evidence and argument in support of her claim, and to respond to the VCAA notice. The purpose behind the notice requirements has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of her appealed claim. See Overton v. Nicholson, 20 Vet. App. 427 (2006). Accordingly, the Board will proceed to a decision on the merits. II. Analysis The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). 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). Under 38 U.S.C.A. § 1154(a), VA is also required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. In Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit ("Federal Circuit") held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3), lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." (footnote omitted). However, the Court has held that "[t]he type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed." Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. 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, and 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 degrees of disability 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 ("DCs") identify the various disabilities and the criteria for specific ratings. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). 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. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2009). 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). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). 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. 38 C.F.R. § 4.40 (2012). It is essential that the examination on 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 innervations, 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 which 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. Id. With regard 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: less movement than normal; more movement than normal; weakened movement; excess fatigability; incoordination; impaired ability to execute skilled movements smoothly; and 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). Painful, unstable, or malaligned joints, due to healed injury are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2012). The Court has held that when evaluating loss in range of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40 ) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. The fact that the revised criteria include symptoms such as pain, stiffness, aching, etc., if present, means that evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). The Board notes that 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, so that its decisions are "equitable and just." 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. §§ 4.2, 4.6 (2012). Under DC 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes. However, when the limitation of motion of the specific joint or joints is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is applicable for each such major joint or group of minor joints affected, to be combined, not added, under DC 5003. Limitation of motion of the knee is evaluated under 38 C.F.R. § 4.71, DCs 5260 and 5261. Under DC 5260, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. Under DC 5261, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Plate II, indicates that normal flexion of the knee is 140 degrees and normal extension of the knee is zero degrees. The Veteran's service-connected left knee disability has been consistently evaluated pursuant to the criteria found at 38 C.F.R. § 4.71a, DC 5257. Under this diagnostic code, slight impairment of either knee, including recurrent subluxation or lateral instability, warrants a 10 percent evaluation. A 20 percent evaluation requires moderate impairment, while a 30 percent evaluation requires severe impairment. 38 C.F.R. § 4.71a. The VA General Counsel has issued a precedent opinion holding that a claimant who has arthritis and instability of the knee may be rated separately under DCs 5010-5003 and 5257, but cautions that any such separate rating must be based upon additional disabling symptomatology. VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997). By way of history, the Veteran sustained a left knee injury during service, resulting in an arthroscopic medial meniscectomy in 1992. An April 1994 VA examination showed chronic left knee impairment, and by a July 1995 rating decision, the Veteran was service-connected for left knee derangement with an initial rating of 10 percent. Thereafter, in a June 1999 rating decision, the Veteran's disability evaluation was increased to 20 percent, effective March 30, 1999. In April 1999, a second VA examination revealed limitation of flexion in the left knee to 110 degrees and extension to zero degrees. An x-ray showed findings of slight narrowing of the medial compartment of the left knee joint along with lateral instability, weakness and tenderness. There was no evidence of dislocation or recurrent subluxation. During a January 2002 VA examination, the Veteran reported daily locking of the left knee with subluxation approximately once per week. Upon physical examination, she displayed an abnormal gait with flexion to 140 degrees and extension to zero degrees, both without any difficulty. There was, however, objective evidence of pain on active and passive range of motion, and moderate instability of the patella medially and laterally with weightbearing. X-rays revealed no evidence of degenerative joint disease, but it was noted that there was slight narrowing of the medial compartment, which the examiner said was often present with degenerative arthritic changes. A private January 2004 clinical record showed that the Veteran reported left knee pain, while a private July 2004 x-ray of the left knee indicated normal findings. Knee pain was also shown on VA outpatient treatment reports. In September 2005, the Veteran underwent a VA magnetic resonance imaging (MRI) after complaints of chronic bilateral knee pain. The results revealed normal findings without evidence of osteoarthritis. The lateral and medial meniscus had a normal appearance with no evidence of tears. The anterior and cruciate ligaments were normal and there was no significant joint effusion. During a November 2008 VA examination, the Veteran reported that she experienced sharp left knee pain during ambulation (which she rated at 7 on a scale of 0 to 10), and said that the knee hurt on most days for several hours. She also said that she used over-the-counter medication as needed and performed physical therapy exercises at home. It was noted that she was not using any assistive devices and there was normal symmetry to the left knee. Upon physical examination, flexion was to 140 degrees and extension was to zero degrees without restriction or crepitus; the examiner noted that she was able to assume a full squat position and rise fairly easily with only some minor medial joint pain. It was further noted that she had a desk job with no restrictions, as she stated that she did not have to engage in prolonged standing or walking and was able to stand and sit at will. An x-ray revealed normal findings. The diagnosis was degenerative joint disease and the examiner opined that the Veteran's complaints of sharp left knee pain were consistent with findings of mild degenerative joint disease. He further noted that there were no complaints or clinical findings of instability. He opined that her knee disability did not affect her ability to obtain or maintain gainful employment. VA outpatient treatment reports show the Veteran was seen in September 2010 for complaints of bilateral knee pain for five days. The clinical examination revealed bilateral crepitus with mild left knee medial joint line tenderness. The Veteran's gait at that time was noted as normal. The clinician referred her to physical therapy for strengthening of the muscles surrounding the knee joint. In April 2011, the Veteran was afforded another VA examination, at which time, she complained of chronic left knee pain with instability and occasional locking with the left leg in an extended position. While she said that she was in no pain during the evaluation, she complained of intermittent pain rated 8-9 on a 0 to 10 scale. She also complained of aggravation when sitting or standing for prolonged periods, but noted that her employer had provided her with a high stool upon which to rest her left leg while sitting. She said that she was completely independent in her activities of daily living. Upon physical examination, she demonstrated normal ambulation without assistance, although she noted that she occasionally used a Velcro knee brace. Symmetry was normal and there was no inflammation, swelling or effusion. Meniscus stress tests and ligamentous testing were normal without evidence of popping or clicking. Lachman's test was negative, and the examiner opined that the knee was felt to be stable. Flexion was to 140 degrees and extension was to zero degrees. Repetitions did not cause a pain flare-up. An x-ray revealed normal findings with slight narrowing of the medial joint compartment likely secondary to her prior surgery. The VA examiner opined that the Veteran's reported symptoms were consistent with the clinical examination findings. He further opined that, as the Veteran did not work in a strenuous occupation and instead worked a desk job, there was no reason that she could not be gainfully employed in her current sedentary position or in a mild to moderate physically-active job setting. During a July 2012 VA examination, the Veteran again reported that prolonged standing and sitting, as well as walking, resulted in flare-ups. She said that she used over-the-counter medication as needed and used a Velcro knee brace (which she wore to the evaluation). Upon physical examination, ambulation was normal without muscle weakness or atrophy. Flexion was to 140 degrees with objective evidence of pain at 70 degrees; extension was to zero degrees without pain. Minor joint crepitus was felt with passive range of motion. The Veteran was able to perform repetitive testing with normal range of motion without any additional loss of motion, but did experience excess fatigability and pain on movement. Muscle strength was normal for both flexion and extension, as was anterior, posterior and medial-lateral stability. The left knee was negative for tenderness or pain on palpation and there was no evidence of patellar subluxation or dislocation. There was normal knee symmetry without effusion, ligamentous pain or give. X-rays revealed only minimal narrowing of the medial compartment. The examiner opined that the Veteran's left knee disorder did not impact her ability to work and there was no history of lost time from work. While he noted that he did not believe that she would be capable of performing any physically-laborious work without aggravating the left knee, he opined that her office occupation was well-suited and not taxing on her left knee. In addition to the medical evidence, the Board has also considered the Veteran's testimony given during the June 2004 Board hearing, in which she stated that, as a result of her left knee disability, she could not sit or stand too long while she worked for the United States Postal Service ("USPS") and had had to resign because she had been missing a lot of time from work. In this regard, VA made several requests to the USPS for the Veteran's personnel records. After several attempts, however, the only document received shows that she was hired in May 2003 and resigned in December 2003. There is no information as to how much time she lost from work (if any) or if any lost time was as a direct result of her left knee disability. Applying the pertinent legal criteria to the facts of this case, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to a disability rating in excess of the current 20 percent rating for her left knee internal derangement under DC 5257. In fact, although the Veteran reported to the April 2011 examiner that she occasionally experienced left knee instability, the last VA examination to note objective findings of instability was in January 2002, over 11 years ago, at which time, the instability was only noted as moderate, which warrants no more than a 20 percent rating under DC 5257. More recently, during the April 2011 examination, the examiner noted that the Veteran's knee was felt to be stable, and there was also no clinical evidence of instability during the July 2012 examination. There has also been no objective evidence of dislocation or recurrent subluxation during the pendency of this appeal. Accordingly, the requirement for "severe" impairment under DC 5257 is not met. The Board has also considered whether an increased rating is warranted under either DCs 5260 or 5261 for limitation of flexion or extension. However, as the Veteran does not have extension limited to 15 degrees, a higher rating is not warranted under DC 5260. Moreover, as the Veteran does not have extension which is limited to 20 degrees, a higher rating is not warranted under DC 5261. 38 C.F.R. § 4.71a. In addition, although the July 2012 examination report showed that the Veteran experienced excess fatigability with repetitive movement, as noted above, there was no evidence of additional limitation of movement to the extent necessary for an increased disability rating. Furthermore, while the Veteran has constantly reported chronic left knee pain, she does not even meet the criteria for a 10 percent rating under either DC 5260 or 5261. Therefore, it appears that the current 20 percent rating adequately compensates her for her service-connected left knee disorder based upon pain and noncompensable limitation of flexion of a major joint pursuant to the provisions of DC 5003. With regard to assigning a higher disability rating or ratings based on functional loss as contemplated by the Court's holding under DeLuca v. Brown, supra, again, the Board has considered the Veteran's reported symptoms due to her left knee disability. However, the Board notes that the 20 percent disability rating currently assigned under 5257 already contemplates the potential problems associated with residuals, status-post surgery. To this end, the Board observes that during the November 2008 and April 2011 examinations, it was specifically noted that repetitive motion of the knee did not produce a flare-up of pain. Furthermore, as noted above, while the most recent VA examiner noted an increase in fatigability upon repetition, there is simply no evidence that the Veteran's disability results in a loss of range of motion. The Board has also considered whether other diagnostic codes are applicable to the Veteran's left knee disability. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."). The remaining diagnostic codes relating to knee disabilities include DC 5256 (ankylosis of the knee), DC 5258 (cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint), DC 5259 (cartilage, semilunar, removal of, symptomatic), DC 5262 (impairment of the tibia and fibula), and DC 5263 (for genu recurvatum, acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). However, as there is no objective evidence of record to indicate that the Veteran has been found to have ankylosis of the knee, impairment of the tibia and fibula, or acquired, traumatic genu recurvatum, these diagnostic codes are also not applicable. With regard to DC 5259, while the Veteran indeed underwent a medial meniscectomy, the highest disability rating available under this diagnostic code is 10 percent, which is less than the current 20 percent rating. Similarly, the highest rating available under DC 5258 is 20 percent. Moreover, as discussed above, a separate rating under either of these diagnostic codes would constitute pyramiding. See 38 C.F.R. § 4.14. The Board has considered whether there is any other basis for granting a higher rating, but has found none. Consideration has also been given to assigning a staged rating; however, at no time during the period in question has the Veteran's disability warranted more than the 20 percent rating currently assigned. See Hart, 21 Vet. App. at 505; Fenderson, 12 Vet. App. at 119. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of her left knee disorder. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Medical evidence is generally required to address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a) (2012); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In denying the Veteran's claim for a higher disability evaluation, the Board also has considered whether she is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule for Rating Disabilities will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). 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 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate 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. Id. In this case, however, as noted above, there is no evidence that the Veteran's left knee disability presents such an exceptional disability picture that the available schedular evaluations are inadequate. Further, the current 20 percent disability rating contemplates the pain that is often to be anticipated following a medial meniscectomy. Finally, there is no evidence that the Veteran's left knee disorder has caused marked interference with employment or frequent periods of hospitalization. As discussed above, while the Veteran reported that she was forced to resign from her job with the USPS, after repeated attempts, VA was unable to obtain sufficient employment records that would document any substantial time lost from this job due to the Veteran's left knee disability. Moreover, during the 2011 and 2012 VA examinations, the examiner found that there was no impairment in the ability of the Veteran to work at her current employment as a result of her left knee disability. Accordingly, referral of this claim for extraschedular consideration is not indicated. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). For the reasons stated above, the Board has concluded that the preponderance of the evidence is against the Veteran's claim. As such, the "benefit-of-the-doubt rule" enunciated in 38 U.S.C.A. § 5107(b) is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). ORDER Entitlement to a rating in excess of 20 percent for left knee internal derangement is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs