Citation Nr: 1308495 Decision Date: 03/13/13 Archive Date: 03/20/13 DOCKET NO. 10-43 565 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty. 2. Entitlement to an initial rating in excess of 10 percent for degenerative changes of the left knee. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD G. E. Wilkerson, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1975 to September 2005. This case comes before the Board of Veteran's Appeals (Board) on appeal from December 2009 and May 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In these decisions, the RO granted service connection for a left knee disability and left shoulder disability, respectively, and assigned 10 percent ratings for each disability. In a September 2011, the Veteran expressed his desire to withdraw his request for a Board hearing. As such, the Board will proceed with a decision. A review of the Veteran's Virtual VA electronic claims file reveals additional VA outpatient treatment records dated through December 2011, which were associated after the most recent readjudication of the claims in October 2010. However, given that the treatment records contained in Virtual VA do not contain additional symptomatology not already of record that will be the basis for the Board's decision and is therefore essentially cumulative of the evidence already of record, the Board finds that remand for initial RO review of this evidence is not required. See 38 C.F.R. § 20.1304 (2012). FINDINGS OF FACT 1. The Veteran is right-handed. 2. The Veteran's left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty, has been productive of limitation of motion of the left arm to shoulder level; however, limitation to 25 degrees from the side has not been shown. 3. The Veteran's degenerative changes of the left knee is not productive of limitation of flexion to 30 degrees; limitation of extension to 10 degrees; recurrent subluxation or instability; removal of semilunar cartilage; ankylosis; malunion of the tibia and fibula; or genu recurvatum. 4. The Veteran has been shown to have a torn meniscus in his left knee with complaints of locking, pain, and swelling. CONCLUSIONS OF LAW 1. Resolving all doubt in favor of the Veteran, the criteria for an initial 20 percent disability evaluation for left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty, but no higher, have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.46, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5201 (2012). 2. The criteria for an initial rating in excess of 10 percent for degenerative changes of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.46, 4.59, 4.71a, Diagnostic Codes 5003, 5256, 5257, 5259, 5260, 5261, 5262, 5263 (2012). 3. Resolving all reasonable doubt in favor of the Veteran, the criteria for a separate 20 percent disability evaluation for dislocated semilunar cartilage have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40-4.46, 4.71a, Diagnostic Code 5010 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Nevertheless, the Veteran in this case is challenging the initial evaluations assigned following the grant of service connection for his left shoulder and left knee disabilities. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8-2003 (December 22, 2003). Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied with respect to the issues on appeal. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claims. The Veteran has not identified any outstanding records that are available and relevant to the claims being decided herein. Moreover, the record includes various written statements provided by the Veteran and his representative. The Veteran was also afforded VA examinations in October 2009 and March 2011. 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). The Board finds that the VA examinations obtained in this case are adequate, as they are predicated on a review of the claims file and all pertinent evidence of record as well as on a physical examination and fully address the rating criteria that are relevant to rating the disabilities in this case. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disabilities since he was last examined. 38 C.F.R. § 3.327(a). 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. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, 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. 38 C.F.R. § 3.159(c)(4). The Board concludes the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claim and did in fact participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. II. Law and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). Similarly, where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. 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). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by 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. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. 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. A. Left Shoulder In this case, the RO granted service connection for left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial decompression and acromioplasty, in a May 2010 rating decision and assigned a 10 percent disability evaluation effective from December 30, 2009. This rating was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5024-5201. Diagnostic Code 5024 provides that tenosynovitis will be rated on limitation of motion of affected parts, as degenerative arthritis. Diagnostic Code 5010 states that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected, which in this case would be Diagnostic Code 5201 (limitation of motion of the arm). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5201, a 20 percent disability evaluation is contemplated for limitation of motion of the arm at shoulder level or when the minor arm is limited to midway between side and shoulder level. A 30 percent disability evaluation is warranted when the minor arm is limited to 25 degrees from the side. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. As demonstrated by the evidence of record, the Veteran is right-handed and as such, minor, as opposed to major, shoulder disability ratings are applicable. 38 C.F.R. § 4.69. The regulations define normal range of motion for the shoulder as forward flexion from zero to 180 degrees, abduction from zero to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. See 38 C.F.R. § 4.71a, Plate I. In this case, treatment records from a private physician, Dr. W. (initials used to protect privacy), include a December 2008 report noting that the Veteran was seen for left shoulder pain. An examination of the left shoulder revealed positive impingement and Hawkins findings, which were minimal. He had some mild weakness with Jobe's testing and no pain with cross body adduction. There was no swelling, erythema, ecchymosis, or other external evidence of pathology about the shoulder. There was also no crepitus or instability. He was neurovascularly intact distally with a minimally positive drop arm test. X-ray of the shoulder showed no significant glenohumeral pathology. There was no elevation of the humeral head, but there were some mild acromioclavicular joint changes. An assessment of impingement and possible rotator cuff tear was noted. On a December 2008 follow-up appointment note, Dr. W. indicated that the Veteran did not appear to have a significant clinical rotator cuff, if any, and a subacromial injection was administered. A March 2009 statement from Dr. W. reflects that the Veteran had been found to have rotator cuff tendinitis with associated type II acromion and mild AC joint arthritis in the shoulder. An April 2009 surgical report reflects that the Veteran had been referred for left shoulder pain, and a past history of bursitis was noted. The Veteran was treated with a cortisone injection, which initially provided relief, but then the pain recurred. A subsequent MRI showed no significant cuff or labral pathology, and a spur on the anterolateral acromion. There was minimal acromioclavicular joint involvement. A subacromial decompression and acromioplasty using a scope was recommended versus a repeat injection. The Veteran underwent this procedure in April 2009. On VA examination in March 2010, the Veteran reported that he injured his left shoulder in service in 2000 and had problems with the left shoulder since this initial injury. He eventually had surgical treatment on the left shoulder in April 2009. He continued to have pain in the left shoulder every day, but not all day. Following the surgery, he completed physical therapy and received a steroid injection in December 2009. It was noted that he is right-hand dominant. He took etodolac with relief of symptoms. With respect to functional impact, the Veteran reported that his activities of daily living were restricted in that he was unable to sleep on his left side and unable to reach and lift with the left arm and shoulder. He had no job restrictions, and he also indicated that he did not experience flare-up of shoulder pain. On physical examination, the left shoulder had 3 well-healed arthroscopic surgical portals, the largest of which measured 1.5 by 1.2 centimeters. The scars were flat, fixed, and nontender with normal color. There was no tenderness. He had 5 out of 5 motor strength in all planes, although it was less than on the right. Range of motion testing revealed abduction to 70 degrees, forward flexion to 90 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees, with pain on all ranges of motion. However, there was no diminution in range of motion with repetitive motion due to factors such as pain, fatigue, weakness, or lack of endurance. Sensation was normal, and there was no atrophy in the upper extremity. An x-ray of the left shoulder was also normal. The examiner concluded by diagnosing left shoulder osteoarthritis and tendinopathy and bursitis, status post surgical subacromial decompression and acromioplasty. An October 2011 VA outpatient treatment report reflects that the Veteran complained of left shoulder pain. Limited range of motion was indicated. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to an initial 20 percent rating for his service-connected left shoulder disability. The March 2010 VA examination reflects that the Veteran's left shoulder flexion has been limited to 90 degrees, or at shoulder level. Abduction was likewise limited to 70 degrees, or just below shoulder level. As such, a 20 percent rating under Diagnostic Code 5201 is warranted. However, a review of the VA examination report, as well as the treatment records, shows that the Veteran's left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty, has not been manifested by a limitation of arm flexion or abduction to 25 degrees from the side. Rather, the only report noting range of motion of the left arm-the March 2010 VA examination report-reflects flexion and abduction to well over 50 degrees. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran's left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent disability evaluation, and no higher. In this regard, the Board observes that the Veteran has complained of pain on numerous occasions. However, the effect of the pain is contemplated in the currently assigned 20 disability evaluation under Diagnostic Codes 5201. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. In fact, the March 2010 VA examiner commented that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Significantly, that examiner also stated that joint function was not additionally limited in degree. The Court has held that pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Therefore, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 20 percent. The Board has also considered other potentially applicable diagnostic codes; however, the Veteran's left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty, is not shown to involve any other factor that would warrant evaluation of the disability under any other provisions of the rating schedule. In this case, there simply is no medical evidence of any ankylosis of the scapulohumeral articulation, or impairment of the humerus or of the clavicle or scapula. As such, there is no basis for evaluation of the disability under Diagnostic Codes 5200, 5202, or 5203. See 38 C.F.R. § 4.71a. The Board acknowledges that the Veteran has scarring of the left shoulder associated with the April 2009 surgical procedure; however, the March 2010 examiner indicated that these scars are not productive of disability warranting a separate evaluation. Accordingly, the Board finds that an initial 20 percent, but no higher, rating for left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty, is warranted for the entire appeal period. B. Left Knee VA 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 General Counsel has 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). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also held 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, 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 DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). In this case, the RO granted service connection for degenerative changes of the left knee in a December 2009 rating decision and assigned a 10 percent disability evaluation effective from December 4, 2008. This rating was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260. Diagnostic Code 5010 states that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected which in this case would be Diagnostic Codes 5260 (limitation of flexion of the leg) and 5261 (limitation of extension of the leg). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5260, a noncompensable evaluation is contemplated for flexion limited to 60 degrees. A 10 percent disability evaluation is assigned when flexion is limited to 45 degrees, and a 20 percent disability evaluation is warranted when flexion is limited to 30 degrees. A 30 percent disability evaluation is assigned when flexion is limited to 15 degrees, which is the maximum evaluation available under Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees, and a 10 percent disability evaluation is contemplated for extension limited to 10 degrees. When there is limitation of extension to 15 degrees, a 20 percent disability evaluation is warranted. A 30 percent rating will be assigned for extension limited to 20 degrees, and a 40 percent rating is contemplated for limitation of extension to 30 degrees. A 50 percent disability evaluation is warranted for extension limited to 45 degrees. The rating schedule provides that the normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Other diagnostic codes provide rating criteria used to evaluate ankylosis, recurrent subluxation or lateral instability, dislocated cartilage, impairment of the tibia and fibula, and genu recurvatum. The pertinent evidence of record includes treatment records from the Tuttle Army Health Clinic. In March 2008, the Veteran complained of left knee pain. An examination revealed no evidence of effusion, callor, erythema, or tenderness to palpation, and there was no pain or laxity with varus and valgus stress. Drawer, Lachmann, and McMurray's tests yielded negative results. A March 2008 x-ray of the left knee revealed tricompartmental degenerative changes. A small loose body was not excluded. A CT scan revealed moderate osteoarthritic changes and associated marginal osteophytes of the medial and lateral tibial eminences with no evidence of a calcified loose body. A July 2008 treatment report reflects that Veteran continued to report left knee pain. An examination revealed no effusion, erythema, or callor, and Drawer, Lachmann, and McMurray's test were negative. There was also no pain or laxity with varus/valgus stress, and no tenderness to palpation. An impression of osteoarthritis of the left knee was indicated. A December 2008 report from private physician Dr. W. reflects that the Veteran was seen for complaints regarding his left knee. An examination of the left knee revealed some mild crepitus with range of motion, and there was mild effusion. The Veteran had minimal medial joint space pain, and a McMurray's test was negative. He had active and passive motion with no pain on resisted leg flexion or extension. An assessment of left knee mild to early moderate arthritis was indicated. In a December 2008 follow-up appointment report, Dr. W. noted that he referred the Veteran for physical therapy to improve range of motion and strengthening. A March 2009 statement from Dr. W. reflects a diagnosis of degenerative joint arthritis of the left knee. A March 2009 treatment report from Dr. W. reflects that there was some mild crepitus in the knee with no instability. There was mild effusion and mild medial joint line pain. The Veteran had good range of motion with no pain on resisted leg flexion or extension. An assessment of left medial joint arthritis was indicated. On VA examination in October 2009, the Veteran reported that his left knee pain began in service in 2000. He had pain daily that came and went and was varying in duration. He denied having any flare-ups. The Veteran did endorse swelling and popping, but he denied locking, buckling, or grinding. He did not have a brace, cane, or crutch. He did not take medication, although he had had injections in the past with only temporary relief. With respect to the impact on his daily activities, the Veteran indicated that he was unable to walk more than 2 to 3 blocks, unable to stand more than 5 to 10 minutes, and unable to sit more than 5 to 10 minutes. He had worked full-time as a plant manager, where he was unable to sit more than 5 to 10 minutes. The Veteran indicated that he had not missed any days of work due to his knee. On physical examination, the Veteran walked with a limp, but used no assistive devices. There was no edema, crepitus, or instability. Drawer testing was negative. On range of motion testing, the Veteran was able to extend to 0 degrees and flex to 120 degrees, both with pain. There was no additional limitation of motion due to pain, fatigue, weakness, or lack of endurance following repetitive use. The examiner indicated that she reviewed previous x-ray reports, and she diagnosed him with degenerative changes of the left knee. A December 2009 treatment report from Dr. W. reflects that the Veteran complained of increased left knee pain. He indicated that it sometimes felt unstable and popped. On examination, he still had joint line pain and crepitus, and there was moderate effusion. Range of motion was from 0 to 110 degrees. It was noted that a November 2009 MRI revealed chronic medial meniscus tear. An assessment of moderate osteoarthritis with superimposed chronic medial meniscus tear was indicated. On VA examination in March 2010, the Veteran reported that he had had injections of the left knee with the last one being in May 2009. His pain occurred 3 to 4 times per week and lasted over 1 hour at time. He did not use a brace, cane, or crutch. He took etodolac, which did provide some relief. He endorsed swelling, locking, buckling, popping, and grinding. Functional limitations included an inability to walk more than a half a block, an inability to stand more than 15 minutes, and an inability to sit more than 1 hour. He indicated that he worked full-time as a plant manager and missed 3 to 4 days of work in the last year related to his left knee pain. The Veteran indicated that he had flare-ups once a week lasting for a few minutes at a time. During flare-ups, he could not do any physical activity other than sit down and stretch the knee. A physical examination revealed that the Veteran walked with a limp and used no assistive devices. He had positive crepitus and McMurray's tests of the knee, but instability was negative. There was mild edema on the medial and lateral aspect of the knee at the lower patellar level. Range of motion testing revealed extension to 0 degrees with pain from 20 to 0 degrees and flexion to 120 degrees with pain at 100 degrees. Range of motion was not additionally limited on repetition due to pain, fatigue, weakness, or lack of endurance. Sensation was normal in the left lower extremity, while the knee reflex was absent. Strength was 5 out of 5. He had no atrophy of the left lower extremity. A diagnosis of left knee degenerative joint disease with chronic meniscus tear was indicated. An October 2011 VA outpatient treatment report reflects that the Veteran complained of left knee pain. Reduced range of motion was indicated. An assessment of left knee arthralgia, status post 5 injections and arthritis with torn meniscus was indicated. In December 2011, the Veteran requested a knee brace for his medial compartment osteoarthritis of the left knee. On examination, there was no gross ligamentous laxity determined, but there was some crepitus on range of motion. A McMurray's test was equivocal. The Veteran reported medial joint line and patellar discomfort. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a higher initial evaluation for his degenerative changes of the left knee. Initially, the Board notes that the Veteran is already assigned a 10 percent disability evaluation under Diagnostic Code 5010, and there is no x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. Thus, a higher initial evaluation is not warranted under Diagnostic Code 5010. The Board has also considered whether the Veteran would be entitled to a higher or separate disability evaluation for limitation of flexion and limitation of extension. However, the evidence does not show that he has flexion limited to 30 degrees or extension limited to 10 degrees. Rather, the evidence shows that, at worst, flexion has been limited to 110 degrees, as noted in private treatment records. Likewise, extension has been full (0 degrees). Therefore, a higher or separate evaluation is not warranted under Diagnostic Codes 5260 and 5261. Nevertheless, the Board has also considered whether an increased evaluation would be in order under other relevant diagnostic codes. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Significantly, the March 2010 VA examiner noted that there was a chronic meniscus tear, and the Veteran reported having swelling and locking at that time. A March 2008 x-ray could not exclude a small, loose body, and a November 2009 MRI revealed a chronic medial meniscus tear. An October 2011 VA treatment record also revealed a torn meniscus. In addition, the Veteran has reported having pain throughout the pendency of the appeal, private medical records dated in December 2008 and March 2009 documented mild effusion, and he had moderate effusion in December 2009. Diagnostic 5258 provides that dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint is rated at 20 percent. "Semilunar cartilage" is one of the menisci of the knee joint. Stedman's Medical Dictionary, 296 (27th ed., 2000). Thus, resolving all reasonable doubt in favor of the Veteran, the Board finds that a separate 20 percent disability evaluation is warranted under Diagnostic Code 5258. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran's left knee disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the combined 30 percent disability evaluation, and no higher. In this regard, the Board observes that the Veteran has complained of pain on numerous occasions. However, the effect of the pain is contemplated in the currently assigned disability evaluations under Diagnostic Codes 5010-5260 and 5258. Moreover, given the fact that the Veteran does not have compensable limitation of motion, it appears that the RO has continued the 10 percent evaluation in light of the painful motion. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. In fact, the October 2009 and March 2010 VA examiners commented that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The Board has also considered other potentially applicable diagnostic codes; however, the Veteran's degenerative changes of the left knee are not shown to involve any other factor that would warrant evaluation of the disability under any other provisions of the rating schedule. There is no evidence of ankylosis, impairment of the tibia and fibula, or genu recurvatum. As such, ratings under Diagnostic Codes 5256, 5262, or 5263 are not warranted. There is also no indication that he has undergone surgery to remove any semilunar cartilage; therefore, a separate or higher rating is not warranted under Diagnostic Code 5259. With regard to other impairment of the knee, as contemplated by Diagnostic Code 5257, the Veteran has indicated that he experiences instability of the left knee and was issued a knee brace. However, on examination, instability of the knee has not been demonstrated, and the Veteran has not described any specific incidents of falls or subluxations. Here, the Board finds that the medical evidence disclosing no instability is more probative. As such, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's left knee disability is manifested by recurrent subluxation or lateral instability, and a higher evaluation than that assigned is not warranted. C. Extraschedular Consideration In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's service-connected left shoulder and left knee disabilities are so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, which primarily consists of pain and limitation of motion of the left shoulder and left knee. Indeed, the assigned evaluations contemplate the overall effect of all of his symptomatology on his occupational and social functioning. As discussed above, there are higher ratings available under the diagnostic codes, but the Veteran's disabilities are not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected left shoulder and left knee disabilities under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). For the foregoing reasons, the Board concludes that there is no basis for staged ratings of the Veteran's left shoulder and left knee disabilities, as his symptoms have been primarily the same throughout the appeal period. ORDER Subject to the provisions governing the award of monetary benefits, an initial 20 percent disability evaluation is granted for left shoulder osteoarthritis with tendinopathy and bursitis, status post surgical subacromial depression and acromioplasty. Entitlement to an initial rating in excess of 10 percent for degenerative changes of the left knee is denied. Subject to the provisions governing the award of monetary benefits, a separate 20 percent disability evaluation for dislocated semilunar cartilage is granted. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs