Citation Nr: 1308933 Decision Date: 03/15/13 Archive Date: 03/25/13 DOCKET NO. 04-42 088 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to a rating in excess of 10 percent for service-connected tendonitis, left knee. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from October 1974 to October 1977 and from February 1991 to July 1991. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in Montgomery, Alabama (RO). This case was remanded by the Board in April 2010 and April 2012 for additional development. FINDING OF FACT The medical evidence of record shows that the Veteran's left knee disability is manifested by pain, crepitus, hyperextension, genu recurvatum, and limitation of motion to, at most, 90 degrees of flexion and 0 degrees of extension. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for tendonitis, left knee, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice 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, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). The Veteran was provided notice in letters dated in February 2004, May 2006, June 2008, and April 2010. Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the November 2012 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claim. The Board notes that the May 2012 VA knee and lower leg conditions examination report contains a typo. Specifically, in the section for measurement of left knee extension, the examiner checked none of the boxes under the section indicating the Veteran's actual range of motion, but checked two boxes under the section indicating where objective evidence of painful motion begins. The two boxes checked were for (1) 0 degrees and hyperextension and (2) 20 degrees of extension. The same May 2012 examination report stated that the Veteran experienced left knee hyperextension, a condition which is also reported in multiple other medical reports of record. Accordingly, the Board finds that the May 2012 report intended to indicate that the Veteran's actual extension was to 0 degrees or hyperextension, and his pain began at 20 degrees. As the Veteran's left knee hyperextension is well documented, the Board finds that this typo is not sufficiently confusing or contradictory to warrant a Remand for an addition examination. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2012). The 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 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). 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 (2012). 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). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Service connection for residual, injury, knee, left, was granted by a March 1978 rating decision and a noncompensable rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5260, effective October 7, 1977. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. Unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and "99." 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that an unlisted musculoskeletal disorder, under Diagnostic Code 5299, was the service-connected disorder, and limitation of flexion of the leg, under Diagnostic Code 5260, was a residual condition. Subsequently, a July 2003 rating decision recharacterized the disability as tendonitis, left knee, and assigned a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5024-5260, effective May 9, 2002. The hyphenated diagnostic code in this case indicates that tenosynovitis, under Diagnostic Code 5024, was the service-connected disorder, and limitation of flexion of the leg, under Diagnostic Code 5260, was a residual condition. A June 2004 rating decision granted a 100 percent rating for tendonitis, left knee, under 38 C.F.R. § 4.30, effective April 9, 2004, with a 10 percent rating assigned effective June 1, 2004. Finally, a November 2012 rating decision granted a separate 10 percent rating for left knee genu recurvatum under 38 C.F.R. § 4.71a, Diagnostic Code 5263, effective May 30, 2012. A February 2004 VA joints examination report noted the Veteran complained of constant left knee pain with occasional giving way, though he denied constitutional symptoms or episodes of dislocation. He reported that he had not lost any time from work. On physical examination of the left knee, there was no erythema, but there was mild inflammation, tenderness on palpation, and pain with movement. The Veteran's knee was stable, but he exhibited considerable guarding and there was audible crepitus. Left knee range of motion was to 130 degrees of flexion and 0 degrees of extension. On X-ray examination, the Veteran's left knee was normal. The diagnosis was left knee strain with mild functional loss of range of motion due to pain. A March 2004 VA outpatient medical report noted the Veteran complained of left knee pain and swelling for the previous month. On physical examination, there was effusion and tenderness of the left knee. The assessment was left knee effusion and osteoarthritis/pre-patellar bursitis. The Veteran was recommended for an X-ray. A March 2004 VA X-ray examination report stated there was an increase in soft tissue anterior to the left patella, most likely representing a lipoma. However, there was no evidence of joint effusion and the joint space and bony structures were normal. An April 2004 VA outpatient medical report noted the Veteran complained of a growing mass in front of his left knee for the previous six weeks. On physical examination, there was a 13 by 8 centimeter cystic mass over the anterior aspect of the left knee. There were no findings suggestive of any intra-articular disorder, including effusion, heat, and redness. The impression was left pre-patellar bursitis. The medical evidence of record shows that the Veteran subsequently underwent a left pre-patellar bursectomy. A May 2004 VA kinesiotherapy report noted the Veteran complained of left knee pain which radiated to his left ankle. A May 2004 VA outpatient medical report stated that, on examination, the Veteran's left knee had a normal range of motion. It was noted he was wearing knee braces. A June 2004 VA outpatient medical report stated that, on examination, the Veteran's left knee had a normal range of motion and that he was wearing knee braces. The assessment was arthralgia status post bursectomy left knee. A July 2004 private neurological report noted the Veteran complained of bilateral knee pain, as well as pain and numbness in the bilateral legs and feet. On neurological testing, multiple left side abnormalities were noted. A September 2004 magnetic resonance imaging (MRI) scan revealed findings suggestive of a strain or partial tear of the medial collateral ligament, a small focal articular defect in the medial articular surface of the patella, pre-patellar bursitis, and a small Baker's cyst. An October 2004 VA outpatient medical report stated that, on examination, the Veteran's left knee had a normal range of motion, but he was wearing knee braces. The assessment was arthralgia. A January 2005 VA outpatient medical report noted a well-healed transverse scar over the anterior patella. The Veteran's left knee range of motion was from 0 degrees of extension to 120 degrees of flexion. There was no effusion, erythema, edema, or synovitis. The knee was stable with Lachman's test, anterior drawer test, posterior drawer test, varus stressing, and valgus stressing. The Veteran ambulated with an antalgic gait and carried a cane in his right hand. McMurray's test was negative and there was no tenderness on palpation. After a review of a November 2004 MRI report, the examiner concluded that there was no orthopedic etiology for the Veteran's pain. A neurological examination was recommended. A March 2005 VA outpatient medical report stated that, on examination, the Veteran's left knee had a normal range of motion and that he was wearing knee braces. The assessment was arthralgia of the knees and osteoarthritis. An April 2005 VA outpatient medical report stated that, on examination, the Veteran's left knee had a normal range of motion and that he was wearing knee braces. The assessment was chronic knee pain, medial collateral ligament tear with Baker's cyst, and degenerative joint disease. An October 2005 VA outpatient medical report stated that, on examination, the Veteran's left knee had a normal range of motion and that he was wearing knee braces. In a February 2008 VA joints examination report, the Veteran complained of constant left knee pain at a level of 9 on a scale from 1 to 10, with stiffness and swelling. He reported occasional locking, but denied instability. On physical examination his gait was antalgic and he used a quad-cane to ambulate. On range of motion testing, the Veteran's left knee movement was guarded, with flexion to 115 degrees and extension to 0 degrees. There was no crepitus or instability noted, but the Veteran was unable to do deep-knee bends. X-ray examination showed early degenerative osteoarthritis of the bilateral knees. The diagnosis was early degenerative osteoarthritis of the bilateral knees with previous left patellar bursectomy. The examiner stated that the Veteran's functional loss due to pain was moderate and that functional loss was moderately severe on repetitive use and/or flare-ups due to pain, fatigue, and weakness. A December 2008 VA outpatient medical report noted that the Veteran wanted a knee replacement, but was not considered a candidate for the surgery by the VA orthopedic department "as his problem [may be] neuropathic, rather than joint." On physical examination, the Veteran's knee appeared stable on Lachman testing, anterior drawer testing, and valgus maneuvers. There were mild hypertrophic changes of the left knee. The Veteran had mild crepitus in both knees, but a full range of motion. There was some left thigh muscle atrophy. The assessment was osteoarthritis. The examiner stated that a total knee replacement was "unsure" due to "minor changes to last MRI. He may have a polyneuropathy that may preclude ortho[pedic] surgery." The examiner noted that MRI and electromyography (EMG) studies would be obtained and that a neurology work-up should be considered because it appeared he had neuropathy. A December 2008 VA X-ray examination report stated that on views of the Veteran's knees, there were small osteophytes from the poles of the patella. No fracture, dislocation, or joint effusion was identified, and the joint spaces were unremarkable. The report stated that there had been no significant changes since the previous examination. The impression was minimal degenerative changes. A January 2009 EMG/nerve conduction velocity report stated that the Veteran was being evaluated for numbness of the bilateral feet and legs, greater on the left than the right. After diagnostic testing, the impression was left peroneal nerve palsy and right L5-S1 lumbar radiculopathy. A January 2009 VA orthopedic consultation report stated that, on examination, the Veteran's left knee was tender at the medial joint line and patellar facets. There was left knee range of motion to 90 degrees of flexion and 0 degrees of extension. The impression was osteoarthritis of the left knee. In a March 2009 VA outpatient medical report, the Veteran complained of left knee pain that was becoming increasingly disabling. On examination, there was left knee limitation of motion with crepitus and slight swelling. The Veteran appeared to be in considerable discomfort. An April 2009 VA MRI report stated that there was a small area of fibrillation or probably a tiny radial tear of the anterior central portion of the posterior horn of the medial meniscus. There was also a small subchondral abnormality that was suspected to represent subchondral cyst formation related to chondral loss in the medial anterior trochlea. On X-ray examination, there were small osteophytes from the poles of the patella, but no fracture, dislocation, or joint effusion was identified and the joint spaces were unremarkable. A May 2009 VA emergency department note stated that the Veteran used a cane and a knee brace for his left knee. A July 2009 VA medical examination report stated that the Veteran's medical records had been reviewed. The Veteran complained of left knee "jumping," numbness, and tingling all the way up his left leg. The report stated that the Veteran's walking was limited by back pain, but that he could ride a stationary bike without difficulty. On examination, the Veteran had normal motor strength in both legs, and no foot drop. On MRI examination of the Veteran's left knee, the joint spaces and menisci were normal and the ligaments were intact. The diagnosis was insufficient evidence of neuropathy due to the left knee joint. The examiner stated that there was "no documentation in his VA orthopedic medical records of neuropathy with a medical connection to his left knee." The examiner also stated that electromyography and nerve conduction velocity test results did not have a clinical correlation with the Veteran's knee joint. An August 2009 VA joints examination report noted the Veteran complained of left knee instability. On physical examination, the Veteran had left knee range of motion of 140 degrees of flexion and 0 degrees of extension. There was objective evidence of pain on active motion. There were no additional limitations after repetitive motion. In an August 2010 VA joints examination report, the Veteran stated that he experienced persistent left leg numbness and tingling due to nerve damage that occurred during a removal of a left knee cyst. He also reported constant chronic left knee pain with associated weakness, instability, giving way, hyperextension, and lack of endurance. The Veteran denied any stiffness, deformity, effusion, dislocation, subluxation, swelling, heat, redness, or drainage. He stated that he experienced unsteadiness and falling, and used a knee brace, cane, and walkers. The Veteran reported that he was able to stand for 20 minutes and walk one-quarter of a mile with a walker. There was no history of inflammatory arthritis, and he denied experiencing flare-ups. It was reported that his left knee disorder had no impact on feeding; a mild impact on lower body dressing and grooming; a moderate impact on recreation, travel, and shower and toilet transfers; a moderate to severe impact on shopping; a severe impact on chores; and prevented sports. On physical examination, the Veteran had a mildly flexed posture with an antalgic gait and poor propulsion. He used bilateral knee braces and a cane. The Veteran's left knee had a mild bony enlargement without edema as well as a well-healed transverse anterior knee surgical scar. The Veteran complained of tenderness to palpation of the entire joint, other than the tibial tuberosity. There was popping throughout the range of motion, which extended from 100 degrees of flexion to -5 degrees of extension, with pain throughout the majority of the range of motion. The Veteran did not have any frank instability and McMurray's test was negative. There was hyperextension of the left knee without the use of a brace, and the Veteran reported that the hyperextension was what caused the giving way. There was no loss of motion following repetitive testing. An April 2011 VA medical examination report stated that the Veteran walked in a symmetric and rhythmic fashion, using a right knee brace as an assistive aide. The Veteran had left knee range of motion 140 degrees of flexion and had hyperextension to 30 degrees. There was no increased loss of function after repetitive motion due to pain, fatigue, weakness, lack of endurance, or incoordination. There was also no joint tenderness, heat, or redness and McMurray's sign was negative. The Veteran had a 12 centimeter transverse operative scar anteriorly. There was no crepitus or patellofemoral pain noted. The Veteran's hyperextension instability was characterized as being moderate to severe in degree. An October 2011 VA medical opinion stated that the Veterans hyperextension was less likely than not related to his service-connected left knee tendonitis. The rationale was that inflammation of the tendons usually caused a loss of flexibility as the tendons are used for movement. It was stated that injury of ligaments can cause them to become stretched, which allows for extra movement of the joint, such as hyperextension or other instability. Hyperextension of the knee was not caused by inflammation of the tendons. A May 2012 VA knee and lower leg conditions examination report stated that the Veteran had diagnoses of left knee tendonitis, hyperextension, and status post pre-patellar bursectomy. The Veteran reported experiencing daily flare-ups of his left knee disorder. On physical examination, the Veteran had left knee range of motion to 140 degrees or more of flexion, with pain at 140 degrees or more. The examiner failed to check any boxes indicating where the Veteran's extension ended, and then checked two boxes indicating where painful motion began. These two boxes were "0 or any degree of hyperextension (check this box if there is no limitation of extension)" and "Unable to fully extend; extension ends at: [X] Other: 20 degrees." The Veteran was able to perform repetitive use testing, and he had no additional limitation of motion following the repetitive use testing. The Veteran also had more movement than normal, pain on movement, and disturbance of locomotion in the left knee. However, there was no functional loss of the left leg, less movement than normal, weakened movement, excess fatigability, incoordination, swelling, deformity, atrophy of disuse, instability of station, or interference with sitting, standing, and weight-bearing. The Veteran also complained of back pain with left knee flexion. There was no tenderness or pain to palpation of the joint line or soft tissue. The Veteran had slightly reduced left knee strength on both flexion and extension. On joint stability testing, the Veteran was positive for anterior instability, but negative for posterior instability and medial-lateral instability. There was no evidence of patellar subluxation or dislocation. The Veteran did not have shin splints, stress fractures, chronic exertional compartment syndrome, or leg length discrepancy, but he did have left side acquired genu recurvatum with weakness and insecurity in weight-bearing. The Veteran did not have and had never had a meniscal condition, meniscal surgery, or a total knee replacement. The Veteran did have a scar related to his left knee disorder, but it was not painful, unstable, or greater than 39 square centimeters in area. He constantly used a brace and walker, but the Veteran's functional impairment was not equivalent to amputation of the extremity. On X-ray examination, the Veteran did not have degenerative or traumatic arthritis or patellar subluxation. The Veteran's left knee disorder was reported to impact his ability to work by making prolonged standing and walking inadvisable. The examiner opined that the Veteran did not presently have any inflamed tendons, and stated that the bursectomy performed in 2004 was not related to the Veteran's service-connected tendonitis. The examiner stated that it could not be determined whether the Veteran's hyperextension, which was also present on the right knee, was related to his service-connected left knee disorder or had a different etiology. The examiner opined that the overall severity of the Veteran's left knee disorder was mild to moderate in degree, and that the Veteran did not have any neurologic deficits from his right knee disorder. Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). Under Diagnostic Code 5260, flexion that is limited to 60 degrees is warrants a 0 percent rating; flexion that is limited to 45 degrees warrants a 10 percent rating; and flexion that is limited to 30 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Under Diagnostic Code 5261, extension that is limited to 5 degrees warrants a 0 percent rating; extension that is limited to 10 degrees warrants a 10 percent rating; and extension that is limited to 15 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2012). Recurrent subluxation or lateral instability of the knee warrants a 10 percent rating when it is slight and a 20 percent rating when it is moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The evidence of record shows that the Veteran's left knee disability is manifested by pain, crepitus, hyperextension, genu recurvatum, and limitation of motion to, at most, 90 degrees of flexion and 0 degrees of extension. Accordingly, the Board finds that a rating in excess of 10 percent is not warranted for the left knee under either Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). In addition, separate ratings for limitation of flexion and extension are not warranted, as the record does not show that the Veteran's left knee ranges of motion have ever been limited to a compensable degree in either flexion or extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012); VAOPGCPREC 9-04 (2004), 69 Fed. Reg. 59990 (2004). The Veteran has reported right knee pain on use, a contention which is substantiated by the medical evidence of record. His pain on motion has been noted on numerous medical reports, including VA examination reports dated in February 2004, February 2008, August 2009, August 2010, April 2011, and May 2012. None of these examination reports, however, have found that his pain resulted in functional loss of range of motion beyond that measured in the various examinations. There is no evidence of record which indicates that the Veteran's left knee pain or dysfunction ever limited his right knee range of motion to 45 degrees of flexion or 10 degrees of extension. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 10 percent for his left knee disorder. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). As for other provisions under the Schedule, the Veteran's left knee has never been ankylosed, there was no malunion or nonunion of either the tibia and fibula, and there were no symptoms from the removal or dislocation of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262 (2012); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). Accordingly, an initial rating in excess of 10 percent is not warranted under these diagnostic codes. While the evidence of record shows that the Veteran does have genu recurvatum, a separate rating was granted for this aspect of the Veteran's left knee disorder in a November 2012 rating decision and the Veteran has not perfected an appeal as to either the rating or effective date assigned. As such, the Veteran's genu recurvatum symptoms are not for consideration in conjunction with the claim on appeal. See 38 C.F.R. § 20.200 (2012). The record also shows that the Veteran has a diagnosis of left knee arthritis, shown through X-ray examination. However, such findings, combined with the limitation of motion elicited, would warrant no more than a 10 percent evaluation under 38 C.F.R § 4.71a, Diagnostic Codes 5003, 5010. See also 38 C.F.R. § 4.45. Additionally, awarding separate evaluations under Diagnostic Code 5003 would constitute prohibited pyramiding. 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Accordingly, an increased or separate rating for left knee arthritis is not warranted. Furthermore, a separate rating for instability is not warranted for the left knee, as the medical evidence of record does not show recurrent subluxation or lateral instability. While the Veteran reported experiencing instability on multiple occasions, no lateral instability has ever been found on physical examination. Medical reports dated in February 2004, January 2005, February 2008, December 2008, and August 2010 specifically stated that the Veteran's left knee was stable. While anterior instability was found on the May 2012 VA knee and lower leg conditions examination report, anterior knee instability affects the stability of the knee in extension and does not constitute lateral instability, which affects the stability of the knee from side-to-side. The same May 2012 report specifically stated that the Veteran did not have medial-lateral instability. In addition, the May 2012 report demonstrates that the Veteran's anterior instability is related to his hyperextension/genu recurvatum, the symptoms of which, as discussed above, are not for consideration in conjunction with the claim on appeal. Accordingly, the Board finds that separate rating for recurrent subluxation or lateral instability is not warranted for the Veteran's left knee disorder. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The medical evidence of record shows that the Veteran has a left knee surgical scar which is related to treatment for which he received a temporary total disability rating under 38 C.F.R. § 4.30. However, there is no evidence of record that this surgical scar has ever been painful, unstable, or covered an area of at least 39 square centimeters. Accordingly, a separate compensable rating is not warranted for the Veteran's left knee surgical scar. See 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804 (2012). Finally, the medical evidence of record includes some commentary regarding the possible presence of a neurologic abnormality which was potentially related to the Veteran's April 2004 surgical operation. However, the May 2012 VA knee and lower leg conditions examination report was written by the same physician who performed that left knee operation, and he stated that the operation was not related to the Veteran's service-connected tendonitis. In addition, he also concluded that the Veteran did not have any neurologic deficits around his left knee which were due to any left knee disorder. As this opinion was provided by the same physician who performed the April 2004 operation, the Board finds it highly probative. Accordingly, the preponderance of the evidence of record shows that the Veteran does not have a current diagnosis of a neurological disorder which is related to his service-connected left knee disorder. This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's left knee symptoms, the evidence shows no distinct periods of time during which his symptoms have varied to such an extent that a rating in excess of 10 percent would be warranted under any diagnostic code. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (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. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun, 22 Vet. App. 111. If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular evaluation is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities rating for his left knee disability inadequate. The Veteran's left knee disorder was rated under all possible diagnostic codes in 38 C.F.R. § 4.71a, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's left knee disability is manifested by pain, crepitus, hyperextension, genu recurvatum, and limitation of motion to, at most, 90 degrees of flexion and 0 degrees of extension. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability rating currently assigned for his left knee disorder. The Board also finds that the criteria for the currently assigned rating for the Veteran's left knee disorder reasonably describe his disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. While the evidence of record shows that the Veteran has retired, it does not show that his left knee disorder alone is sufficiently severe to make him unable to work or to have marked interference with his ability to maintain employment. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, The Board finds that the preponderance of the evidence is against the claim for an increased rating for tendonitis, left knee. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). ORDER A rating in excess of 10 percent for service-connected tendonitis, left knee, is denied. ____________________________________________ T. L. Douglas Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs