Citation Nr: 1309516 Decision Date: 03/20/13 Archive Date: 04/01/13 DOCKET NO. 07-31 265 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the right knee. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from March 1986 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case was previously before the Board in February 2010 and July 2012 for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with the mandates of the remand orders. See Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to service connection for a left knee disorder, to include as secondary to the appellant's service-connected right knee disability, was referred to the RO in the previous remands and is again referred for further consideration. The issue of entitlement to service connection for a left knee disorder, to include as secondary to the appellant's service-connected right knee disability, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDING OF FACT During the period on appeal, the evidence demonstrates that the appellant's service-connected patellofemoral syndrome of the right knee has been manifested by flexion limited to no less than 120 degrees, normal extension, and pain. CONCLUSION OF LAW The criteria for entitlement to an initial rating greater than 10 percent for patellofemoral syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.159, 4.71a, Diagnostic Code 5260, 5261 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant'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, each piece of evidence of record. 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 appellant 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 appellant). 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 appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). More specific notice is required in claims for increased compensation. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here the appellant is appealing the initial rating assignment as to his 10 percent rating for patellofemoral syndrome of the right knee. In this regard, because the January 2006 rating decision granted the appellant's claim of entitlement to service connection, such claim is now substantiated. His filing of a notice of disagreement as to the initial rating assigned in the January 2006 determination does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3). Rather, the appellant's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Under 38 U.S.C.A. § 7105(d), upon receipt of a notice of disagreement in response to a decision on a claim, the agency of original jurisdiction must take development or review action it deems proper under applicable regulations and issue a statement of the case if the action does not resolve the disagreement either by grant of the benefits sought or withdrawal of the notice of disagreement. If VA receives a notice of disagreement in response to notice of its decision on a claim that raises a new issue, section 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved; however, section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue. See VAOPGCPREC 8-03 (December 22, 2003); 69 Fed. Reg. 25180 (2004); 38 C.F.R. § 3.159(b)(3) (2012). As a consequence, VA is only required to advise the appellant of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here. The statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic code (DC) for rating the disability at issue, and included a description of the rating formulas for all possible schedular ratings under this diagnostic code. The appellant was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the appellant has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file. Private medical records identified by the appellant have been obtained, to the extent possible. As requested by the Board in the July 2012 Board remand, the RO requested that the appellant identify the names, address and dates of treatment for all medical care providers in August 2012 and October 2012. The appellant did not reply. Thus, the Board finds VA satisfied its duty to assist. See Stegall, 11 Vet. App. at 268. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the appellant. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the appellant's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran appropriate VA examinations in October 2005, October 2007 and October 2012. The examinations are adequate because they are based on a thorough examination, a description of the Veteran's pertinent medical history, and appropriate diagnostic tests. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The appellant has not reported receiving any recent treatment specifically for this condition and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the appellant's service-connected disorder 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. The VA examination reports are thorough and provided findings pertinent to the rating criteria. The examinations in this case are adequate upon which to base a decision. The October 2012 VA examination was also completed in compliance with the mandates of the July 2012 remand. See Stegall, 11 Vet. App. at 268. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the appellant. Id. § 4.3. An appeal from the initial assignment of a disability rating, such as the appeal in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). 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 these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by 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, 4.45, see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. The appellant's service-connected patellofemoral syndrome of the right knee is currently evaluated at 10 percent under Diagnostic Code 5261. Extension limited to 5 degrees warrants a noncompensable rating, to 10 degrees warrants a 10 percent rating, to 15 degrees warrants a 20 percent rating, to 20 degrees warrants a 30 percent rating, to 30 degrees warrants a 40 percent rating, and to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under diagnostic code 5260, flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. If there is evidence of subluxation or instability, a separate rating may be warranted under Diagnostic Code 5257. Slight recurrent subluxation or lateral instability warrants a 10 percent evaluation; moderate recurrent subluxation or lateral instability warrants a 20 percent evaluation; and severe recurrent subluxation or lateral instability warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate" and "severe" as used in various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code, without violating the prohibition on pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97. A January 2006 rating decision granted entitlement to service connection for patellofemoral syndrome of the right knee with an evaluation of 10 percent effective April 1, 2005. Thus, the period on appeal is from April 1, 2005. III. Analysis The appellant contends that he is entitled to a rating in excess of 10 percent for his service-connected right knee disability. For the reasons that follow, the Board concludes that a higher rating is not warranted. An August 2005 private treatment record reflects that the appellant reported that he had symptoms of pain, associated with limping, popping, locking, catching, clicking, stiffness, giving way and weakness which all seemed to be getting worse of late. On physical examination, the right knee had a range of motion of 0 to 140 degrees without pain. No ligamentous instability was present. There was tenderness of 2+ at the media joint line. No lateral joint line tenderness was noted. The impression was right knee pain. A September 2005 private treatment record reflects that the knee had range of motion of 0 to 140 degrees without pain and no ligamentous instability was present. There was 2+ medial joint line tenderness and no lateral joint line tenderness. An arthroscopic evaluation was recommended. The appellant's right knee was evaluated at a VA examination in October 2005. An X-ray of the right knee was negative. The appellant reported that the pain in the right knee was between a level of 1 to 3 on a regular basis. The knee would lock up daily. The appellant stated that the only treatment was a patella strap which he wore regularly. He stated that flare-ups occurred daily and the pain at that time was a level of 3 and would last from 5 to 10 minutes when the knee locked up. It was precipitated by standing and alleviated by rest. He bathed, fed, groomed, dressed and used the toilet without assistance. There was no history of surgery for the condition. On physical examination the knee had a range of motion of flexion of 130 degrees with pain on the medial joint line and extension of 0 degrees with pain. Medial and lateral collateral ligaments in neutral and 30 degrees of flexion. There was no abnormal motion. Anterior and posterior cruciate ligaments had 30 degrees of flexion with the foot stabilized. There was no abnormal motion. McMurray's test was absent. There was pain on motion, but no additional limitation of motion after repetitive motion. There were flare-ups and the VA examiner noted that there would likely be an increase in limitations of function during a flare-up. The VA examiner stated that it was not feasible to attempt to express this in terms of additional limitation of motion as these matters could not be expressed with any degree of medical certainty. The diagnosis was patellofemoral syndrome of the right knee. A November 2006 private treatment record indicates the appellant reported recurrent right knee pain and right knee patellar tendonitis. On examination, there was no atrophy, deformity, scarring or tenderness present. He had well healed arthroscopic portals present with no atrophy, deformity or tenderness present. The range of motion of the knee was 0 to 140 degrees. No ligamentous instability was present. He had 2+ medial joint line tenderness and trace positive lateral joint line tenderness. Tenderness was seen along the patellar tendon without palpable defect noted. A December 2006 private treatment record reflects that the appellant reported recurrent right knee pain and a had right knee patellar tendonitis. He reported that he faithfully wore a Matt-pat strap and when he did not wear it, he had significant increased pain. On examination, the appellant ambulated without any immobilization or assistive devices with a normal non-antalgic gait. The knee had well healed arthroscopic portals with no atrophy, deformity or tenderness present. Range of motion was 0 to 135 degrees without pain. No ligamentous instability was present. There was 2+ medial joint line tenderness and trace positive lateral joint line tenderness. Tenderness was seen along the patellar tendon without palpable defect noted. A February 2007 private treatment record reflects that the appellant still had pain along the joint line. The diagnosis was right knee patella tendonitis. On examination, the appellant ambulated without any immobilization or assistive device with normal non-antalgic gait, though a well-fitting Matt-pat strap was noted. Range of motion of the right knee was 0 to 135 degrees without pain. No ligamentous instability was present (negative Lachman, negative anterior/posterior drawer, negative varus/ valgus instability at 0 or 30 degrees, negative pivot shift). He had 2+ medial joint line tenderness and trace positive lateral joint line tenderness. Tenderness was seen along the patellar tendon without palpable defect noted. The knee was cool without effusion. The examination revealed well healed arthroscopic portals present with no atrophy, deformity or tenderness. The appellant's right knee was evaluated at a VA examination in October 2007. The appellant reported that he had locking and instability "every day" at any situation. The pain was documented as a 5/10 on the Mankosi pain scale as constant, burning, stinging, located in the lateral kneecap. Flares were associated with cold weather or sleeping wrong and was a 9/10 that could last anywhere from four to five minutes to 30 minutes. It was aggravated by exercise. He reported that he took Darvocet, Tylenol and Motrin. The scar associated with it had a fatty deposit residual. No infections were noted. On physical examination, the appellant had passive range of motion of flexion from 0 to 140. Extension was full at zero. The appellant had active range of motion of flexion of 110 and extension at 20. The knee had negative Lachman's, posterior anterior drawer, McMurray's, grind test, genu varum, valgus and recurvatum. The knee was positive for lateral joint line tenderness. The VA examiner stated that additional limitation of function due to repetitive use or flare-ups could not be determined without resorting to mere speculation. No discomfort or difficulty with range of motion testing or effusion, edema, erythema, tenderness, palpable deformities was found except as noted. The diagnosis was right knee strain. No significant abnormalities were identified. The appellant's VA treatment records reflect that the appellant had knee arthralgia. He primarily complained of pain in his left knee. See April 2011 VA treatment record. The VA treatment records indicate he wore a brace for knee pain. A September 2012 X-ray indicated a normal right knee series. The knee joint spaces were well preserve and no bony, joint, or soft tissue abnormality was seen. The appellant's right knee was evaluated at a VA examination in October 2012. The appellant stated that he did not request an increase for his right knee condition, but rather a request for service-connected for his left knee. He stated that he knew the examination would be a "waste of time" since his left knee was the bad one (not the right). The VA examiner found that there were no current objective findings of a right knee condition. There was a decreased range of motion due to suboptimal effort, active resistance, Waddell's signs and deconditioning. The VA examiner noted that there were constant inconsistencies noted on documentation versus member statements. Objective data contradicted member statements. Active resistance was noted during passive range of motion, and the appellant demonstrated higher range of motion inadvertently during examination. The VA examiner noted that normal range of motion was documented after the arthroscopy in 2005 by an orthopedic, but there was now "decreased" range of motion without changes on X-rays or pathology to support it. The VA examiner also noted that both knees had exactly the same range of motion when the appellant stated at the beginning of the interview that his examination of the right knee was a waste of time since it was his left knee that had problems. On examination, the appellant did not report having flare-ups that impacted the function of the knee and/or lower leg. The right knee had flexion of 120 degrees. There was no objective evidence of painful motion. The right knee had extension of 0 degrees and there was no objective evidence of painful motion. As noted above, the VA examiner found that the decreased range of in the right knee was due to suboptimal effort, active resistance, Waddell's signs and deconditioning. The appellant was able to perform repetitive testing with 3 repetitions. Post-test range of motion testing revealed right knee flexion of 120 degrees and extension of 0 degrees. There was no additional limitation in range of motion of the knee and lower leg following repetitive-use testing. The appellant did not have any functional loss or functional impairment of the knee and lower leg. Right knee flexion and extension had muscle strength of 5/5 indicating normal strength. Anterior instability, posterior insatiability, and medial-lateral instability testing indicated the appellant's right knee was normal. There was no evidence or history of recurrent patellar subluxation or dislocation. No other conditions were noted. The appellant had a scar relating to the knee. The VA examiner indicated that the scar was not painful and/or unstable, or had a total area of greater than 39 square cm. The VA examiner found the right knee did not impact the appellant's ability to work. A November 2012 VA treatment record reflects that the appellant was measured for bilateral patella knee braces. Based on the above evidence of record, the Board finds that the preponderance of the evidence is against a finding that the appellant is entitled to an evaluation in excess of 10 percent for patellofemoral syndrome of the right knee. The Board finds that the overall evidence of record does not reflect that the appellant has extension limited to a degree warranting a higher evaluation. The Board acknowledges that the October 2007 VA examination report indicated the appellant's right knee had active extension limited to 20 degrees. However, the rest of the evidence of record indicates the appellant's extension was normal, at 0 degrees. The August 2005 and September 2005 private treatment records reflect that the right knee had extension of 0. The October 2005 VA examination report also indicates the appellant had extension of 0 degrees with pain. The November 2006, December 2006, and February 2007 private treatment records note that the appellant had extension of 0 degrees. The October 2007 VA examination report indicates the appellant's right knee had passive extension of 0 degrees. The October 2012 VA examination report indicates the appellant's right knee had extension of 0 degrees. The Board also notes that the October 2012 VA examiner noted that the appellant's decreased range of motion was due to suboptimal effort, active resistance, Waddell's signs and deconditioning. As all of the evidence of record except the October 2007 VA examination report finding indicate the appellant had normal extension, and the October 2012 examiner indicated that the appellant exerted suboptimal effort at that examination, the Board finds that a higher rating for limited extension of the right knee is not warranted. The Board has considered whether the appellant is entitled to a higher rating under another Diagnostic Code. The appellant's right knee did not have limitation of flexion warranting a higher rating. As noted above, under Diagnostic Code 5260, flexion limited to 60 degrees warrants a noncompensable rating. The April 2005 and September 2005 private treatment records reflect that the appellant's right knee had flexion of 140 degrees without pain. The October 2005 VA examination report indicates the right knee had flexion of 130 degrees. The November 2006 private treatment record indicates the appellant's right knee had flexion of 140 degrees. The December 2006 and February 2007 private treatment records reflect that the right knee had flexion of 135 degrees without pain. The October 2007 VA examination report indicates the appellant's right knee had active flexion of 110 degrees. The October 2012 VA examination report indicates the right knee had flexion of 120 degrees. As noted above, the examiner also found that the decreased range of motion was due to suboptimal effort, active resistance, Waddell's signs and deconditioning. Although the appellant reported instability in the right knee during the period on appeal, the Board finds that the preponderance of the evidence reflects that the appellant did not have subluxation or instability warranting a separate rating under Diagnostic Code 5257. The August 2005 and September 2005, November 2006, December 2006, February 2007, private treatment records noted that no ligamentous instability was present. The October 2005 VA examination report did not indicate that the right knee was unstable. On examination, there was no abnormal motion of the medial and lateral collateral ligaments or the anterior and posterior cruciate ligaments. The October 2007 VA examination report reflects that the appellant reported having instability every day in his right knee. However, on examination, the appellant had negative Lachman's, posterior anterior drawer, McMurray's, grind test, genu varum, valgus and recurvatum tests, indicating he did not have instability. The October 2012 VA examination report reflects that anterior instability, posterior instability, and medial-lateral instability testing indicated the appellant's right knee was normal. There was no evidence or history of recurrent patellar subluxation or dislocation. The appellant is competent to report symptoms capable of lay observation, such as knee instability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Board finds the appellant's assertion that he had instability in his right knee every day at the October 2007 VA examination to be less than credible as it is contradicted by the objective evidence of record. The Board finds that a preponderance of the evidence reflects that the appellant is not entitled to a separate evaluation under Diagnostic Code 5257. The Board has also considered whether any alternate Diagnostic Codes may serve as a basis for an increased rating. However, the evidence of record does not demonstrate that the appellant suffers from ankylosis, as contemplated by Diagnostic Code 5256, dislocated semilunar cartilage, as contemplated by Diagnostic Code 5258, the absence of semilunar cartilage, as contemplated by Diagnostic Code 5259, impairment of the tibia and fibula, as contemplated by Diagnostic Code 5262, or genu recurvatum, as contemplated by Diagnostic Code 5263. Therefore, the appellant is also not entitled to a higher evaluation under these Diagnostic Codes. The Board notes that it has also considered application of 38 C.F.R. § 4.40 and 4.45 in light of the Court's ruling in DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The record demonstrates the appellant has complained of experiencing right knee pain. The October 2005 VA examination indicated that the appellant's knee range of motion was 0 to 130 degrees with pain. The October 2012 VA examination report indicated that there was no additional limitation in range of motion of the knee and lower leg following repetitive-use testing. Additionally, the appellant's right knee is already rated as 10 percent disabling for painful motion as the majority of the evidence indicated the appellant had normal extension. Thus, the appellant has already been compensated for painful motion. 38 C.F.R. §§ 4.40, 4.45 (2008); DeLuca, 8 Vet. App. at 206. Further, the Board finds that there has been no demonstration, by clinical evidence or the appellant's statements, of additional functional impairment comparable to the next higher evaluation under Diagnostic Code 5260 or 5261. The October 2012 VA examination report reflects that the appellant did not have any functional loss or functional impairment of the knee and lower leg. The Board notes that the appellant had a right knee diagnostic arthroscopy in May 2005. The evidence of record does not reflect that the appellant has symptoms from a scar resulting from the arthroscopy. The November 2006 private treatment record indicated there was no deformity or scarring present. The February 2007 private treatment record indicated that the appellant had well healed arthroscopic portals present with no atrophy, deformity or tenderness. The October 2007 VA examination indicated the scar associated with the right knee had a fatty deposit residual. The October 2012 VA examination report indicated that the scar was not painful and/or unstable, or had a total area of greater than 39 square cm. Thus, the Board finds that a separate rating for a scar is not warranted. In light of the above findings, the Board concludes that throughout the rating period on appeal, the appellant's right knee disability symptomatology more nearly approximates the currently assigned 10 percent evaluation. Accordingly, the Board concludes that an initial rating in excess of 10 percent under Diagnostic Code 5261 is not warranted. The Board has considered the appellant's statements that he has pain in his right knee. The Board finds that the appellant's statements that he had pain in the right knee are credible and he is competent to report pain. However, pain in the right knee is consistent with the 10 percent initial rating. As discussed above, the Board does not find the appellant's assertion that he had instability of the knee to be credible. The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the right knee disability. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the right knee disability are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the right knee disability is primarily manifested by pain and some limitation of motion due to pain. Many of the applicable diagnostic codes used to rate the appellant's disability provide for ratings based on limitation of motion, and the effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, 8 Vet. App. 202. The effects of the appellant's disabilities have been fully considered and are contemplated in the rating schedule. Consideration of whether the appellant's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service- connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that the disability at issue renders him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER Entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the right knee is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs