Citation Nr: 1310405 Decision Date: 03/29/13 Archive Date: 04/09/13 DOCKET NO. 10-26 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased rating for a right knee disability, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from January 1999 to January 2003. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, that continued a 10 percent rating for the Veteran's right knee disability. The Board notes that a March 2010 rating decision granted service connection for a left knee disability. This grant represents a full grant of the benefit sought on appeal for a left knee disability, and therefore, this issue is not before the Board. The Veteran indicated in his June 2010 Substantive Appeal that he wanted to be scheduled for a videoconference hearing. However, the Veteran withdrew his hearing request in September 2010. As the record does not contain any additional requests for an appeals hearing, the Board deems the Veteran's request for a hearing to be withdrawn. See 38 C.F.R. § 20.702 (2012). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. FINDING OF FACT The Veteran's right knee disability has been manifested by full extension and flexion limited at most to 126 degrees. There is no instability, subluxation, or ankylosis. There is no x-ray evidence of arthritis. Although there is evidence of a dislocated semilunar cartilage with frequent episodes of pain, the evidence does not show frequent episodes of locking and effusion. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent disabling for a right knee disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5257, 5258, 5260, 5261 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act The Veterans Claims Assistance Act (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the appellant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The Veteran was provided VCAA notice in a March 2009 letter. This letter advised the Veteran of what information and evidence is needed to substantiate his claim for a higher rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter also advised the Veteran of the necessity of providing medical or lay evidence demonstrating the level of disability and the effect that the disability has on his employment. The notice also provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The letter further advised the Veteran of how effective dates are assigned, and the type of evidence which impacts those determinations. The claim was last readjudicated in February 2013. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. Specifically, the information and evidence that have been associated with the claims file include service treatment records, a private MRI report, VA examination reports, and the Veteran's statements. The Board notes that the RO had scheduled the Veteran for a November 2012 VA examination. However, the Veteran failed to report to the November 2012 VA examination. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). As discussed above, the VCAA provisions have been considered and complied with. The appellant was notified and aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran has been an active participant in the claims process by reporting for VA examinations, responding to notices, and submitting evidence and argument. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, supra; Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon 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 the 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. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2012). Raters must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14 (2012). The guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, the Board notes that the provisions of 38 C.F.R. § 4.40 (2012) and 38 C.F.R. § 4.45 (2012) should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). In addition, the Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2011). For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2012). The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a (2012). For VA purposes, normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II (2012). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Diagnostic Code 5010 (traumatic arthritis) directs that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5010. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. In this case, there is no x-ray evidence of arthritis, and even if there were arthritis present, the Veteran is already in receipt of a compensable rating under a limitation of motion diagnostic code, or under a diagnostic code whose rating is predicated on limitation of motion. Therefore, the criteria listed under Diagnostic Code 5003 cannot serve as a basis for an increased rating for the right knee disability. 38 C.F.R. § 4.14. The Board will therefore discuss the applicability of the other regulatory criteria. A claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Code 5003 and Diagnostic Code 5257, and rating a knee disability under both of those codes does not amount to pyramiding under 38 C.F.R. § 4.14 (2012). VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate rating must be based on additional compensable disability. Separate ratings may also be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). The Veteran's right knee disability has been rated as 10 percent disabling under Diagnostic Code 5260, which pertains to limitation of flexion of the leg. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Other potentially applicable diagnostic codes include Diagnostic Code 5257, which contemplates recurrent subluxation or lateral instability; Diagnostic Code 5258, which contemplates dislocation of semilunar cartilage; and Diagnostic Code 5261, which contemplates limitation of extension of the leg. 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5258, 5261 (2012). In considering the applicability of other diagnostic codes, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5259 (symptomatic removal of semilunar cartilage), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable in this instance, as the medical evidence does not show that the Veteran has any of those conditions. Specifically, no report of VA examination demonstrates any objective finding of genu recurvatum, impairment of the tibia and fibula, or removal of semilunar cartilage. Similarly, ankylosis of the right knee has not been demonstrated. As an initial matter, the Board notes that the Veteran had been scheduled for a November 2012 VA examination. However, he failed to report to this examination. As a result, the Board must come to a determination solely on the basis of information included in the record. 38 C.F.R. § 3.655 (2012). The Board reminds the Veteran that the duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). On VA examination in May 2009, the Veteran complained of unbearable right knee pain with every step that he took. He described the pain as a constant, severe ache behind the kneecap on the medial and lateral patellar femoral region, with the medial region being worse than the lateral. He reported that the pain varied between a 7-8/10 in severity and was worsened with any increased weightbearing activity or strenuous weightbearing, such as running, carrying over 20 pounds, walking more than 0.25 mile, standing up from a seated position, kneeling, squatting, and going up and down stairs. He denied any swelling, redness, increased warmth, locking, dislocation, recurrent subluxation, or inflammatory arthritis. He stated that he felt a sensation of pressure in the knee when it bothered him more than usual. He indicated that he had popping in the knee and a feeling of instability, but reported that the knee had not given way on him since discharge from service. The Veteran did not use orthotic footwear or a cane, but he wore a knee brace for strenuous weightbearing activities. He did not take any medications or use any topical agents, but treated his knee with rest and elevation. He complained that he could no longer play sports, go biking, or go hiking. He reported that prior to being laid off from working as a welder, his right knee condition made it difficult for him to move into position to weld fixtures properly. Examination revealed that the Veteran was in no acute distress and that he ambulated from the waiting room with no apparent difficulty. He did not use any mechanical aids for ambulation. The right knee had no redness, increased warmth, effusion, or visible swelling. Patella had normal tracking without crepitation, and ballottement was negative. Range of motion testing showed 140 degrees flexion and 0 degrees extension. There was pain starting at 132 degrees. Anterior and posterior drawer signs and Lachman's were negative. There was no collateral ligament instability on varus and valgus stressing. McMurray's test was positive for medial joint pain. There was no genu varum or valgum on standing. The Veteran could squat and rise without difficulty or audible popping. He could also stand and walk on his toes without complaints of knee pain. His right forefoot did have callus formation superficially under the first and fifth metatarsophalangeal joints. Tandem gait showed no evidence of limping or ataxia. The Veteran had normal stride length without any antalgic gait. An April 2009 MRI of the right knee indicated that there was a large tear of the posterior horn of the medial meniscus, a small bone contusion of the posterior medial femoral condyle, and some intramuscular edema, which suggested a possible mild strain of the proximal gastrocnemius. An x-ray of the right knee was negative for any abnormalities. The examiner diagnosed the Veteran with torn medial meniscus of the right knee and found that upon repetitive testing, there was no evidence of further limitation of motion due to pain, weakness, stiffness, or fatigability. At a February 2010 VA examination, the Veteran complained that his right knee pain was a 5-6/10 in severity on average and that during flare-ups, the pain would increase to an 8/10 in severity. He reported that flare-ups occurred by mid and late afternoon on Thursday and Friday of his working week. He stated that he did a considerable amount of squatting, occasional stair climbing, and some lifting and carrying that was not excessively heavy because there were blocks, tackles, and chains. He indicated that he had a mild degree of intermittent slight locking of the right knee and would manually reduce it, sometimes needing to sit down to do this. He maintained that he had a slight amount of swelling during flare-ups, but denied any aspiration or effusion. He reported that he treated flare-ups with elevation, an ice gel, and nonsteroidal anti-inflammatory drugs. He complained that he no longer did any aerobic activities such as jogging or bicycling. Although the Veteran had been offered right knee surgery for his medial meniscus tear, he had declined it. He instead wore a knee brace, which helped with supporting his right knee while he worked. He also indicated that he used arch supports to help with his knee. He described his knee pain as an infrapatellar type of pain, which became rather aching and generalized during flare-ups. Examination revealed that the Veteran had considerable tenderness upon direct compression of the examiner's palm over his right patella. He had positive McMurray's sign of a definite nature with an audible click and immediate pain during maneuver of the right knee. There was no right knee swelling, but there was a mild degree of crepitus below the patella during flexion and extension. Range of motion testing showed 126 degrees flexion and 0 degrees extension, with pain and stiffness in equal proportions. However, there was no fatigability, weakness, or incoordination, and the Veteran's right knee function was not additionally limited by any factors following repetitive motion. The Veteran had no gross clinical instability at the right knee, and drawer's sign was negative. The right knee was 1 centimeter larger in circumference than the left knee. The bilateral thighs and calves measured equally in circumference. The Veteran had normal gait and was independently ambulatory. An x-ray of the right knee was negative. The Veteran was diagnosed with large horizontal oblique tear of the posterior horn of the medial meniscus of the right knee reaching the superior articular surface near the junction, with the posterior root ligament being the most prominent neuroimaging finding. The examiner noted that the Veteran had a markedly positive McMurray's sign that was consistent with his right medial meniscus tear that symptomatically and historically had been present for a considerable period of time. For VA purposes, normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II. On the above examinations, the Veteran's right knee had flexion limited at most to 126 degrees, as demonstrated at a February 2010 VA examination. The flexion of the Veteran's right knee must be limited to 30 degrees in order to warrant an increased rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Diagnostic Code 5260 therefore cannot serve as a basis for an increased rating in this case. Similarly, an increased rating is not warranted under Diagnostic Code 5261. The Veteran had full extension on both of the above examinations. The Veteran's right knee extension would have to be limited to 15 degrees in order to warrant an increased rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Because there is no evidence that the Veteran's right knee extension was limited to 15 degrees, Diagnostic Code 5261 cannot serve as a basis for an increased rating for the Veteran's right knee disability. The Board also finds that the Veteran is not entitled to an increased rating due to functional impairment as a result of pain on repetitive use. The Board notes that although the Veteran had pain on motion at his May 2009 VA examination and pain and stiffness on motion at his February 2010 VA examination, at no time did the Veteran have additional functional limitation or loss of motion due to pain, weakness, stiffness, fatigability, or incoordination with repetitive use. There was no evidence which suggests, that, on repetitive use, the right knee would be restricted by pain or other factors to only 30 degrees flexion or 15 degrees extension, the criteria for a 20 percent rating, or restricted such that any separate compensable rating for extension would be warranted. Thus, even considering the effects of pain on use, the evidence does not show that the right knee is limited in motion to 15 degrees extension or 30 degrees flexion, and thus the requirements for an increased rating are not met. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Furthermore, the Board finds that the evidence does not show that any additional functional limitation would result in the Veteran warranting any separate compensable rating for limitation of extension. Diagnostic Code 5257 provides a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). In this case, the medical evidence does not show any recurrent subluxation, nor does the Veteran report any subluxation. With respect to instability, although the Veteran indicated at his May 2009 VA examination that he had a feeling of right knee instability, he reported that the knee had not given way on him since discharge from service. Additionally, the objective medical evidence does not show any right knee instability on examination. Indeed, the May 2009 VA examiner found no collateral ligament instability on varus and valgus stressing, and the February 2010 VA examiner found no gross clinical instability of the right knee. Therefore, the Board finds that a separate rating is not warranted for the Veteran's right knee disability under Diagnostic Code 5257. Under Diagnostic Code 5258, a 20 percent rating is provided for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2012). An April 2009 MRI of the right knee indicated that there was a large tear of the posterior horn of the medial meniscus, and both the May 2009 and February 2010 VA examiners diagnosed the Veteran with torn medial meniscus of the right knee. The objective medical evidence shows that the Veteran does indeed have a dislocation of the semilunar cartilage and that he suffers from frequent right knee pain. Nevertheless, there is no evidence that the Veteran experiences frequent locking or effusion into the joint. Indeed, at his May 2009 VA examination, the Veteran denied any episodes of locking, and no effusion was found on examination. Moreover, on VA examination in February 2010, the Veteran denied having any effusion and reported only a mild degree of intermittent slight locking. Because there has been no objective evidence of locking or effusion, and the Veteran has not consistently reported repeated episodes of locking or effusion, the Board finds that the overall evidence does not demonstrate frequent locking or effusion. The criteria under Diagnostic Code 5258 are conjunctive, not disjunctive; thus all criteria must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Although the Veteran has a medial meniscal tear in the right knee with frequent pain, he does not meet the criteria for frequent locking or effusion. Because the objective medical evidence does not show frequent episodes of locking and effusion related to the Veteran's dislocated medial meniscus, the Board finds that a separate higher 20 percent rating for a right knee disability is not warranted under Diagnostic Code 5258. The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of his right knee disability. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluation assigned and do not more nearly approximate the criteria for a higher evaluation at any time during all periods on appeal. See 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5257, 5258, 5260, 5261 (2012); see also Fenderson, supra. The Board has also considered whether the Veteran's right knee disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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 Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. The Veteran's 10 percent rating for his right knee disability contemplated his subjective complaints of pain, stiffness, popping, and occasional swelling and locking, as well as his functional impairment. There was no evidence that his right knee disability was manifested by compensable limitation of extension, instability, subluxation, frequent episodes of locking and effusion, ankylosis, or arthritis. Therefore, the Veteran's subjective complaints were included in the 10 percent rating. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER A rating in excess of 10 percent disabling for a right knee disability is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs