Citation Nr: 1310893 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 05-11 768 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an increased disability rating for left knee meniscectomy residuals, currently evaluated as 30 percent disabling. 2. Entitlement to an increased disability rating for left knee osteoarthritis, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The Veteran served on active duty from April 11, 1976 to August 12, 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which in pertinent part denied a higher rating for left knee disabilities. The Veteran's timely Notice of Disagreement (NOD) with the foregoing rating decision had also encompassed the issue whether new and material evidence had been received to reopen a claim for service connection for right knee meniscectomy residuals. The RO issued a March 2011 Statement of the Case (SOC) on that issue, the Veteran did not submit a timely Substantive Appeal in response, Therefore, the petition to reopen involving right knee disability is not on appeal. Previously, the Veteran was scheduled for a September 2011 Travel Board hearing at the RO, but did not appear. He has not offered good cause justification for nonappearance or requested another hearing date, and hence the prior hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(e) (2012). The Board remanded this case for further development of the record in April 2012, and it has since returned for appellate disposition. As the Board observed in its prior remand, the Veteran's April 2005 Substantive Appeal form raised a claim for service connection for a chronic acquired psychiatric disorder to include depression, which the Board referred to the RO as the proper Agency of Original Jurisdiction (AOJ). Thus far, no action has been undertaken to initially adjudicate the claim. This matter is again referred to the RO for appropriate consideration. FINDINGS OF FACT 1. The Veteran is already in receipt of the highest available 30 percent schedular rating for left knee meniscectomy residuals, evaluated under Diagnostic Code 5257 on the basis of "other" knee impairment with lateral instability and/or recurrent subluxation. 2. The most probative assessment of the Veteran's left knee range of motion is that of from 0 to 90 degrees, when taking into consideration the potential impact of pain on use and other recognized forms of functional loss. CONCLUSIONS OF LAW 1. The criteria are not met for an evaluation higher than 30 percent for left knee meniscectomy residuals. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10; 4.71a, Diagnostic Code 5257 (2012). 2. The criteria are not met for an evaluation higher than 10 percent for left knee osteoarthritis. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71; 4.71a, Diagnostic Codes 5010, 5260, and 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist the Claimant The Veterans Claims Assistance Act, codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2012), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations were created, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. See also Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004) ("Pelegrini II"). A regulatory amendment effective for claims pending as of or filed after May 30, 2008 removed the requirement that VA specifically request the claimant to provide any evidence in his or her possession that pertains to the claim. 73 Fed. Reg. 23,353-56 (Apr. 30, 2008), later codified at 38 CFR 3.159(b)(1) (2012). The RO has informed the Veteran of what evidence would substantiate his claims for increased rating through VCAA correspondence dated in August 2003 that notified him as to each element of satisfactory notice. The VCAA notice further indicated the joint obligation between VA and the Veteran to obtain pertinent evidence and information, including that VA would undertake reasonable measures to assist in obtaining further VA medical records, private treatment records and other Federal records. See Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). The relevant notice information must have been timely sent because it was issued prior to the RO rating decision adjudicating the increased rating claims being decided, and therefore met the criteria for timely notice. See Pelegrini II; see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The RO (including through the Appeals Management Center (AMC)) has taken appropriate action to comply with the duty to assist the Veteran through obtaining VA treatment records. The Veteran has also undergone several VA examinations. See 38 C.F.R. §4.1 (for purpose of application of the rating schedule accurate and fully descriptive medical examinations are required with emphasis on the limitation of activity imposed by the disabling condition). The RO/AMC substantially complied with the terms of the prior Board remand by requesting the Veteran's authorization to obtain any additional relevant private treatment records (he did not respond with any further information), obtaining more recent VA medical records, and arranging for an updated VA examination. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has provided lay statements in support of his appeal. The Veteran previously requested a Travel Board hearing, but did not appear for this proceeding. The record as it stands includes sufficient competent evidence to decide the claims. Under these circumstances, no further action is necessary to assist the Veteran. The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). Background and Analysis Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, 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). When evaluating a musculoskeletal disability based upon range of motion, consideration is given to the degree of any additional limitation upon motion due to functional loss. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). This includes the analysis of additional functional impairment above and beyond the limitation of motion objectively demonstrated involving such factors as painful motion, weakness, incoordination, and fatigability, etc., particularly during times when these symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. Id.; see also 38 C.F.R. §§ 4.40, 4.45 and 4.59. In this regard, manifestation of pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The RO has evaluated the service-connected left knee meniscectomy residuals on the basis of other impairment of the knee, characterized by lateral instability and/or recurrent subluxation, under 38 C.F.R. § 4.71a, Diagnostic Code 5257. Left knee osteoarthritis has been evaluated at 10 percent disabling, based on 38 C.F.R. § 4.71a, Diagnostic Code 5010, pertaining to traumatic arthritis. The rating decision on appeal is dated from April 2004, the Veteran has had a pending claim for increase for left knee disability since March 2002, and thus the Board's review of the evidence is ongoing from that time period. Under Diagnostic Code 5010, traumatic arthritis is to be rated on the provisions regarding degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis will be rated on the basis of limitation of motion of the specific joint or joints involved. When however, limitation of motion at the joint(s) involved is noncompensable, a 10 percent rating is warranted for each major joint or group of minor joints affected by limitation of motion, to be combined, not added, under this diagnostic code. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Where there is no limitation of motion but x-ray evidence of involvement of two or more major joints or minor joint groups, a 10 percent rating is assigned. A 20 percent rating is assigned where the above is present but with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a (2012). Diagnostic Code 5260 pertains to limitation of leg flexion, and provides for a noncompensable rating when flexion is limited to 60 degrees. A 10 percent rating requires flexion limited to 45 degrees; a 20 percent rating requires flexion limited to 30 degrees; and the highest available 30 percent rating requires flexion limited to 15 degrees. Id. Diagnostic Code 5261 provides that limitation of motion of the knee will be assigned a noncompensable rating when extension is limited to 5 degrees. A 10 percent evaluation requires extension limited to 10 degrees; a 20 percent rating requires extension limited to 15 degrees; a 30 percent rating requires extension limited to 20 degrees; a 40 percent rating requires extension limited to 30 degrees; and a maximum 50 percent rating is assigned when extension is limited to 45 degrees. Id. Normal range of motion for the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5257, "other" knee impairment is evaluated based upon recurrent subluxation and/or lateral instability. This Diagnostic Code provides that a 10 percent disability rating is warranted for slight disability, a 20 percent rating is warranted for moderate disability, and a maximum 30 percent evaluation is warranted for severe disability. The words "slight," "moderate" and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 VA's Office of General Counsel determined that separate disability ratings may be assigned for limitation of knee flexion and of knee extension without violation of the rule against pyramiding (at 38 C.F.R. § 4.14), regardless of whether the limited motions are from the same or different causes. VAOPGCPREC 9-04 (September 17, 2004), 69 Fed. Reg. 59,990 (2004). VAOPGCPREC 23-97 held that a claimant may receive separate disability ratings for arthritis and instability of the knee, under Diagnostic Codes 5003 and 5257, respectively. See VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997). In order for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 does not have to be compensable, but must meet the criteria for a zero-percent rating. VAOPGCPREC 9-98 (August 14, 1998), 63 Fed. Reg. 56,704 (1998). The primary source of evaluative information regarding the Veteran's service-connected left knee disability consists of the reports of VA examinations. The Veteran underwent a VA examination in June 2002, at which time he reported inability to carry out various activities of daily living, but otherwise being able to complete such activities as driving a car, going shopping, and dressing himself. On physical examination, the Veteran walked with a mildly antalgic gait, favoring the left side, secondary to left knee pain. His gait was not unsteady or unpredictable. He did not require an assistive aid to ambulate across the room. There was evidence of a 10-cm long, nondisfiguring scar on the left lateral patella, that was soft and nontender, with no evidence of adherence, drainage, or exudates. Leg lengths from the anterior superior iliac spine to the medial malleoli, were 92-cm on the right and 93-cm on the left. There was no evidence of abnormal weight bearing. Evaluation of the left knee revealed evidence of mild swelling and mild crepitus. There was no evidence of heat, redness, effusion, drainage or instability. There was evidence of weakness. Drawer sign was negative. McMurray test could not be performed due to complaints of pain. Range of motion of the left knee was from -5 to 85 degrees. While motion was limited by pain and weakness, with pain having the major functional impact, there was no measurable diminution of joint mobility directly due to pain on use. There was evidence of mildly antalgic gait. Upon re-examination in March 2004, the Veteran described significant bilateral knee pain which had been worse over the past couple of years. The pain required him to take over-the-counter pain relievers. He described bilateral knee pain predominantly over the anterior and medial aspects with swelling, stiffness and marked decreased flexion. He had great difficulty climbing stairs and using crutches. He was capable of using a recumbent bike for exercise for about an hour. He could not bend both knees well, and both knees frequently locked up. He had marked functional impairment because of diminished flexion. He reportedly had not been able to hold a steady job because of a bilateral knee condition. He denied a history of intrarticular joint corticosteroid injections or aspiration. He had lost time from work fairly frequently while he was working but did not remember the details. On objective examination, there were no signs of abnormal weight bearing in the lower extremities. There were no callosities, corns or breakdown or unusual shoe wear. The Veteran walked with a slow gait without assistive devices. Leg lengths appeared equal bilaterally. Gait was normal. He did not have a limp but walked very slowly. He had great difficulty assuming an upright position from a chair. The left knee had severe tenderness over the anterior, medial and lateral aspects with slight swelling medially. Range of motion was from 0 to 30 degrees. Left knee range of motion was not additionally limited by fatigue, weakness, lack of endurance or incoordination. There were multiple small well-healed arthroscopic portal scars present over the left knee as well as a surgical scar measuring 4-cm present over the lateral and medial aspects. All the scars were slightly hypo-pigmented, and less than six square inches. They were slightly disfiguring and flat. There was no tenderness, tissue loss, ulcerations, or keloid formation. There was no abnormal texture, instability, adherence, or limitation of motion due to scars. There was no ankylosis. Drawer and McMurray tests were no attempted. The physical examination overall was suboptimal as the Veteran had significant tenderness. The diagnosis was status-post left knee trauma and multiple surgeries with residual scars, tenderness, swelling, arthritis, and marked decrease in range of motion. At his May 2012 VA examination, the Veteran stated that his gait was affected by the pain in his left knee. He did not report any flare-ups which impacted the function of the left knee or the left lower leg. Left knee range of motion was from 0 to 100 degrees, with onset of painful motion at 90 degrees. After repetitive motion testing, left knee flexion remained to 100 degrees. The examiner further noted limiting factors in the left knee joint of less movement than normal, pain on movement, and interference with sitting, standing and weight-bearing. There was tenderness to palpation for the joint line or soft tissues of the left knee. Muscle strength in the left knee was 5/5. Joint stability tests showed normal Lachman's test, posterior drawer test, and medial-lateral instability test. There was no evidence or history of recurrent patellar subluxation or dislocation. There was a history of left side meniscectomy, due to meniscal tear, but there were no residual signs and/or symptoms due to meniscectomy. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to the left knee condition. The Veteran did not use any assistive devices as a normal mode of locomotion. There was an impact upon occupation in that the Veteran was unable to perform work that required prolonged standing, walking or kneeling. Upon the thorough review of the VA examination findings, and viewing the available evidence as presenting the best approximation of service-connected symptomatology, the Board will continue the assignment of the existing rating scheme for left knee disability, that of a 30 percent evaluation for meniscectomy residuals evaluated as joint instability along with a 10 percent evaluation for left knee osteoarthritis. The Board will consider each of these components of left knee disability distinctly. First, in regard to the service-connected left knee meniscectomy residuals, the Board observes that the Veteran is already in receipt of the highest assignable evaluation under Diagnostic Code 5257 of 30 percent, for severe "other" impairment of the knee. This is based upon symptomatology involving recurrent subluxation and/or lateral instability. No higher evaluation is assignable pursuant to the VA rating schedule as a matter of law. Because the Veteran is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable. Johnston, 10 Vet. App. at 80. Therefore, the claim for increased rating specifically for the condition of left knee meniscectomy residuals must be denied. Next, turning to the condition of service-connected left knee osteoarthritis, the existing disability evaluation is at the level of 10 percent, rated on the basis of limitation of motion, and as set forth under Diagnostic Codes 5260 and 5261, there is the potential for the assignment of greater compensation under the VA rating schedule. Consequently, unlike the preceding claim, the issue of an increase for left knee osteoarthritis does warrant objective evaluation of the medical facts. To this effect, the Veteran could establish entitlement to the next higher 20 percent rating through demonstrating either limitation of flexion to 30 degrees under Diagnostic Code 5260, or limitation of extension to 15 degrees under Diagnostic Code 5261. 38 C.F.R. § 4.71a. Also available is assignment of two separate 10 percent ratings, for limitation of flexion to 45 degrees in conjunction with limitation of extension to 10 degrees, for sufficiently limited motion in both measured planes of motion. Id. See also VAOPGCPREC 9-04. The Board finds that the preponderance of the evidence when weighed carefully stands against the award of any further compensation for left knee osteoarthritis. The first VA examination for review, dated from March 2002, indicates range of motion for -5 to 85 degrees. Besides this initial objective measurement, there was no additional diminution of motion due to pain, fatigue, weakness, repetitive use, or other recognized forms of functional loss, as VA is required to consider when determining joint mobility. See DeLuca, supra; 38 C.F.R. §§ 4.45, 4.59. These findings do not establish a more severe level of disability. While the results are not consistent with full knee flexion (knee extension was at or near normal), the retained joint mobility still falls well outside the range of what will objectively warrant a higher rating. Thereafter, just two years later, the Veteran on VA examination of March 2004 had measured range of motion from 0 to 30 degrees, not additionally limited by an form of functional loss -- i.e., with flexion to 30 degrees, and thereby ostensibly within the framework under Diagnostic Code 5260 for what could constitute a higher rating. However, on repeat examination of May 2012, the Veteran had markedly better range of motion, now from 0 to 100 degrees, and 0 to 90 degrees when factoring the impact of pain on motion (with no other factors limiting joint mobility). Having noted the disparity here between 2004 and 2012 exam findings, the Board ultimately finds the 2012 results most probative, particularly given that the May 2012 examination is far more recent and would be expected to present a more severe depiction of disability than prior evaluations. Moreover, the May 2012 exam showed substantially improved left knee flexion, nearly 45 degrees more than that which would otherwise be needed to establish even a compensable evaluation under Diagnostic Code 5260. Likewise, the March 2004 VA examiner had expressly observed that the overall physical examination was "suboptimal" given the Veteran's significant tenderness at that time, suggesting another grounds upon which the results were less than fully reliable, or at least not as reliable as the more recent exam. Nor is there any other intervening medical evidence between 2004 and 2012 which otherwise substantiates such a pronounced loss of left knee flexion as the 2004 examination did. Therefore, evaluating the record before it, the Board must ascribe the most probative weight to the 2012 examination findings, which do not objectively support a greater evaluation than 10 percent based on limitation of motion. Having evaluated the existing disability rating scheme, the Board briefly observes that there is no readily apparent basis for assignment of any further separate ratings for components of left knee disability. See 38 C.F.R. § 4.14 (providing that as to assignment of separate ratings, under VA's "anti-pyramiding rule," the evaluation of the same manifestation under different diagnoses is to be avoided). See also Esteban v. Brown, 6 Vet. App. 259, 262 (1994); Brady v. Brown, 4 Vet. App. 203, 206 (1993). Whereas the record shows that the Veteran underwent a left knee meniscectomy for damage of cartilage, the affected area lacks persistent symptomatology, such as effusion or knee joint locking. As such, a separate 10 percent rating is not warranted under Diagnostic Code 5259 for removal of the semilunar cartilage, where symptomatic. As for other potentially applicable Diagnostic Codes, the Veteran's knee has never been ankylosed, there was no malunion or nonunion of the tibia and fibula, and there were no symptoms from the removal or dislocation of semilunar cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5262 (2012); see also VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). Accordingly, application of these Diagnostic Codes is unwarranted. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of Diagnostic Code should be upheld if supported by explanation and evidence). The Board next considers the pertinent applicable rating criteria for scars, as involving the right knee postoperative scar. Under the rating criteria for scars effective August 30, 2002, 38 C.F.R. § 4.118, Diagnostic Code 7801 provides that scars other than on the head, face, or neck, that are deep or that cause limited motion, and cover an area of at least 6 square inches (39 square cm.) warrant a compensable evaluation. According to Diagnostic Code 7802, scars other than on the head, face, or neck, that are superficial and do not cause limited motion, and cover an area of at least 144 square inches (929 square cm.) warrant a compensable evaluation. Under Diagnostic Code 7803, a scar that is superficial and unstable warrants the assignment of a maximum 10 percent rating. Diagnostic Code 7804 further provides that a scar that is superficial and painful on examination warrants the assignment of a 10 percent rating. Diagnostic Code 7805 provides that other scars (not otherwise considered under the rating schedule) are to be rated on the basis of limitation of function of the affected part. Effective October 23, 2008, VA again revised the criteria for the evaluation of scars. The implementing regulation for the new rating criteria provides that these revisions apply only to applications for benefits received by VA on or after October 23, 2008. A claimant rated under a previous version of the criteria may request review under the most recent criteria. The Veteran's claim for increase preceded October 2008, and he has not requested evaluation under the latest revised criteria. From all the evidence before it, the Veteran's postsurgical scar on the left knee does not meet any of the criteria for a separate compensable evaluation. The scar does not meet the minimum surface area requirements of Diagnostic Codes 7801 or 7802, is not unstable or painful as to warrant evaluation under Diagnostic Codes 7803 or 7804, and does not involve limitation of function as to implicate Diagnostic Code 7805. It follows that no further assignment of separate disability evaluations for the service-connected left knee disorder is warranted. Meanwhile, aside from the VA rating schedule, the potential application of other provisions of Title 38 of the Code of Federal Regulations has also been considered, including 38 C.F.R. § 3.321(b)(1), which provides procedures for assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In Thun v. Peake, 22 Vet. App. 211 (2008), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, there initially is no basis to find that the Veteran's left knee disability (and all associated components) presents such an exceptional disability picture that the applicable schedular criteria are inadequate, particularly as the rating criteria are thorough, and he does not manifest or describe symptomatology outside of those criteria. Essentially, the rating criteria premised upon both knee joint instability, and limitation of motion with associated pain and/or discomfort (and some forms of recognized functional loss, per DeLuca v. Brown) fairly accounts for nearly all of the Veteran's symptoms as presented, including from his descriptions upon VA examination and on other occasions. The Board has likewise found that the Veteran does not have distinctly ratable impairment due to post-surgical scars, or damage to the left knee cartilage. Thus, the Board cannot conclude that the Veteran's condition is consistent with an exceptional disability picture as to render the schedular rating criteria inadequate. The first stage of the standard for determining availability of an extraschedular rating not having been met, the potential application of the next two steps becomes a moot issue. In the absence of the evidence of such factors, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). When entitlement to a total disability rating based on individual unemployability (TDIU) under the provisions of 38 C.F.R. § 4.16 is raised during the adjudicatory process of evaluating the underlying disabilities, it is part of the claim for benefits for the underlying disabilities. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). At his March 2004 VA examination, the Veteran reported that his knee disabilities prevented him from holding a steady job. At his May 2012 VA examination, the examiner found that the Veteran's left knee disabilities impacted his ability to work. Specifically, the examiner found that they rendered him incapable of performing work that "requires prolonged standing, walking, and kneeling." This does not eliminate all types of employment, such as sedentary employment. Because the record does not show that the Veteran's knee disabilities render him incapable of maintaining substantially gainful employment, further consideration of entitlement to TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). For these reasons, the Board is denying the claims for higher rating for the Veteran's left knee disability. This determination takes into full account the potential availability of "staged rating" based upon incremental increases in severity of service-connected disability during the pendency of the claims under review. Hart, 21 Vet. App. at 505. The preponderance of the evidence is against the claims, and under these circumstances the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER An increased disability rating for left knee meniscectomy residuals, currently evaluated as 30 percent disabling, is denied. An increased disability rating for left knee osteoarthritis, currently evaluated as 10 percent disabling, is denied. ____________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs