Citation Nr: 1311226 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 04-01 606 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to a rating in excess of 10 percent prior to January 19, 2010 and in excess of 20 percent thereafter for left knee osteochondritis dessicans. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from September 1987 to February 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, which denied a compensable rating for left knee osteochondritis dessicans. In March 2009, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In a June 2010 rating decision, the RO assigned a 20 percent rating for left knee osteochondritis dessicans, effective from May 26, 2010, based upon moderate instability of the knee. The 20 percent rating was assigned as of the date of the May 2010 VA examination. The Board notes that in a November 2010 decision, the Board denied a rating in excess of 10 percent prior to May 26, 2010 and a rating in excess of 20 percent on or after May 26, 2010. The Board also granted a separate 10 percent rating for osteochondritis dessicans of the left knee with x-ray evidence of arthritis with painful motion under Diagnostic Code 5003 effective from May 26, 2010. The decision was vacated, however, by order of the Court dated in July 2011. The separate 10 percent rating for arthritis was not effectuated by the RO. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a Joint Motion dated in July 2011, the Court vacated the November 2010 Board decision and remanded the matter to the Board for proceedings consistent with the Joint Motion. In a December 2010 rating decision, the RO increased the evaluation for the left knee disability, recharacterized as left knee unicondylar knee replacement and increased the rating to 100 percent from November 22, 2010 and assigned a 30 percent rating from January 1, 2012 under Diagnostic Code 5055 pertaining to knee replacement. The Board remanded this matter in December 2011 for additional development, including a VA examination. The Board is satisfied as to substantial compliance with its remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). By rating action in December 2012, the RO assigned a 20 percent rating for left knee unicondylar knee replacement under Diagnostic Code 5055 effective from January 19, 2010, a 100 percent rating effective from November 22, 2010 and a 20 percent rating effective from January 2, 2012. The RO further indicated that service connection for limitation of flexion of the left knee was being granted and assigned a 10 percent rating under Diagnostic Code 5260 from January 2, 2012. FINDINGS OF FACT 1. Prior to January 19, 2010, left knee osteochondritis dessicans was manifested by full range of motion with pain and by dislocation of semilunar cartilage without episodes of locking, pain or effusion. 2. From January 19, 2010, left knee osteochondritis dessicans was manifested by moderate instability, flexion greater than 45 degrees, and full extension of the knee and without ankylosis, tibia or fibula impairment or genu recurvatum. 3. From January 2, 2012, left knee osteochondritis dessicans was manifested by a left total unicondylar knee replacement and painful motion of the knee with flexion of 95 degrees and extension of 0 degrees and without impairment of the tibia or fibula or chronic residuals consisting of severe painful motion or weakness. 4. From January 2, 2012, left knee osteochondritis dessicans was manifested by moderate subluxation. CONCLUSIONS OF LAW 1. Prior to January 19, 2010, the criteria for a rating in excess of 10 percent for osteochondritis dessicans of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5257-5261 (2012). 2. From January 19, 2010 to January 1, 2012, the criteria for a rating in excess of 20 percent for osteochondritis dessicans of the left knee based on instability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257(2012). 3. Effective May 26, 2010 to January 1, 2012, the criteria for a separate evaluation of 10 percent for osteochondritis of the left knee with x-ray evidence of arthritis with painful motion have been met. U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003 (2012). 4. From January 2, 2012, the criteria for a 30 percent rating for a left knee replacement have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5055 (2012). 5. From January 2, 2012, the criteria for a separate 20 percent rating for moderate subluxation of the left knee have been met. U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist As provided for by VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) ; 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ, in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence required to substantiate the claim, namely evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in December 2006. The letter informed the Veteran of what evidence was required to substantiate his claim for a increased ratings and of the Veteran's and VA's respective duties for obtaining evidence. Although the notice was provided after the rating decision on appeal, any defect in the timing of the VCAA notice was cured because the RO readjudicated the claim in the September 2007 supplemental statement of the case. Pricket v. Nicholson, 20 Vet. App. 370, 376 (2006). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159. In this case, the record indicates that the RO obtained all information relevant to the Veteran's claim. Moreover, the Veteran underwent adequate and probative VA medical examinations for his claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained relevant records, and has provided adequate examinations to the Veteran. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). (CONTINUED ON NEXT PAGE) II. Analysis Rating Criteria 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; 38 C.F.R. § 4.1. 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. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluation 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. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (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. Francisco v. Brown, 7 Vet. App. 55, 58 (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 was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). The pertinent Diagnostic Codes in this case are Diagnostic Codes 5055 and 5256 through 5263. Diagnostic Code 5055 pertains to total knee replacement. For one year after a prosthetic replacement of the knee joint, the knee is rated at 100 percent. Thereafter, a 60 percent rating is assignable for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion are rated under Diagnostic Codes 5256 (ankylosis), 5261 (limitation of extension) and 5262 (impairment of the tibia and fibula). The minimum rating after a knee replacement is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). Disabilities of the knee are rated under Diagnostic Code 5256 through 5263 of 38 C.F.R. § 4.71a (2012). Diagnostic Code 5256 pertains to ankylosis of the knee. Diagnostic Code 5257 addresses recurrent subluxation or lateral instability, and provides that a 10 percent rating is assignable for slight symptoms, a 20 percent rating for moderate symptoms, and a 30 percent rating for severe symptoms. Diagnostic Code 5258 provides that a 20 percent rating is warranted for dislocated cartilage in the knee manifested by frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides that a 10 percent rating is assignable for removal of semilunar cartilage, symptomatic. Diagnostic Codes 5260 and 5261 address limitation of flexion and extension of the leg. Under Diagnostic Code 5260, ratings from 0 to 30 percent for limitation of flexion beginning at 60 degree. Diagnostic Code 5261 provides ratings from 0 to 50 percent for limitation of extension beginning at 10 degrees. Diagnostic Code 5262 addresses impairment of the tibia and fibula. Diagnostic Code 5263 addresses genu recurvatum. 38 C.F.R. § 4.71a . Diagnostic Code 5003 is also applicable in this case and provides that degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. When the limitation of motion is noncompensable under the appropriate diagnostic codes, a 10 percent rating is assignable for each major joint or group of minor joints affected by limitation of motion to be combined, not added, under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2012). Pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45 (2012). Painful, unstable, or malaligned joints, due to a healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2012). However, pain alone does not constitute a functional loss under VA regulations. Mitchell v. Shinseki, 25 Vet. App. (2011). The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Prior to January 19, 2010 Service connection for osteochondritis dessicans of the left knee was granted in an October 1992 rating decision, and a non-compensable rating was assigned under Diagnostic Codes 5099-5002. This hyphenated code is intended to show that the Veteran's disability was rated analogously to arthritis, Diagnostic Code 5002. See 38 C.F.R. § 4.20 (2012) (an unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization, and symptomatology are closely analogous); 38 C.F.R. § 4.27 (2012) (unlisted disabilities rated by analogy are coded first by the numbers of the most closely related body part and then "99"). A claim for an increased rating was received in August 2002. An October 2006 rating decision assigned a 10 percent rating, effective August 7, 2002, pursuant to Diagnostic Code 5099-5003. Again the rating was analgous to arthritis under Diagnostic Code 5003. By rating action in December 2012, the RO assigned a 20 percent rating for the left knee replacement, effective from January 19, 2010. Therefore the Board will consider whether a rating in excess of 10 percent is warranted prior to January 19, 2010. Upon VA examination in December 2002, the Veteran reported popping and cracking of his knee. He denied swelling. He reported occasional giving way of the knee and denied locking. Examination of the knee showed no effusion. There was no medial joint line tenderness or lateral joint line tenderness. There was no medial collateral or lateral collateral ligamentous instability. There was a negative drawer sign, negative McMurray's, negative Apley's grind and negative chondramalacia sign. Flexion was to 119 degrees. Extension was to 0 degrees. X-rays showed osteochondritis dessicans of the medial femoral condyle. The Veteran had surgery on his left knee in March 2004. He underwent excision of the osteochondritis medial femoral condyle of the left knee. A March 2004 VA treatment report showed that the range of motion of the left knee was 0 to 45 degrees. There was no neurovascular deficit and no swelling or drainage. At an October 2006 VA examination, the Veteran reported that his left knee was progressively worse since his service injury. There was no joint deformity. The Veteran reported instability. There was no stiffness or weakness. There were no episodes of dislocation or subluxation. There were no locking episodes and no effusion. The Veteran reported severe flare-ups every 1 to 2 months. On physical examination, the Veteran had active and passive flexion to 140 degrees, with pain starting at 120 degrees. There was no additional loss of motion with repetitive use. Crepitation was noted. The VA examiner indicated there was no grinding, instability, or patellar abnormality. After a review of the lay and medical evidence for the time period prior to January 19, 2010, the Board finds that the criteria for a rating in excess of 10 percent were not met. Under Diagnostic Code 5003, 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. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, but not added, under Diagnostic Code 5003. In this case, prior to January 19, 2010, the weight of evidence does not establish that there was compensable limitation of flexion of the knee, as flexion was not limited to 45 degrees. There was one finding of flexion to 45 degrees in March 2004; however the 2002 and 2006 VA examinations reflect that the flexion was 119 degrees and 140 degrees, respectively. Therefore, a compensable rating under Diagnostic Code 5260 is not assignable. A compensable rating is not assignable under Diagnostic Code 5261, as the Veteran did not have extension limited to 10 degrees. During the period prior to January 19, 2010, ankylosis, subluxation, instability, impairment of the tibia and fibula and genu recurvatum were not shown. Accordingly, ratings under Diagnostic Codes 5256, 5257, 5259, 5262 and 5263 are not applicable. The Veteran is competent to report instability of his knee. Layno v. Brown, 6 Vet. App. 435 (1994). However, the 2002 and 2006 VA examinations both found no objective evidence of instability. At the time of the December 2002 examination, it was indicated that was no medial collateral or later collateral ligamentous instability. At the time of the October 2006 VA examination, the examiner noted that the Veteran reported instability but no episodes of dislocation or subluxation. On examination, there was no instability. The Board finds the weight of the evidence does not demonstrate that a separate rating for instability is warranted prior to January 19, 2010. The evidence shows that the Veteran's left knee disability was manifested by dislocation of cartilage. The December 2002 VA examination noted osteochondritis dessicans of the medial femoral condyle. A May 2006 VA MRI report noted that there was a suspicion of a tear involving the medial meniscus. Although dislocation of cartilage was shown, the evidence does not show that the Veteran had frequent locking, pain and effusion. The December 2002 and October 2006 VA examinations both noted that no locking or effusion was present. Therefore, as the evidence does not show that dislocation of cartilage was manifested with frequent episodes of locking, pain and effusion, the Board concludes that a separate rating under Diagnostic Code 5258 is not warranted for the time period prior to January 19, 2010. The effects of pain and functional impairment associated with the Veteran's left knee disability have been considered in the assigned rating. Upon VA examination in 2006, the Veteran reported flare-ups of joint pain every 1 to 2 months. The clinical evaluation did not show additional loss of motion on repetitive use. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. For these reasons, the Board concludes that the criteria for a rating in excess of 10 percent for osteochondritis dessicans were not met prior to January 19, 2010. As there is a preponderance of the evidence against the claim, reasonable doubt may not be resolved in the Veteran's favor. 38 U.S.C.A. § 5107. From January 19, 2010 In a June 2010 rating decision, the RO assigned a 20 percent rating for left knee osteochondritis dessicans, effective from May 26, 2010, based upon moderate instability of the knee. The 20 percent rating was assigned as of the date of the May 2010 VA examination. The Board notes that in a November 2010 decision, the Board denied a rating in excess of 10 percent prior to May 26, 2010 and a rating in excess of 20 percent on or after May 26, 2010. The Board also granted a separate 10 percent rating for osteochondritis dessicans of the left knee with x-ray evidence of arthritis with painful motion under Diagnostic Code 5003 effective from May 26, 2010. The decision was vacated, however, by order of the Court dated in July 2011. By rating action in December 2012, the RO assigned a 20 percent rating for the left knee replacement, effective from January 19, 2010. Therefore the Board will consider whether a rating in excess of 20 percent is warranted from January 19, 2010. Upon VA examination in May 2010, the Veteran reported left knee pain, weakness, stiffness, giving way and lack of endurance. He denied deformity, locking, effusion and dislocation. He reported left knee swelling and heat as well as tenderness but denied redness. The Veteran reported flare-ups on a daily basis, especially with walking up the steps and stairs, as well as standing. He reported that his flare-ups lasted a whole day, which eased up with sitting down, foot elevation and rest. Upon physical examination, the Veteran's gait was antalgic. He could not walk on his left toes because of his left foot, but he walked on his right foot toes. The Veteran had tenderness over the left knee joint, especially medial, lateral, suprapatellar region without any evidence of deformity, crepitation, and swelling. The Veteran had 0 degrees of extension, both active and passive, with pain at the endpoint. Left knee flexion was 0 to 115 degrees, both active and passive, with pain at the endpoint. More than three repetitions did not change his range of motion. The Veteran had moderate laxity and instability to both medial and lateral collateral ligaments of the left knee joint, both in neutral and in 30 degrees flexion. The left knee anterior and posterior drawer tests were negative. The Veteran's left knee anterior and posterior drawer tests were negative. McMurray's and Lachman's tests were also negative. The examiner opined that it would be speculation to state whether there was pain, weakness, incoordination or lack of endurance with a flare-up of the joints. The examination report indicated that an MRI of the left knee revealed extensive osteonecrosis involving the medial femoral condyle in association with bone fragments and joint mice in a defect and in association with adjacent osteoarthritis and underlying narrow edema including the abutting portion of the tibial plateau. The diagnosis was degenerative joint disease with osteochondritis dessicans of the left knee joint. The report noted an extensive horizontal tear of the posterior horn of the medial meniscus extending into the truncated body of medial meniscus and in association with a significant tear and significant laxity of the middle third of the medial collateral ligament. There was joint effusion in association with a small Baker's cyst. For the time period from January 19, 2101, the weight of the evidence demonstrates that the Veteran's knee disability was manifested by no more than moderate laxity and instability of the knee. There was x-ray evidence of arthritis. The MRI report of May 2010 noted that there was a significant tear of the medial meniscus. Joint effusion was also noted. In VAOPGCPREC 23-97, the VA General Counsel held that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating is based upon additional disability. VAOPGCPREC 23-97 (July 1, 1997). Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X- ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (Aug. 14, 1998). The General Counsel has also directed that separate ratings also are available if a particular knee condition causes both the limitation of extension and limitation of flexion of the same joint. VAOPGCPREC 9-04 (Sept. 17, 2004). Specifically, where a veteran has both a limitation of flexion and a 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). In this case, the May 2010 VA examination noted a diagnosis of degenerative joint disease. The Board finds that a separate 10 percent rating is assignable for left knee arthritis under Diagnostic Code 5003. VAOPGCPREC 23-97. A 20 percent rating is not assignable under Diagnostic Code 5003, as the evidence does not show that there are two major joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. A higher rating is not warranted under Diagnostic Codes 5260 or 5261, as the evidence does not show compensable limitation of flexion or extension. Ankylosis, subluxation, impairment of the tibia and fibula and genu recurvatum are not shown. Accordingly, ratings under Diagnostic Codes 5256, 5259, 5262 and 5263 are not applicable. The Board has considered whether a rating under Diagnostic Code 5258 is appropriate. The May 2010 VA examination noted an extensive tear of the cartilage of the knee with joint effusion. The Board obtained a medical opinion in February 2012 in order to determine whether the symptoms of left knee dislocated cartilage differ from the symptoms of left knee instability and arthritis. The VA examiner stated that it is not possible to distinguish the symptoms of the Veteran's left knee instability and left knee arthritis from the symptoms of left knee dislocated cartilage. The VA examiner explained that the pain generated in the knee is transmitted by the same nerve ending in dislocated cartilage, knee instability and knee arthritis. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In this case, the manifestations of instability and arthritis are compensated under the ratings assigned pursuant to Diagnostic Codes 5003 and 5257. The medical evidence of record indicates that it is not possible to distinguish the symptoms of instability and arthritis from those associated with dislocated cartilage of the knee. Accordingly, the Board finds that a separate evaluation is not warranted under Diagnostic Code 5258, as that would constitute pyramiding. The effects of pain and functional impairment associated with the Veteran's left knee disability have been considered in the assigned rating. The 2010 VA examination noted pain at the endpoint of flexion of 115 degrees. The Veteran did not have additional loss of motion with repetition. The 2010 VA examination also indicated that the it would require speculation to state whether there was pain, weakness, incoordination or lack of endurance with a flare-up of the joints. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. For these reasons, the Board finds that a rating in excess of 20 percent rating is not warranted for instability of the left knee. The Board finds that a separate 10 percent rating is warranted for arthritis, pursuant to Diagnostic Code 5003, from May 26, 2010 to January 1, 2012. As will be discussed fully below, the Veteran's left knee condition is most appropriately rated under Diagnostic Code 5055 regarding knee replace effective from January 2, 2012. Because the rating of the knee replacement under Diagnostic Code 5055 is based on consideration of pain and limitation of motion, the continuation of a separate 10 percent evaluation of osteochondritis of the left knee with x-ray evidence of arthritis with painful motion assigned as of May 26, 2010 would constitute pyramiding. See 38 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). From January 2, 2012 On November 22, 2010, the Veteran underwent left knee unicondylar knee replacement arthroplasty. By rating action in December 2010, the RO assigned a 100 percent evaluation for 13 months following prosthetic replacement of the knee joint, pursuant to Diagnostic Code 5055. A December 2010 rating decision assigned 30 percent rating from January 1, 2012, pursuant to DC 5055. A December 2012 rating decision assigned separate assigned a 20 percent evaluation for moderate patella subluxation and slight lateral instability of the left knee, and indicated that the rating of 20 percent remained under Diagnostic Code 5055 pertaining to the total knee replacement. The rating was effective January 2, 2012. The decision also indicated that service connection was being granted or limitation of flexion of the knee with a separate 10 percent evaluation assigned under Diagnostic Code 5260 effective from January 2, 2012. The RO based this evaluation on painful motion of the knee. The Board notes that the separate evaluation for the left knee flexion is not considered as a grant of service connection as the Veteran's left knee disability has been rated by analogy as arthritis and as discussed above, separate ratings for flexion and/or extension may be assigned for the disability. See VAOPGCPREC 9-04. In a December 2012 rating decision, the RO assigned a 20 percent rating for instability of the knee, pursuant to Diagnostic Code 5257 and assigned a 10 percent evaluation for limitation of flexion, pursuant to Diagnostic Code 5260, from January 2, 2012. The RO indicated that the change in rating was on the basis that the Veteran had a partial knee replacement and the provisions of Diagnostic Code 5055 pertained only to total knee replacement. Therefore, the RO indicated that the left knee disability would not be rated total knee replacement but would be rated based on limitation of motion, painful motion, subluxation or instability, and dislocated cartilage. The provisions of Diagnostic Code 5055 pertain to knee replacement (prosthesis). By its very terms, the Diagnostic Code does not differentiate between total and partial knee replacements. There is no indication of any intent on the part of VA to limit the application of Diagnostic Code 5055 only to total knee replacements. See Fed. Reg. 45,348 (final rule). The RO impermissibly read into the Diagnostic Code a limitation that was not otherwise present. To the extent that the scope of the Diagnostic Code is ambiguous, that ambiguity must be resolved in the Veteran's favor. See Brown v. Gardner, 513 U.S. 115, 118 (1994); Kilpatrick v. Principi, 16 Vet. App. 1, 6 (2002). Accordingly, the Board finds that Diagnostic Code 5055 applies to the partial or unicompartmental knee replacement and must be considered in determining whether a higher rating may be assigned. The Veteran had a VA examination in February 2012. The Veteran denied flare-ups that impacted the function of the knee. Range of motion testing showed flexion of 95 degrees, with pain starting at 95 degrees. The Veteran had extension to 0 degrees. The Veteran was able to perform repetitive use testing with three repetitions. The VA examiner noted that there was evidence of moderate recurrent patellar subluxation. The examiner indicated that the residuals were intermediate degrees of residual weakness, pain or limitation of motion. The examiner indicated that there were no meniscal symptoms such as meniscal dislocation, meniscal tear, episodes of locking, joint pain and joint effusion. The examiner noted that dislocated cartilage is a radiological finding, and this was discussed with the radiologist. The VA examiner indicated that it is mild to moderate in extent. The examiner opined that it is not possible to distinguish symptoms due to cartilage dislocation from symptoms due to left knee instability and arthritis. The examiner noted that pain that generates in the knee is transmitted by the same nerve ending in dislocated cartilage, knee instability and knee arthritis. There is no separate nerve ending for separate knee structures. Based on the above, the Veteran's left knee disability has been manifested by a left knee replacement with painful motion and moderate subluxation. Under Diagnostic Code 5055, a minimum rating of 30 percent is assignable for a total knee replacement. Diagnostic Code 5055 provides that intermediate degrees of residual weakness, pain or limitation of motion must be rated by analogy to Diagnostic Codes 5256, 5261 or 5262. Diagnostic Code 5256 pertains to ankylosis. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). A 30 percent rating under Diagnostic Code 5256 requires ankylosis at a favorable angle in full extension or in slight flexion between 0 and 10 degrees. As ankylosis is not shown in this case, an evaluation under Diagnostic Code 5256 is not warranted. The Board concludes that a 30 percent rating is warranted for left knee replacement, pursuant to Diagnostic Code 5055, from January 2, 2012. As indicated above, the evidence indicates that the Veteran underwent knee replacement surgery in November 2010 and was assigned a 100 percent rating from the date of surgery. A higher rating under Diagnostic Code 5055 is not assignable based upon intermediate degrees of residual weakness, pain, limitation of motion. Under Diagnostic Code 5261, a rating in excess of 30 percent requires limitation to 30 degrees of extension. In the instant case, the Veteran has full extension to 0 degrees. Accordingly, a higher rating is not assignable under Diagnostic Code 5261. The higher available rating under Diagnostic Code 5260 pertaining to limitation of flexion is 30 percent. The Veteran does not meet the criteria for a 30 percent rating under DC 5262, as the evidence does not show malunion of the tibia and fibula with marked knee or ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The evidence does not show that the Veteran's knee replacement is manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity. Accordingly, the criteria for a 60 percent rating under DC 5055 are not met. The Board has considered whether a separate evaluation is warranted under Diagnostic Code 5258. The 2012 VA examination indicated that there are no symptoms associated with the meniscus condition. The Board acknowledges that the Veteran reported knee pain at the 2012 VA examination; however, the Board finds that a separate rating under Diagnostic Code 5258 is not warranted, given the absence of findings of locking or effusion. The February 2012 VA examination reflects that the Veteran has moderate subluxation of the left knee. The Board finds that a separate 20 percent rating is warranted for moderate subluxation, pursuant to Diagnostic Code 5257. A separate evaluation under Diagnostic Code 5257 does not constitute pyramiding, as subluxation is not considered in the rating assigned under Diagnostic Code 5055. The Board has considered whether there is evidence of pain or functional loss. The 2012 VA examination reflects that the Veteran was able to perform repetitions. The Veteran did not have additional loss of motion with repetition. The Veteran denied flare-ups. The functional impairment associated with the Veteran's disability have been taken into account when applying the pertinent rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. For these reasons, the Board concludes that a 30 percent rating is warranted for a left knee replacement from January 2, 2012, pursuant to DC 5055. The Board finds that a separate 20 percent rating is warranted for moderate subluxation of the left knee from January 2, 2012, pursuant to DC 5257. Extraschedular considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Veteran's left knee disability has been manifested by degenerative joint disease, painful motion, instability and subluxation. The schedular rating criteria specifically contemplate such symptomatology. The schedular rating criteria specifically provides ratings for such noncompensable limitation of motion due to painful arthritis (Diagnostic Codes 5003, 38 C.F.R. § 4.59), and contemplate ratings based on limitation of motion (Diagnostic Codes 5256, 5260, 5261), including motion limited to orthopedic factors such as pain, weakness, and stiffness (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), as well as instability and subluxation (Diagnostic Code 5257). In this case, comparing the Veteran's disability level and symptomatology of the disability of the left knee to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are therefore adequate. Because the schedular rating criteria are adequate to rate the Veteran's left knee disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER An evaluation in excess of 10 percent for osteochondritis dessicans of the left knee prior to January 19, 2010 denied. An evaluation in excess of 20 percent for osteochondritis dessicans of the left knee based on instability from January 19, 2010 to January 1, 2012 is denied. Effective May 26, 2010 to January 1, 2012, a separate 10 percent evaluation for osteochondritis dessicans of the left knee with degenerative arthritis based on painful motion is granted, subject to regulations governing the payment of monetary benefits. A 30 percent rating is granted for left total knee replacement from January 2, 2012, pursuant to DC 5055, subject to regulations governing the payment of monetary benefits. A 20 percent evaluation is granted for moderate subluxation of the left knee from January 2, 2012, pursuant to DC 5257, subject to regulations governing the payment of monetary benefits. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs