Citation Nr: 1311328 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 10-33 871 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to a rating in excess of 30 percent for a right total knee replacement (except for periods when temporary total ratings were in effect). REPRESENTATION Appellant represented by: Virginia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1975 to December 1999. This matter comes before the Board of Veterans' Appeals (Board) from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In that decision, the RO granted a temporary total (100 percent) rating for the service-connected right knee disability based on surgical treatment necessitating convalescence, effective from January 23, 2008 through February 28, 2009. A 30 percent rating was continued from March 1, 2009. In April 2012, the RO granted a temporary total (100 percent) rating for the service-connected right knee disability based on surgical treatment necessitating convalescence, effective from August 23, 2011 through October 31, 2011. A 30 percent rating was continued from November 1, 2011. As the Veteran was granted the full benefit he sought during the periods from January 23, 2008 through February 28, 2009 and from August 23, 2011 through October 31, 2011, his claim for an increased rating for the service-connected right knee disability during those periods is not on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran testified before the undersigned at an October 2012 hearing at the RO (Travel Board hearing). A transcript of that hearing has been associated with his claims folder. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. The documents in this file have been reviewed and 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 total knee replacement is manifested by pain, tenderness, effusion, stiffness, swelling, lack of endurance, fatigability, instability, warmth, and crepitus; knee flexion is to between 100 and 130 degrees and knee extension is to between 5 and 0 degrees, with no additional loss of motion due to such factors as pain, weakness, lack of endurance, and fatigability. It is not exhibited by severe painful motion or weakness. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for a right total knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5055, 5256-5263 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in March 2009, the RO notified the Veteran of the evidence needed to substantiate his claim for an increased rating for a right total knee replacement. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claim, in the March 2009 letter. The Court held in Vazquez-Flores v. Peake that 38 U.S.C.A § 5103(a) requires, at a minimum, that the Secretary notify the Veteran that, to substantiate an increased rating claim, the Veteran must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated sub nom, Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Additionally, the Veteran must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. Id. Furthermore, the Court directed that as with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation -- e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Id. The March 2009 letter told the Veteran that evidence of worsening could substantiate the increased rating claim. He was notified in the letter that medical or lay evidence could be submitted to substantiate his increased rating claim and was provided with specific examples. The letter also stated that the Veteran could submit letters from individuals who could describe the manner in which his disability had worsened. The March 2009 letter explained that disability ratings are determined by applying VA's rating schedule under which the RO would assign a rating from 0 to 100 percent, and that it would consider evidence of the nature of the symptoms of the condition, their severity and duration, and their impact upon employment. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2012) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's October 2012 hearing, the undersigned identified the issue on appeal and asked the Veteran about the symptoms and history of his service-connected right knee disability, as well as the treatment received for the disability to ensure that all relevant records had been obtained. The Veteran did not identify any additional treatment records that were not already in the claims file. Further, the Veteran and his representative provided testimony as to the symptoms and history of the service-connected right knee disability, described the treatment provided for the disability, and explained why it was believed that the Veteran's knee symptoms were severe so as to warrant a higher rating under the appropriate diagnostic code. Also, the Veteran has submitted additional relevant evidence during the claim period. Thus, the Veteran has demonstrated actual knowledge of the ability to identify and submit additional relevant evidence and of the criteria for a rating in excess of 30 percent for his service-connected right knee disability. The duties imposed by Bryant were thereby met. VA obtained the Veteran's service treatment records and all of the identified relevant post-service VA treatment records and private medical records. In addition, he was afforded VA examinations to assess the severity of his service-connected right knee disability. In an October 2012 statement and during the October 2012 hearing, the Veteran and his representative contended that a February 2012 VA examination conducted for purposes of assessing the severity of the service-connected right knee disability was inadequate. Specifically, it was argued that the examiner who conducted the examination was a physician who specialized in anti-aging and aerospace (as opposed to an orthopedist), that the examination was brief, and that the examiner did not listen to the Veteran's reports during the examination. Initially, it is noted that there is no requirement that VA establish the qualifications of VA physicians and medical experts providing medical opinions. Absent some challenge to the expertise of a VA expert, there is no requirement that VA present affirmative evidence of a medical professional's qualifications in every case as a precondition for the Board's reliance upon that person's opinion. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009). Neither the Veteran nor his representative have presented any specific challenge to the qualifications of the physician who conducted the February 2012 VA examination, other than to note that the examiner was reportedly not an orthopedist. Additionally, the February 2012 VA examination report contains the findings necessary to rate the Veteran's right knee disability and was the product of an in-person examination and consideration of the Veteran's reported symptoms. Hence, the February 2012 VA examination is adequate and a new examination is not required. Analysis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's right total knee replacement is currently rated under 38 C.F.R. § 4.71a, DC 5055 as a knee replacement with prosthesis. Under DC 5055, a 100 percent rating is assigned for one year following implantation of a knee prosthesis for a service-connected knee disability, followed thereafter by a 60 percent rating when there are chronic residuals consisting of severe painful motion or weakness. With intermediate degrees of residual weakness, pain, or limitation of motion, a rating is made by analogy to DCs 5256, 5261, and 5262. The minimum rating is 30 percent under DC 5055. 38 C.F.R. § 4.71a, DC 5055. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis can also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel has subsequently held that separate ratings can also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Limitation of knee flexion is rated as follows: a noncompensable rating is warranted when it is limited to 60 degrees; a 10 percent rating is warranted when it is limited to 45 degrees; a 20 percent rating is warranted when it is limited to 30 degrees; and a 30 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Limitation of knee extension is rated as follows: a noncompensable rating is warranted when it is limited to 5 degrees; a 10 percent rating is warranted when it is limited to 10 degrees; a 20 percent rating is warranted when it is limited to 15 degrees; a 30 percent rating is warranted when it is limited to 20 degrees; a 40 percent rating is warranted when it is limited to 30 degrees; and a 50 percent rating is warranted when it is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Knee impairment with recurrent subluxation or lateral instability is rated as follows: a 10 percent rating is warranted if the condition is slight; a 20 percent rating is warranted if the condition is moderate; and a 30 percent rating is warranted if the condition is severe. 38 C.F.R. § 4.71a, DC 5257. In this case, a January 2008 examination report from Mary Immaculate Hospital includes a report of chronic right knee pain. Examination of the knee revealed lateral joint line tenderness, mild effusion, and a well healed incisional scar. The ranges of knee motion were recorded as flexion to 100 degrees and extension to 0 degrees. The Veteran was diagnosed as having a failed right total knee replacement with possible loosening. During an April 2009 VA examination, the Veteran reported constant localized right knee pain which was burning, aching, and sharp in nature, was 1-8/10 in intensity, was elicited by physical activity, and was alleviated by medications. The Veteran was able to function during episodes of pain with the use of such medications. Additionally, there was knee range of motion loss, weakness, stiffness, swelling, lack of endurance, and fatigability. However, there was no heat, redness, giving way, locking, or dislocation. The Veteran was not receiving any ongoing treatment for his right knee disability at the time of the April 2009 examination. As a result of his right knee disability, he experienced pain and fatigue while walking up and down stairs, ladders, or inclines. However, he had joined a health and fitness facility in January 2009 and performed two hours of circuit training three times per week. This training included cardio and weight exercises that included use of the lower body and legs. He was employed as a motorcycle riding coach/instructor, but had to greatly reduce the number of classes that he taught due to swelling, pain, and stiffness which was incurred after standing on his feet for 6 to 7 hours per day. Also, most daily tasks (including housework, yardwork, and vehicle maintenance) were negatively impacted by his knee disability. Examination revealed that there was a level scar on the anterior right knee due to the Veteran's knee replacement surgery. The scar measured approximately 17.5 centimeters by 0.4 centimeters and was hypopigmented, but there was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, keloid formation, hyperpigmentation, abnormal texture, or limitation of motion caused by the scar. The Veteran's gait and posture were normal, his feet exhibited no signs of abnormal weight bearing or breakdown, there were no callosities or any unusual shoe wear pattern, and he did not require any assistive devices for ambulation. There was right knee effusion, weakness, and tenderness, but there were no signs of edema, redness, heat, guarding of movement, subluxation, locking pain, genu recurvatum, or crepitus. The ranges of right knee motion were recorded as flexion to 130 degrees with pain beginning at 125 degrees and extension to 5 degrees with pain beginning at 10 degrees. Right knee function was additionally limited by pain, weakness, and lack of endurance following repetitive use, but there was no additional limitation in the ranges of knee motion. Knee function was not additionally limited by fatigue or incoordination following repetitive use. The stability of the anterior and posterior cruciate ligaments and medial and lateral collateral ligaments was within normal limits and the medial and lateral meniscus test was within normal limits. A diagnosis of degenerative joint disease of the right knee, status post medial meniscal debridment was provided. This disability affected the Veteran's occupation in that it caused him to become easily fatigued and limited his ability to bend, stoop, and crouch. VA and private treatment records dated from May 2009 to July 2011 and from November 2011 to January 2012 and the Veteran's August 2010 substantive appeal (VA Form 9) reflect that he reported chronic right knee pain, stiffness, weakness, instability, swelling, warmth, and limitation of motion. The knee pain was continuous and caused poor sleep, occasionally radiated up and down the leg, was 0-8/10 in intensity and aching in nature, was aggravated by physical activity (including standing, walking, and going up and down stairs and inclines) and cold/rainy weather, and was alleviated by rest and medications. He continued to exercise 2 to 4 times per week at a fitness center (e.g. treadmill, weights, circuit training) at times during this period and participated in a home exercise program following an August 2011 revision of his total knee replacement. The strength in his legs had improved and he reported that he felt "good overall" at the time of a May 2009 evaluation. He was employed and his job did not require him to be on his feet, but he was mostly sedentary at home with his leg elevated. After being on his feet for an extended period of time, he required approximately 3 days to recover. Examinations of the right knee revealed occasional swelling and tenderness, a well healed midline scar, occasional trace to moderate effusion, mild anterior crepitus, and only occasional slight limitation of motion. Specifically, ranges of knee motion were recorded as flexion to between 120 and 139 degrees and extension to 0 degrees. There appeared to be a mid flexion laxity to valgus stress during a July 2010 examination with Trinity O. Pilkington, M.D. At that time, the Veteran walked mildly with a valgus stress with heel-to-toe gait. There was a lot of instability associated with knee flexion (particularly at 90 degrees) during a July 2010 examination with Adrian T. Baddar, M.D and there was 1+ varus laxity in extension with severe flexion instability during a July 2011 examination with Jason R. Hull, M.D. However, the knee was otherwise stable. The Veteran occasionally walked with a limp. Moreover, there was no locking, buckling, redness, edema, inflammation, or signs of infection, there was good tracking and mobility of the patella, muscle strength was normal (5/5) and equal bilaterally (including muscle strength associated with knee flexion and extension), alignment was normal, the calf was soft and nontender, and Veteran had not experienced any falls due to his knee disability. Furthermore, X-rays and gallium and bone scans revealed increased blood flow around the total knee replacement with focal hot spots in both tibial and femoral components medially and laterally and in the patella. There was a revision of the tibial component of the knee replacement, synovial thickening or fluid in the suprapatellar bursa, a soft tissue inflammatory process around the total knee replacement, and possible evidence of loosening. However, the right knee prosthesis was intact and in good alignment, there was no definite evidence of loosening, and there was no evidence of fracture or osteomyelitis. The Veteran was diagnosed as having a right total knee replacement, degenerative joint disease, and knee arthralgia (pain) status post revision surgery with mid flexion laxity. The report of a VA examination dated in February 2012 reflects that the Veteran did not report any flare ups of knee symptoms. Ranges of knee motion were recorded as flexion to 130 degrees and extension to 0 degrees. There was no objective evidence of painful motion, there was no additional limitation in range of knee motion following repetitive motions, and there was no functional loss or functional impairment (including, but not limited to, pain, weakened movement, excess fatigability, and incoordination) of the knee or lower leg. There was no tenderness or pain on palpation of the joint line or soft tissues, muscle strength associated with knee flexion and extension was normal (5/5), there was no anterior, posterior, or medial-lateral instability, and there was no evidence of any patellar subluxation or dislocation. There was a scar associated with the Veteran's right knee replacement which measured 26 centimeters by 0.4 centimeters. However, the scar was not painful or unstable. Furthermore, the Veteran had no history of any shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial/fibular impairments, there were no meniscus-related symptoms, he had not undergone any meniscectomy, and he did not use any assistive devices for ambulation. The functional impairment of the right lower extremity was not such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. A diagnosis of status post total right knee replacement associated with degenerative joint disease, status post medial meniscal debridement was provided. During the October 2012 hearing, the Veteran reported that he had undergone one total knee replacement, two revisions of the replacement, and a kneecap resurfacing. He experienced knee pain, swelling, stiffness, weakness, instability, and limitation of motion, and he had experienced several falls due to his knee weakness. However, he had only seldomly taken medications for his knee problems since approximately January 2012. He was employed as a motorcycle riding instructor, but had difficulty performing his job due to knee pain and swelling. In order to warrant a rating in excess of 30 percent for the Veteran's service-connected right knee disability, the Veteran would have to be found to have chronic residuals of a right knee replacement consisting of severe painful motion or weakness, ankylosis of the knee in flexion between 10 degrees and 20 degrees, limitation of knee extension to 30 degrees, nonunion of the tibia and fibula with loose motion and the need for a brace, or some combination of levels of limitation of extension, limitation of flexion, subluxation, or instability which equals a rating in excess of 30 percent. The above evidence reflects that the Veteran has consistently reported chronic right knee pain and weakness. However, the Board finds that there has not been severe painful motion or weakness of the right leg at any time during the claim period so as to warrant a 60 percent rating under DC 5055. With respect to pain, the intensity has varied widely between 0/10 and 8/10, the Veteran reported during the April 2009 VA examination that he was able to function during episodes of pain with the use of medication, and he has been able to perform knee flexion to between 100 and 130 degrees and knee extension to between 5 and 0 degrees. Although there was pain associated with knee range of motion following repetitive use during the April 2009 VA examination, such pain did not begin until 125 degrees of flexion and 10 degrees of extension. There was no pain associated with knee ranges of motion during the February 2012 VA examination and there were no reported flare ups or any other functional limitations at the time of that examination. As for weakness, the range of knee motion was limited by weakness during the April 2009 VA examination, there is evidence of occasional knee instability (characterized as severe flexion instability during Dr. Hull's July 2011 examination), and the Veteran has reported falls due to leg weakness. However, there was no objective evidence of knee instability during the April 2009 VA examination, there was no additional knee range of motion loss due to weakness during that examination, and muscle strength associated with knee flexion and extension has always been found to be normal (5/5). Moreover, the Veteran joined a fitness facility in January 2009 at which he exercised (including cardio exercise, circuit training, and weight training which involved the lower extremities) 2 to 4 times per week for up to 2 hours at a time, he reported that he was not receiving any ongoing treatment for his knee problems at the time of the April 2009 VA examination, he engaged in a home exercise program following the August 2011 revision of his knee replacement, his gait has generally remained normal (with the exception of an occasional limp), he has never required any assistive devices for ambulation, and he reported during the October 2012 hearing that he had only seldomly taken medication for his knee symptoms since approximately January 2012. In light of the above described evidence, and particularly the fact that the ranges of knee flexion and extension have been well in excess of half the normal ranges, that pain has only occasionally been found to accompany active knee motion, that neither pain nor weakness have ever been found to cause additional range of motion loss of the knee, that muscle strength associated with knee motion has always been found to be normal, and that the Veteran has engaged in strenuous and prolonged physical activities despite his knee disability, the Board finds that the residual pain and weakness of the Veteran's right knee replacement are not severe and that such symptoms more closely approximate the criteria for a 30 percent rating under DC 5055. Thus, a rating in excess of 30 percent for a right total knee replacement under DC 5055 is not warranted at any time during the claim period. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DC 5055. As for whether a higher rating is warranted on the basis of limitation of knee extension or some combination of limitation of knee flexion, limitation of knee extension, and knee subluxation/instability, there is evidence of a right knee disability with pain, weakness, and lack of endurance. Also, the Veteran has provided subjective reports of fatigability and flare ups. He has been able to perform knee flexion to between 100 and 139 degrees and extension to between 5 and 0 degrees. Although there was pain beginning at 125 degrees of flexion and 10 degrees of extension during the April 2009 VA examination, the Veteran was still able to perform flexion and extension to 130 degrees and 5 degrees, respectively. Pain itself does not constitute functional loss and the examiner who conducted the April 2009 VA examination specifically reported that there was no additional range of motion loss or loss of function due to pain, weakness, fatigue, or incoordination. Also, the Veteran was able to perform flexion and extension to 130 degrees and 0 degrees, respectively, during the February 2012 VA examination. During that examination there were no reported flare ups, there was no pain associated with knee range of motion, and there was no additional limitation in range of knee motion or additional functional impairment due to such factors as pain, weakness, fatigue, or incoordination. Thus, even considering pain and other functional factors, the Veteran's right knee symptoms have not been shown to be so disabling to actually or effectively result in limitation of knee flexion to 45 degrees or limitation of knee extension to 10 degrees -the requirements for compensable ratings for limitation of knee flexion and extension under DCs 5260 and 5261. This entails a finding that the knee symptoms do not result in limitation of knee extension to 30 degrees, which is the requirement for a 40 percent rating under DC 5261. Hence, a rating in excess of 30 percent for a total right knee replacement on the basis of limitation of knee extension or some combination of limitation of knee flexion and extension under DCs 5260 and 5261 is not warranted at any time during the claim period. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DCs 5260-5261. The Board acknowledges that there is evidence of knee instability throughout the claim period. However, even if it were assumed that there has been severe knee instability during the entire claim period, such impairment only warrants a 30 percent rating under DC 5257 and this is the maximum schedular rating under that diagnostic code. As explained above, the criteria for compensable ratings for limitation of knee flexion and extension under DCs 5260 and 5261 have not been met at any time during the claim period. Hence, even considering the evidence of knee instability, a rating in excess of 30 percent for a right total knee replacement is not warranted on the basis of limitation of knee motion and instability. 38 C.F.R. § 4.71a, DCs 5257, 5260-5261. Additionally, the Veteran is not entitled to a rating under DCs 5256, 5258-5259, or 5262-5263 as there is no evidence of ankylosis, cartilage removal or dislocation, tibia or fibula impairment, or genu recurvatum. The Veteran has been diagnosed as having degenerative joint disease of the right knee associated with his service-connected knee disability. He has been granted service connection for degenerative joint disease of the right knee and was assigned a noncompensable disability rating for this disability from January 1, 2000 to August 26, 2006. However, arthritis is rated on the basis of painful limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). As the 30 percent rating under DC 5055 contemplates painful range of motion, a separate rating for arthritis would constitute prohibited pyramiding and is thus not warranted. 38 C.F.R. § 4.14 (2012). There is also evidence of a right knee scar associated with the right total knee replacement. The April 2009 VA examination report reveals that the scar measured approximately 17.5 centimeters by 0.4 centimeters and that there was no tenderness, adherence, instability, or limitation of motion caused by the scar. The February 2012 VA examination report indicates that the scar was 26 centimeters by 0.4 centimeters and that it was not painful or unstable. The rating criteria for scars were revised during the course of this appeal, effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). These amendments, however, are only effective for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria. In this case, the Veteran has not requested such consideration. As his claim for an increased rating was received in September 2008, the 2008 amendments are not applicable in this appeal. To warrant a compensable rating under the applicable criteria, a scar would need to involve the head, face or neck and have at least one character of disfigurement (DC 7800); be deep or cause limited motion and affect an area or areas exceeding at least 6 square inches (39 square centimeters) (DC 7801); be superficial and affect an area or areas of 144 square inches (929 square centimeters) or greater (DC 7802); be superficial and unstable (DC 7803); be superficial and painful on demonstration (DC 7804); or cause some limitation of the function of the part affected (DC 7805). 38 C.F.R. § 4.118, DCs 7800-7805 (2008). In this case, the right knee scar does not involve the head, face, or neck and there is no evidence that it is deep, causes any limitation of motion or function, affects an area exceeding at least 6 square inches, or is unstable or painful. Hence, a separate compensable rating for a right knee scar is not warranted at any time during the claim period. Id. Extraschedular Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). The Board must specifically address whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, 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 a 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), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). 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"). There is no allegation or evidence of exceptional factors in this appeal with regard to the Veteran's service-connected right knee disability. The symptoms of his disability include knee pain, limitation of motion, tenderness, effusion, weakness, stiffness, swelling, lack of endurance, fatigability, instability, warmth, and crepitus. All of these symptoms are contemplated by the diagnostic criteria set forth in DCs 5055 and 5256 to 5263. Thus, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1). Total Rating for Compensation Purposes Based on Individual Unemployability (TDIU) The Court has held that entitlement to a TDIU is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). The evidence reflects that the Veteran has reported difficulties with his job due to his service-connected right knee disability. However, he has remained employed as a motorcycle driving instructor during the entire claim period. Thus, although he has reported that his right knee disability has had some adverse impacts upon his employment, he has not reported, and the evidence does not otherwise reflect, that he is prevented from securing and following gainful employment due to a service-connected disability. As there is no evidence of unemployability, the question of entitlement to a TDIU is not raised under Roberson and Rice in this instance. ORDER Entitlement to a rating in excess of 30 percent for a right total knee replacement is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs