Citation Nr: 1311980 Decision Date: 04/11/13 Archive Date: 04/19/13 DOCKET NO. 09-06 363 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a disability rating greater than 10 percent for patellofemoral pain syndrome of the left knee. 2. Entitlement to a disability rating greater than 10 percent for patellofemoral pain syndrome of the right knee. 3. Entitlement to service connection for allergic rhinitis claimed as sinusitis due to nose injury. 4. Entitlement to service connection for low back spasms, also claimed as low back condition secondary to service-connected patellofemoral pain syndrome of the knees. 5. Entitlement to service connection for deviated nasal septum (claimed as nasal condition, residuals of broken nose). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran had active service from May 1988 through April 1994. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas and a September 2010 rating decision of the RO in Waco, Texas. The case is currently under the jurisdiction of the RO in Waco, Texas. In July 2012, the Veteran testified before the undersigned at a Travel Board hearing. A transcript of this proceeding has been associated with the claims file. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals VA treatment records dated through July 2012. However, the most recent supplemental statement of the case dated in April 2012 only reviewed VA treatment records dated through April 2012. The remainder of the documents in the Virtual VA paperless claims file are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. With regard to the VA treatment records dated from April 2012 through July 2012, these records note complaints of continuing knee pain. This evidence is cumulative of VA treatment records noting knee pain dated prior to April 2012 and is not material to the determination of the matter. Accordingly, the Board agrees with the RO that the additional evidence associated with the claims file after the issuance of the April 2012 supplemental statement of the case did not require the issuance of a new supplemental statement of the case. See 38 C.F.R. § 19.31 (2012). The Board recognizes that the Court of Appeals for Veterans Claims has clarified that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities exists as part of a claim for an increase (whether in an original claim or as part of a claim for increased rating). Rice v. Shinseki, 22 Vet. App. 447 (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). The Board observes that the RO denied entitlement to TDIU in a separate December 2010 rating action. In a notice of decision letter dated in December 2010, the Veteran was advised of the denial and his appellate rights. No appeal ensued. In Locklear v. Shinseki, the Court distinguished the instant case from Rice and recognized that VA's Secretary specifically separated the adjudication of the schedular disability rating from the adjudication of entitlement to TDIU. 24 Vet. App. 311, 315 (2011). The Court in Locklear held that "[b]ifurcation of a claim generally is within the Secretary's discretion." Id. Here, the RO bifurcated the TDIU issue, and the Veteran did not appeal the denial of TDIU. Given all of the foregoing, no action on the part of the Board on any TDIU issue is indicated at this time. The issues of entitlement to service connection for allergic rhinitis and a low back disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's patellofemoral pain syndrome of the left knee is primarily manifested by 140 degrees flexion, 0 degrees of extension, and no additional limitation of motion followed by repetitive use. There is X-ray evidence of arthritis. 2. The Veteran's patellofemoral pain syndrome of the right knee is primarily manifested by 140 degrees flexion, 0 degrees of extension, and no additional limitation of motion followed by repetitive use. There is X-ray evidence of arthritis. 3. The competent and credible medical opinion evidence of record shows that the Veteran's current deviated nasal septum is not etiologically related to a contusion of the nose he sustained in service. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 10 percent for patellofemoral pain syndrome of the left knee have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1 -4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5299-5020 (2012). 2. The criteria for a disability rating greater than 10 percent for patellofemoral pain syndrome of the right knee have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1 -4.7, 4.10, 4.40, 4.45, 4.71a, DCs 5299-5020 (2012). 3. Service connection for deviated nasal septum is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal arises out of the Veteran's assertion that his service-connected patellofemoral syndrome of the left and right knees is more disabling than currently evaluated. He also contends that a deviated nasal septum is related to his military service with the United States Army from May 1988 to April 1994. Increased Rating Issue Disability ratings are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. A request for an increased rating is to be reviewed in light of the entire relevant medical history. See generally 38 C.F.R. § 4.1; Payton v. Derwinski, 1 Vet. App. 282, 287 (1991). Moreover, disabilities may be rated by analogy to a closely related disease where the functions affected and the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. The Veteran's service treatment records show that he injured both of his knees on several occasions during military service. Specifically, treatment records dated in October 1988 and June 1989 show that the Veteran fell from a tank to the ground and was treated for a contusion of the right knee. Treatment records dated in January, June, and September 1991 show treatment for sprains and an abrasion of the left knee due to basketball injuries. He submitted a claim for service connection for a bilateral knee disorder in November 2000 and was afforded a VA examination in April 2001 which showed a diagnosis of bilateral patellofemoral pain syndrome. By rating decision dated in September 2002 the RO granted service connection for patellofemoral syndrome of each knee, assigning 10 percent disability ratings for each knee effective November 30, 2000, the date of the Veteran's claim for service connection. These 10 percent disability ratings for each knee were continued by rating decisions dated in January and August 2005. The Veteran's service-connected patellofemoral syndrome of the knees is currently rated under 38 C.F.R. § 4.71a, DC 5299-5020. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen; unlisted disabilities requiring rating by analogy will be coded first the numbers of the most closely related body part and "99." In this case, the hyphenated code indicates that the Veteran's disability is evaluated as synovitis based on the criteria found under DC 5020. Under DC 5020, synovitis is rated as degenerative arthritis under DC 5003, which in turn, is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (here, DC 5260-5261). When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is assignable for each major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003. Limitation of flexion of a leg warrants a noncompensable evaluation if flexion is limited to 60 degrees, a 10 percent evaluation if flexion is limited to 45 degrees, a 20 percent evaluation if flexion is limited to 30 degrees or a 30 percent evaluation if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Limitation of extension of a leg warrants a noncompensable evaluation if extension is limited to 5 degrees, a 10 percent evaluation if extension is limited to 10 degrees, a 20 percent evaluation if extension is limited to 15 degrees, a 30 percent evaluation if extension is limited to 20 degrees, a 40 percent evaluation if extension is limited to 30 degrees or a 50 percent evaluation if extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Where a claimant has both limitation of flexion and limitation of extension of the same leg, he must be rated separately under DC's 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. VAOPGCPREC 9-2004 (September 17, 2004). Further, under certain circumstances, a separate disability evaluation may be assigned for arthritis of the knee under DC 5003 in addition to the rating for instability under DC 5257. VAOPGCPREC 9-98 and VAOPGCPREC 23-97. Evidence relevant to the severity of the Veteran's patellofemoral syndrome of the knees includes VA examination reports dated in October 2004, July 2005, July 2006, October 2010, and August 2011. During the October 2004 VA examination the Veteran reported a history of pain and stiffness of the knees which was getting worse. He indicated that his left knee would give out and felt weak. There was no history of swelling, heat and redness, or instability. He treated the pain with Naproxen with some relief and no side effects. Precipitating factors included walking around the house and standing too long. Alleviating factors included rest and medication. With regard to any additional limitation of motion or functional impairment during a flare-up the Veteran reported temporary impairment in standing and walking. The Veteran wore a brace. There was no history of surgery on the knees. The Veteran reported that he twisted his knee playing basketball and also his knees when in his tank during military service. There were no episodes of dislocation or recurrent subluxation and there was no inflammatory arthritis or constitutional symptoms. With regard to the effects of the condition on the Veteran's usual occupation and daily activities the Veteran reportedly had pain in his knees on prolonged standing or walking. He had discomfort on squatting, climbing up and down the stairs, and was unable to jump. Bending his knees, especially on long drives, aggravated the pain. He had to stop and stretch his knees. In part from above, his daily activities were not significantly affected. He remained independent in self care and activities of daily living. It was noted that the Veteran's bilateral knee disorder interferes with his ability to fully enjoy recreational activities, complete vigorous household chores, and engage in any forms of employment which may require continuous demanding physical endurance. On range of motion testing of the left knee the Veteran had 100 degrees of flexion out of 140 degrees with pain and stiffness at 110 degrees. There was quadriceps wasting, left knee, tenderness on infra patellarfossa. With regard to the right knee the Veteran had 130 degrees of flexion out of 140 degrees with stiffness at 120 degrees. The knees did not catch, grind, or pop. There was subpatellar crepitus and pain with inhibition in knees. Stability was normal and there was no effusion or quadriceps wasting on the right knee. There was mild tenderness on supra patellarfossa on the right knee. Collaterals were stable to varus and valgus stress. Cruciates were stable and Lachman's and Drawers tests were negative. Meniscus was stable with negative McMurray's testing. There was no change with repeated or resisted motion of any joint. The examiner noted that the knees were not painful on motion, however, joint function was additionally limited by stiffness. There was no edema, effusion, instability, weakness, redness, heat, or abnormal movement. The examiner noted that the Veteran had a normal gait. The Veteran complained of pain and stiffness on prolonged standing and walking. Prolonged bending of the knees on long drives aggravated the pain causing him to stop and stretch his knees. There was no evidence of abnormal weight bearing. The examiner wrote that ankylosis was not present and that there were no signs of inflammatory arthritis. X-ray examination revealed fairly maintained joint spaces. There was linear ossification at medial supracondylar region of the left femur suggesting Pellegrini-Stedida disease. There was small ossification inferior to left patella, two to three small ossifications inferior to the right patella, probably representing previous post traumatic changes. Otherwise negative plain radiographic study of both knees. The diagnosis was bilateral patellofemoral syndrome, traumatic arthritis knees. During the July 2005 VA examination the Veteran reported stiffness, swelling, and popping in his knees. These symptoms occurred constantly but he indicated that his condition did not cause incapacitation. At that time he was treated with knee braces and Naproxen. He had not had any prosthetic implants of the joint. From the above condition the functional impairment was walking and running. He was not working when he developed this disorder. On musculoskeletal examination, leg length from the anterior superior iliac spine to the medial malleolus was 101 centimeters on the right and 101 centimeters on the left. Examination of the feet did not reveal any signs of abnormal weight bearing. The Veteran's posture and gait were within normal limits. He required a brace for ambulation due to knee pain. Physical examination of the knees was within normal limits. There was evidence of "locking pain" and crepitus. Range of motion testing revealed flexion to 140 degrees and extension to 0 degrees, bilaterally. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Both Drawer and McMurray's tests of both knees were within normal limits. X-ray examination of the right knee revealed patella alta and x-ray examination of the left knee revealed old medial collateral ligament injury. The examiner continued the Veteran's previously established diagnosis of patellofemoral pain syndrome, bilateral knees. Additionally, the examiner noted that the right patella alta could be the cause for the right knee patellofemoral syndrome. With regard to the left knee, Pellegrini-Stieda syndrome, the relationship between this syndrome and patellofemoral pain syndrome could not be established given the limited history. The examiner noted that the effect of the condition on the Veteran's usual occupation and daily activities was moderate. During the July 2006 VA examination the Veteran complained of popping and sensation of instability to valgus on the left knee. He also complained of retropatellar pain upon using stairs. With regard to the right knee the Veteran complained of pain upon walking, riding a bike, or using the stairs. Both knees would reportedly swell if he played basketball with his kids. Neither knee locked or gave way or showed lack of endurance. The Veteran reported daily pain of 7-8 out of a scale of 1 to 10. Pain improved upon resting within 30 minutes. Either knee might hurt at night sometimes. He often rubbed Trolamine Salicylate on his knees as "it relaxes the knee." He also took Naproxen and Pool Kt with good response and no side effects. There was no decrease in range of motion or joint function during the flare ups unless it swelled, sometimes (when playing basketball or football with his children) then he limited himself to the necessary walking afterwards. The examiner noted that the Veteran used hinged braces for both knees. With regard to injuries of the knees the Veteran reported that he injured his left knee falling of a tank during service and with regard to the right knee the Veteran reported a hyperextension injury when another player hit it in its front. There were no surgeries. There were no episodes of dislocation or recurrent subluxation and there was no inflammatory arthritis. With regard to the effects of the Veteran's condition on his usual occupation the Veteran was a student (geomedics). The examiner noted that there was no effect on activities of daily living but that this bilateral knee disorder affected him for recreational activities. On physical examination of the knees the Veteran had full range of motion (0 to 140 degrees). There was no painful motion, both McMurray's, Lachman's, and Drawers were negative, and stability was normal. There was no weakness, tenderness, abnormal movement or guarding of movements, effusion, swelling, or deformities. Repetitive squats did not decrease range of motion or joint function but caused repeated painful pops on the left knee. There was no indication of abnormal weight bearing and ankylosis was not present. Leg length was normal and there was no inflammatory arthritis. X-ray examination revealed linear ossification at medial supracondylar region of the left femur suggesting Pellegrini-Steida disease. There was also a small ossification inferior to the left patella and two to three small ossifications inferior to the right patella, probably representing previous post traumatic changes. Otherwise, the X-ray was negative and showed a plain radiographic study of both knees. The diagnosis was post traumatic Pellegrini-Steida disease of the left knee and patellofemoral pain syndrome of the right knee. During the October 2010 VA examination the Veteran reported that he was taking college courses while seeking employment. With regard to the knees, the Veteran reported popping, aching, and some swelling. He initially indicated that both of his knees gave way but later stated that the left knee would give way but not the right knee. He wore bilateral knee braces. He took Tramadol for the pain and his response to current treatments was good. On physical examination of the knees the Veteran had full range of motion (0 to 140 degrees). There was no objective evidence of pain on active motion, no pain on motion after at least three repetitions of range of motion, and no additional limitations of motion after repetitive motion. Neurologic and sensory examinations of the lower extremities were normal. X-ray examination of the knees revealed minor degenerative changes. The examiner diagnosed PFS (patellofemoral pain syndrome) of the knees and indicated that there were no effects on usual occupation and resulting work problems and no effect on usual daily activities. It was noted that the Veteran could function in an occupational environment based on his service-connected conditions, however, the examiner noted that the Veteran's nonservice-connected substance abuse could hinder him from employment. During the August 2011 VA examination the examiner noted a diagnosis of mild degenerative joint disease of both knees. The Veteran stated that while in service, he injured his knees when he fell on a tank twice and also while playing basketball when another player landed on his left knee. He stated that he had pain and swelling with the injuries, but did not remember what he was diagnosed with at the time. He stated that he had swelling in the knees at times and that they gave out and sometimes locked up. He wore braces on both knees and stated that the left knee was worse than the right knee. The Veteran denied flare-ups. On range of motion testing the Veteran had 0 to 140 degrees of motion with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions without loss of motion. There was no functional loss and/or functional impairment of the knee and the lower leg. There was no functional loss of either the right or left lower extremity. The Veteran did have tenderness or pain to palpation for joint line or soft tissues of both knees. Muscle strength testing and joint stability tests were normal. There was no patellar subluxation/dislocation. The Veteran denied "shin splints," stress fractures, chronic exertional compartment syndrome, and any other tibial and/or fibular impairment. There were no meniscal conditions and there was no history of surgical procedures for a meniscal condition. There was no history of joint replacement and no indication of scars on the knees. The Veteran did use braces on both knees. There was no indication that the Veteran's bilateral knee disorder resulted in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation or prosthesis. It was noted that traumatic arthritis had been documented by X-ray but there was no X-ray evidence of patellar subluxation. The examiner noted that the Veteran's bilateral knee disorder did not impact his ability to work. In summary, the examiner wrote that the Veteran's bilateral knee examination was essentially normal. The mild degenerative joint disease found on X-ray examination was consistent with normal findings for the Veteran's age. During the July 2012 Travel Board hearing the Veteran reported that he had recently started a job and had trouble walking more than 40 yards. He also indicated that he received physical therapy through VA two to three times per week. Also of record are VA outpatient treatment notes dated through July 2012 and private treatment records dated through February 2010. In light of the foregoing, the Board is unable to find that the medical evidence of record supports assignment of disability ratings greater than 10 percent under DC 5020 for the Veteran's service-connected bilateral patellofemoral pain syndrome of the knees. Notably, the Veteran's loss of motion is noncompensable under 5260-5261. The Veteran had 110 degrees of flexion of the left knee and 130 degrees of flexion of the right knee during the October 2004 VA examination, and he had full flexion of both knees to 140 degrees during the July 2005, July 2006, October 2010, and August 2011 examinations. As noted above, a loss of flexion to 110 degrees does not constitute compensable limitation of motion under DC 5260. As noted above, flexion must be limited to at least 30 degrees for the next higher rating under DC 5260. Also, the Veteran's reported extension of 0 during the October 2004, July 2005, July 2006, October 2010, and August 2011 VA examinations does not constitute compensable limitation of motion under DC 5261. Indeed, in Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011), the Court held that, although pain may cause a functional loss, pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance." Id. (quoting 38 C.F.R. § 4.40 (2012)). Here, additional functional loss to an appreciable degree is not shown. Thus, disability ratings greater than 10 percent for bilateral patellofemoral pain syndrome of the knees are not warranted. Other potentially applicable DC's that provide for evaluations in excess of 10 percent include 5256 (ankylosis of the knee), 5257 (recurrent subluxation and lateral instability) and 5258 (dislocated semilunar cartilage). There is no clinical evidence of ankylosis of the knee, recurrent subluxation and lateral instability, or dislocated semilunar cartilage with frequent episodes of "locking," and effusion into the joint. In fact, the medical evidence of record, as summarized in pertinent part above, is primarily negative for symptoms such as locking or effusion. While "locking pain" was noted on VA examination in 2005, the Drawer and Murray tests were negative and no true locking of the knee was demonstrated on any VA examination thereafter. Also, the October 2004, July 2005, July 2006, October 2010, and August 2011 VA examinations described above are negative for ankylosis and "subluxation." There is a November 2007 VA treatment record that noted a finding of "slight increase in laxity," but this is an outlier and not representative of the disability as no instability was clinically demonstrated on numerous VA examinations. Lastly, no X-rays of the knees above showed any evidence of fracture, dislocation, or joint effusion. Thus, DCs 5256, 5257, and 5258 are not for application. In regard to DeLuca, while the October 2004 VA examiner reported additional limitation of joint function from stiffness, this was not expressed in terms of additional degrees of loss of range of motion. It is presumed that it was not possible to do so as the examiner was specifically asked to do so "if possible." Notably, there was no change with repeated motion of the joints on all other VA examinations. As detailed above, the Veteran does not meet the criteria for a compensable rating under any of the diagnostic codes. Rather, his complaints of symptomatic knees are accounted for under the current ratings as it is the intent of the schedule to recognize painful motion with joint or periarticular pathology as productive of disability, and it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012); Burton v. Shinseki, 25 Vet. App. 1 (2011). In regard to flare-ups, the Veteran reported on VA examination in 2006 that he experienced no loss of motion during flare-ups unless he was also experiencing swelling. On VA examination in October 2004, it was noted that the Veteran experiences temporary impairment when walking and standing. The Veteran is not describing flare-ups. Rather, the Veteran's description of what he experiences during flare-ups is essentially the same as his general description of the impairment associated with his knees during "regular" times-which is pain, swelling, popping, give away, and locking on use. Indeed, subsequent VA examinations show denials of flare-ups. Thus, there is no credible showing of possible additional functional loss during a flare-up. The Board finds that the currently assigned 10 percent disability ratings for each knee are appropriate. In deciding the Veteran's claim, the Board has considered the Court's determination in Hart and whether he is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. The Board does not find evidence that the Veteran's disability evaluation should be increased for any separate period based on the facts found during the appeal period. The evidence of record supports the conclusion that he is not entitled to an increased evaluation for separate periods and that he meets the criteria for separate 10 percent disability ratings for each knee for the entire length of the appeal. The Board has also considered his statements that his disability is worse than evaluated. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, and he is credible in his belief that the impairment associated with his knees warrant higher ratings. See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluated the true extent of the knee impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of impairment associated with the Veteran's complaints. Indeed, the Veteran believes he experiences true give away and locking of the knees, but the medical evidence of record (other than the outlier 2007 VA treatment record) shows that this is not the case. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment and the extent to which a determination can be made on the degree of functional impairment experienced during physical activity and flare-ups. As such, the Board finds the examination reports to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. In conclusion, the Board finds that the preponderance of the evidence is against an increased rating for the claimed disabilities and the appeal is denied. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1)(2012); Thun, 22 Vet. App. at 116. The rating criteria in this case are not inadequate. An evaluation in excess of the assigned ratings is provided for certain manifestations of the service-connected disabilities, but the evidence reflects that those manifestations are not present in this case. The Veteran primarily complains of pain, swelling, popping, give away, and locking on use. These are not exceptional or unusual features of the disabilities and are symptoms contemplated in the rating criteria and related regulations. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Service Connection Issue Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In addition, certain chronic diseases may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 C.F.R. §§ 3.307, 3.309. Disorders diagnosed more than one year after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that, absent a diagnosis of a chronic disease as defined in 38 C.F.R. § 3.309(a), service connection may not be awarded based on continuity of symptomatology. See Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1372. The Veteran's service treatment records show that the Veteran suffered a nose contusion in August 1988. At that time, there was no evidence of fracture or complaints of sinusitis/nasal congestion. There are no other complaints regarding the nose during military service with the exception of clogged up sinuses in December 1993 when the Veteran was experiencing flu symptoms. Upon separation examination in October 1993, the Veteran reportedly had a normal nose and sinuses. Furthermore, during an October 1993 report of medical history the Veteran denied a history of "ear, nose, or throat trouble" and "sinusitis." The Veteran submitted a claim for service connection for a sinus condition due to an in-service nose injury in November 2005. VA treatment records that the Veteran underwent septoplasty for deviated nasal septum in December 2010. The Veteran was afforded a VA examination specific to his nose in July 2006. At that time the Veteran reported a history of constant nasal stuffiness since 1997 ("never before.") There was no discharge, headaches, tenderness, or antibiotic treatments, only treatment for allergic rhinitis. The Veteran reported that his nose condition decreased the breathing through his nose. There was no purulent discharge and no dyspnea at rest or on exertion. There was no speech impairment. The examiner noted that there was no chronic sinusitis either upon examination or by history. With regard to allergic attacks the Veteran reported constant nasal stuffiness, some days worse than others. There were no other symptoms noted and there were no periods of incapacitation. On physical examination the examiner noted nasal polyps as well as congested turbinates. There was no evidence of granulomatous disease including rhinoscleroma. There was a partial obstruction, 50 percent, on each side. There was no tenderness, purulent discharge, or crusting as the mucosa was reportedly dry. X-ray examination of the sinuses revealed no air-fluid levels in the paranasal sinuses. No significant mucosal thickening was visualized and no bone destruction was apparent. Frontal sinuses had not developed. The diagnosis was allergic rhinitis. The Veteran was afforded a VA examination specific to his nose in July 2010. At that time the examiner reviewed the claims file and noted that the Veteran was seen for "septal bulge to the left side" in June 2003, consulted an ear, nose, and throat physician in March 2009 for nose bone pushed to one side, and was seen again in May 2010 for severely deviated nasal septum occluding nasal airway. The examiner opined that the Veteran's current deviated nasal septum was less likely than not caused by the Veteran's in-service nose contusion. The examiner noted that the Veteran was on active duty for six years. He sustained a nasal injury in August 1988 and the examination revealed mild nose swelling without deviation or bleeding and a diagnosis of nasal contusion. There were no X-rays to document whether he fractured his nose and there were no follow-up visits for complaints of difficulty breathing due to his nasal contusion because of a deviated septum. He was seen in June 2003 with "septal bulge to left side" and in March 2009 was found to have a severely deviated septum occluding his right airway. Based on the documentation that there was no indication of deviated septum on the single visit for nasal contusion, no documentation of difficulty breathing on his separation examination, and that the Veteran's first documentation of "septal bulge to left side" is dated in 2003, the Veteran's current treatment for deviated nasal septum is less likely than not caused by or a result of his in-service nose contusion. An October 2010 VA general examination shows a normal nose and sinuses. As noted above, VA treatment records show that the Veteran underwent septoplasty for deviated nasal septum in December 2010. Given the evidence of record, the Board finds that service connection for deviated nasal septum is not warranted. While there is evidence that the Veteran injured his nose during service, the July 2010 VA examiner opined with supporting rationale that the Veteran's current deviated nasal septum is not related to the in-service nasal injury. A competent medical expert has made this opinion and the Board is not free to substitute its own judgment for that of such expert. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). There are no other contrary medical opinions of record. In fact, the only evidence tending to support this case consists of the Veteran's allegations and testimony of record. The Veteran has described his history of treatment for a nose injury in August 1988 which is shown by his service treatment records. The Veteran also contends that he has experienced nasal problems since military service. A deviated nasal septum is not a chronic disease as defined in 38 C.F.R. § 3.309(a). Thus, his assertions of continuity of symptomatology alone cannot support a grant of service connection. Moreover, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, relating current nose problems to an in-service nose contusion, this falls outside the realm of common knowledge of a lay person. See Jandreau 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Rather, the competent and credible medical opinion evidence of record shows that the Veteran's deviated septum is not etiologically related to the in-service contusion of the nose. Accordingly, the opinion of the July 2010 VA examiner is highly probative and outweighs the other evidence of record, including the Veteran's testimony and contentions. As such, service connection is not in order. There is no doubt of material fact to be resolved in the Veteran's favor. Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Substantially compliant notice was sent in November 2005, October 2008, and September 2009 and the claim was readjudicated in an April 2012 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board. No violation of Bryant v. Shinseki, 23 Vet. App. 488 (2010) is shown by the record. Also, the VA examinations and opinions are adequate as the examiners either reviewed the claims file or otherwise had knowledge of the "relevant facts" regarding the Veterans medical history, considered the contentions of the Veteran, provided the information necessary to evaluate the Veteran's disability under the applicable rating criteria, and provided a supporting rationale for the opinion reached. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. ORDER A disability rating greater than 10 percent for patellofemoral pain syndrome of the left knee is denied. A disability rating greater than 10 percent for patellofemoral pain syndrome of the right knee is denied. Service connection for deviated nasal septum (claimed as nasal condition, residuals of broken nose) is denied. REMAND A review of the record discloses further development is necessary prior to the adjudication of the Veteran's remaining claims of service connection. Allergic Rhinitis The Veteran was afforded a VA examination specific to his nose in July 2006. The Veteran reported that his experiences of "constant nasal stuffiness" had its onset in 1997. The examiner noted that the Veteran's allergic rhinitis began in 1997. The examiner opined that the Veteran's allergic rhinitis was not secondary to the contusion of the nose he suffered during military service. The examiner, however, did not provide a rationale for the opinion rendered. A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). For these reasons, the examination report must be returned to the July 2006 examiner for an addendum in which the examiner provides a rationale for the opinion reached. Low Back Disorder With regard to the issue of entitlement to service connection for low back spasms, also claimed as low back condition secondary to service-connected patellofemoral pain syndrome of the knees, the Board notes that the Veteran was afforded a VA examination with regard to his low back in July 2006. This examiner provided a diagnosis of "history of low back spasms, normal exam." The examiner also opined that the Veteran's low back spasms were less likely than not related to his bilateral knee disorder. Notably, while the July 2006 VA spine examiner found no current disability of the low back, a subsequent June 2007 computed tomography scan of the lumbar spine showed spinal stenosis of the neural foramina bilaterally at L5-S1 due to a disc herniation centrally. Bilateral nerve root impingement could not be excluded. In light of this additional relevant evidence added to the record since the July 2006 VA examination, the examination report should be returned to the examiner for another opinion that addresses whether the Veteran's low back disorder is caused or aggravated by the Veteran's service-connected bilateral knee disorder. Accordingly, the case is REMANDED for the following action: 1. Return the examination report and claims file to the examiner who conducted the July 2006 VA Nose, Sinus, Larynx, and Pharynx examination (or another appropriate examiner if unavailable) for an addendum opinion in regard to the Veteran's claimed allergic rhinitis disability. In regard to the examiner's opinion that the "Veteran's allergic rhinitis is not secondary to contusion of the nose he suffered in service," please provide a supporting rationale for the conclusion reached. 2. Return the examination report and claims file to the examiner who conducted the July 2006 VA spine examination (or another appropriate examiner if unavailable) for an addendum opinion in regard to the Veteran's claimed low back disability. While the examiner found that the Veteran's spine exam was normal, additional evidence (June 2007 CT scan of the lumbar spine) since this exam showed stenosis and disc herniation of the lumbar spine. In light of the foregoing, the examiner is asked to address whether any low back disorder is at least as likely as not (50 percent or greater probability) (a) caused by or (b) aggravated by the service connected bilateral knee disorder. In so opining, the examiner should address the Veteran's theory of entitlement that overcompensation of his knees (one knee is reportedly worse than the other) caused or aggravated his back disorder. If such aggravation is found, the examiner should address the following medical issues: (a) the baseline manifestations of the Veteran's low back disorder found prior to aggravation; and (b) the increased manifestations that are proximately due to the bilateral knee disorder. If the examiner is unable to answer any question without a resort to speculation, then he or she should so indicate and provide a rationale for why an answer could not be provided. 3. After the development requested above has been completed, the AMC/RO should readjudicate the Veteran's claims. If the benefits sought continue to be denied, the AMC/RO should issue a supplemental statement of the case (SSOC) to the Veteran and his representative. Thereafter the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs