Citation Nr: 1312246 Decision Date: 04/12/13 Archive Date: 04/19/13 DOCKET NO. 08-15 988 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a rating higher than 10 percent for right carpal tunnel syndrome. 2. Entitlement to a higher initial rating for right knee chondromalacia and degenerative joint disease status post meniscal tear repair at a compensable level before September 22, 2011, and a rating higher than 10 percent from September 22, 2011. 3. Entitlement to a higher initial rating for right knee chondromalacia and degenerative joint disease status post meniscal tear repair with instability at a compensable level before September 22, 2011, and a rating higher than 10 percent from September 22, 2011. 4. Entitlement to a higher initial rating for left knee degenerative joint disease at a compensable level before September 22, 2011, and a rating higher than 10 percent from September 22, 2011. 5. Entitlement to a higher initial rating higher for a lumbar spine strain with degenerative joint disease at a compensable level before September 22, 2011, and a rating higher than 10 percent from September 22, 2011. REPRESENTATION Veteran represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD N. L. Northcutt, Counsel INTRODUCTION Pursuant to 38 C.F.R. § 20.900(c), the appeal has been advanced on the Board's docket. The Veteran, who is the appellant, served on active duty from August 1998 to April 2006. These matters come before the Board of Veterans' Appeals (Board) on appeal of an August 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado, which assigned an initial 10 percent rating for the Veteran's service-connected right carpal tunnel syndrome and initial non-compensable ratings for her service-connected low back and bilateral knee disabilities. In May 2011, the Veteran testified a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the Veteran's claims file. In July 2011, the Board remanded the appeal to the Appeals Management Center (AMC) for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). In February 2013, the AMC assigned 10 percent ratings for the low back disability, right knee functional loss, right knee instability, and left knee disability, effective September 22, 2011. FINDINGS OF FACT 1. Throughout the appeal, right carpal tunnel syndrome symptoms did not approximate or equate to moderate incomplete paralysis of the median nerve. 2. Before September 27, 2010, the right knee was manifested by dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 3. From September 27, 2010, the right knee has been manifested by symptomatic removed semilunar cartilage. 4. Throughout the appeal, the right knee has been productive of slight recurrent subluxation or lateral stability. 5. Before September 22, 2011, the left knee disability was productive of at least 135 degrees of flexion and 0 degrees of extension, and there was no evidence of recurrent subluxation or lateral instability, dislocated semilunar cartilage or its symptomatic residuals or x-ray evidence of arthritis. 6. From September 22, 2011, the left knee disability was productive of at least 120 degrees of flexion and 0 degrees of extension, and was not manifested by dislocated semilunar cartilage or its symptomatic residuals and was not productive of recurrent subluxation or lateral instability. 7. Before September 22, 2011, the low back disability was manifested by forward flexion of at least 100 degrees, and a combined range of motion greater than 235 degrees without painful motion, muscle spasm, guarding, or localized tenderness. 8. From September 22, 2011, the s low back disability is manifested by forward flexion that more nearly approximates 50 degrees. CONCLUSIONS OF LAW 1. The criterion for an initial rating higher than 10 percent for right carpal tunnel syndrome has not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). 2. The criteria for an initial 20 percent for a right knee disability, currently referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair, before July 16, 2010, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258 (2012). 3. The criteria for an initial 10 percent rating for a right knee disability, currently referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair, from July 16, 2010, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5259 (2012). 4. The criteria for a 10 percent rating for right knee instability, referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair with instability, prior to September 22, 2011, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2012). 5. The criteria for an initial rating higher than 10 percent for right knee instability, referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair with instability, from September 22, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2012). 6. The criteria for an initial compensable rating for a left knee disability, currently referred to as left knee degenerative joint disease, before September 22, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5257, 5258, 5259, 5260, 5261 (2012). 7. The criteria for an initial rating higher than 10 percent for a left knee disability, currently referred to as left knee degenerative joint disease, from September 22, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5257, 5258, 5259, 5260, 5261 (2012). 8. The criteria for an initial compensable rating for a low back disability, currently diagnosed as lumbar spine strain with mild degenerative joint disease, before September 22, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 9. The criteria for an initial 20 percent rating for a low back disability, currently diagnosed as lumbar spine strain with mild degenerative joint disease, after September 22, 2011, have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). VA's Duties to Notify and Assist Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. The appeal arises from the Veteran's disagreement with the initial evaluations assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, and any additional notice is not required. Thus, any defect in the notice is not prejudicial and will not be discussed. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With regard to VA's Duty to Assist, the RO determined that the Veteran's service treatment records are unavailable after the National Personnel Records Center reported their unavailability. The RO documented the attempts to obtain these records, made a formal finding of their unavailability, and informed the Veteran of their unavailability. Fortunately, the Veteran was able to provide a complete copy of her service treatment records to VA, and these copied records are associated with her claims file. Accordingly, while the Board acknowledges the Veteran's representative's request during the Veteran's Board hearing that VA undertake further efforts to obtain the Veteran's service treatment records, any further attempts are not warranted. The Veteran's VA medical treatment records have been obtained; the Veteran did not identify any private treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that she is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). VA examinations were conducted in 2007 and 2011; the Veteran has not argued, and the record does not reflect, that these examinations are inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examination reports reflect that the examiner's conducted thorough physical examinations of the Veteran and provided findings relevant to the applicable rating criteria. The examination reports also chronicle the Veteran's reported symptomatology. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders/Simmons, 556 U.S. 129 (2009); Dingess/Hartman, 19 Vet. App. at 486. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS General Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Right Carpal Tunnel Syndrome Rating Criteria Carpal tunnel syndrome is currently rated under 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Veteran is right-handed, and the disability therefore involves her dominant or major side, that is, the right upper extremity. Under Diagnostic Code 8515, the criterion for a rating higher than 10 percent, that is, a 30 percent rating for the major upper extremity, is moderate incomplete paralysis of the median nerve. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Facts In April 2005, the Veteran was noted to have right ulnar nerve paresthesias, for which she had received a physical profile exempting her from performing pushups. In May 2005, the Veteran completed some diagnostic testing to assess the severity of her diagnosed right ulnar nerve irritation, and the evaluating occupational therapist concluded that the Veteran's right hand strength was decreased by six pounds. In June 2005, the Veteran demonstrated initial readings of active right wrist range of motion of flexion to 79 degrees, extension to 46 degrees, ulnar deviation to 18 degrees, and radial deviation to 7 degrees. On repetitive testing, the Veteran's ranges of flexion and extension improved, but the range of ulnar and radial deviation decreased to 17 and 5 degrees, respectively. An assessment of localized wrist joint pain was noted. In October 2005, the Veteran demonstrated 75 degrees of right wrist active range of motion, extension to 55 degrees, radial deviation to 15 degrees, and ulnar deviation to 35 degrees, with no additional limitation of motion on repetitive testing and no pain on motion. A provisional diagnosis of chronic hand numbness was noted. In November 2005, the Veteran demonstrated some right extremity grip and pinch strength weakness, when compared to her left extremity strength, and she reported experiencing pain on right wrist movement. An assessment of cubital tunnel syndrome was noted and nerve conduction studies were ordered. The results of these studies, also performed in November 2005, showed both right carpal tunnel syndrome and right cubital tunnel syndrome. On VA examination in February 2007, the Veteran reported that her right carpal tunnel syndrome produces numbness and a pins and needles sensation when she is not using a brace. She stated that her carpal tunnel syndrome results in difficulty typing and doing household chores, such as vacuuming. She demonstrated right wrist flexion to 80 degrees, extension to 70 degrees, radial deviation was from 0 to 20 degrees, and ulnar deviation was from 0 to 45 degrees. Right hand motor strength was assessed as a 4 of 5 when compared to her left hand motor strength. On VA examination in September 2011, the Veteran stated she experienced daily right hand pain and numbness, as well as weakness after prolonged gripping or engaging in a repetitive activity, such as operating her computer mouse. She stated that her right wrist disability did not affect her performance of her activities of daily living nor preclude her functioning in her usual occupation. She reported that she was not receiving any related medical treatment. On physical examination, the Veteran had abnormal sensation in her right thumb, middle, and long fingers, but demonstrated normal muscle tone, full strength in her right wrist extensor, and no muscular atrophy. On range of motion testing, she demonstrated flexion to 85 degrees, extension to 50 degrees, radial deviation to 35 degrees, and ulnar deviation to 50 degrees. Nerve conduction studies conducted in conjunction with this examination were interpreted to reveal mild, right sensory carpal tunnel syndrome. Based on these findings, the examiner characterized the Veteran's right carpal tunnel syndrome as resulting in mild neuralgia of the medial nerve distribution and a mild right wrist sprain with no instability. Analysis The Veteran's main complaints are pain, tingling, and numbness. No muscular atrophy has been observed, and the Veteran has demonstrated essentially normal right wrist range of motion throughout the rating period. While some decreased grip strength has been noted, she has not reported dropping objects or been assessed with grip strength so decreased as to cause her to drop objects. Rather, the Veteran's motor strength was assessed as only slightly impaired in 2007 (4 of 5) and as normal in 2011. Moreover, 2011 nerve conduction studies revealed that her right carpal tunnel syndrome as productive of mild neuralgia, and the Veteran has demonstrated consistent symptomatology throughout the rating period. Indeed, she has not reported, and the record does not reflect, that she has sought treatment for her right carpal tunnel syndrome since service. Therefore, the Veteran's right carpal tunnel syndrome symptomatology throughout this appeal does not more nearly approximate the criteria for the next higher rating, moderate incomplete paralysis of the median nerve. Right Knee Disability Rating Criteria The Veteran's right knee disability, referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair, has been assessed as noncompensably disabling prior to September 22, 2011, and as 10 percent disabling based on evidence of functional loss after September 22, 2011. Additionally, in a February 2013 rating decision the AMC granted a separate compensable rating for right knee instability under Diagnostic Code 5257, effective September 22, 2011. Accordingly, the Veteran has effectively been in receipt of a separate, noncompensable rating for right knee instability before September 22, 2011, and a 10 percent rating from September 22, 2011. Under Diagnostic Code 5257, the criterion for a 10 percent rating is slight recurrent subluxation or lateral instability of the knee. The criterion for a 20 percent rating is moderate recurrent subluxation or lateral instability. The criterion for a 30 percent rating, the maximum rating under Diagnostic Code 5257, is severe recurrent subluxation or lateral instability. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint is rated as 20 percent disabling. Diagnostic Code 5259 provides for a 10 percent rating based on evidence of symptomatic, removed semilunar cartilage. A semilunar cartilage is one of the menisci of the knee joint. See Stedman's Medical Dictionary, 296 (27th ed., 2000). Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. Limitation of motion of the knee is rated under Diagnostic Code 5260 (limitation of flexion) and Diagnostic Code 5261 (limitation of extension). Under Diagnostic Code 5260, the criterion for a 10 percent rating is flexion limited to 45 degrees. The criterion for the next higher rating, 20 percent, is flexion limited to 30 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of extension to 5 degrees warrants a noncompensable rating. Limitation of extension to 10 degrees warrants a 10 percent rating. Limitation of extension to 15 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a. Normal knee motion is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings may be assigned for limitation of flexion and for extension. VAOPGCPREC 9-04 (September 17, 2004). In rating a disability of the musculoskeletal system, the following factors are for consideration. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca at 206-07. Also with arthritis or periarticular pathology, painful motion is factor to be considered. The intent of the Rating Schedule is 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. Right Knee Chondromalacia and Degenerative Joint Disease Status Post Meniscal Tear Repair The Veteran's right knee disability, right knee chondromalacia and degenerative joint disease status post meniscal tear, is rated at a noncompensable rate prior to September 22, 2011, the date of her most recent VA examination, and at 10 percent from September 22, 2011, under Diagnostic Codes 5003 and 5261, as cited in the February 2013 rating. However, the rating decision itself reflects that the 10 percent rating assigned from September 22, 2011, was assigned on the basis of satisfactory evidence of painful motion, equating to functional loss, pursuant to 38 C.F.R. § 4.40 and 4.45. Facts The service treatment records show that in April 2005 an assessment of chronic right knee arthritis was noted. In June 2005, the Veteran demonstrated 126 degrees of active flexion, which increased to 127 degrees on repetitive testing, and plus 2 degrees of extension, indicating hyperextension. In September 2005, McMurray testing (designed to detect meniscal tears) of the right knee was positive. In October 2005, the Veteran complained of right knee pain that was increased when running, jumping, or standing for long periods of time. The Veteran demonstrated full range of right knee motion, with active range of motion from 0 to 135 degrees, and no evidence of effusion, limitation of motion, or pain on motion. On VA examination in February 2007, the Veteran reported experiencing flare-ups of her right knee disability, resulting in pain, stiffness, fatigability, and instability, and that her symptoms are alleviated by resting and applying heat to her knee. On examination, the Veteran had no right knee swelling, instability, or ligament laxity, and she demonstrated right knee flexion from 0 to 145 degrees, without pain. There was no additional limitation of motion on repetitive testing, including as due to pain, weakness, impaired endurance, incoordination, or instability, and the examiner stated that there would be no additional limitation of motion during a flare-up. X-rays of the right knee were deemed normal. VA treatment records show that in March 2007 (shortly after her misstep in which she believed she reinjured her right knee), the Veteran demonstrated pain with deep right knee flexion, but had full active range of right knee motion. In April 2007, McMurray's testing of the right knee was positive, indicating the presence of a meniscal tear, but Apley testing designed to determine meniscal problems, was negative, and testing designed to detect cruciate ligament tears or instability also had negative results. In June 2007, a magnetic resonance imaging (MRI) study was interpreted to reveal right knee meniscal rotational laxity, as the MRI revealed a loss of shape of both the medial and lateral meniscus. In November 2007, the Veteran reported a history of undergoing right knee surgeries to repair her meniscus and anterior cruciate ligament (ACL), and that her right knee meniscus and ACL were presently symptomatic. Additionally, the Veteran reported that she was experiencing right knee cap pain. She was assessed with right knee internal derangement with patellofemoral syndrome. In February 2008, McMurray's testing of the right knee was positive. In March 2008, McMurray's testing was also positive, and the Veteran demonstrated full range of right knee motion. In May 2008, the Veteran underwent a series of three right knee steroidal injections to treat her right knee pain. In July 2009, an assessment of right knee tricompartmental osteoarthritis and a meniscal horn tear was made based on the results of an MRI study. In September 2009, the Veteran reported that her right knee pain had not improved after her steroidal injections. McMurray's, Lachman's, anterior/posterior drawers, and valgus/varus stress testing revealed negative results. In July 2010, the Veteran underwent right knee surgery, which revealed an intact ACL, but a posterior horn meniscal tear and chondromalacia. On post-surgical follow-up in July 2010, the Veteran's right knee pain was assessed as minimal, and the Veteran demonstrated 0 to 130 degrees of right knee motion. In another post-surgical follow-up visit on September 27, 2010, the Veteran demonstrated full active range of right knee motion, with a positive Lachman's testing result and negative results for McMurray's and drawer testing. At a VA examination in September 2011, the Veteran reported experiencing locking episodes and right knee stiffness, and intermittent right knee pain three to four times per week, with each episode of knee pain lasting a few hours. The Veteran also reported experiencing fare-ups of her right knee pain bi-monthly, triggered by prolonged activity such as walking or hiking, and lasting six to eight hours. On physical examination, Lachman's testing was mildly positive, but McMurray's testing was negative. On range of motion testing, the Veteran had flexion to 120 degrees, with pain beginning at 100 degrees, and extension to 0 degrees without pain. After repetitive range of motion testing, only the Veteran's right knee flexion was further limited by 10 degrees due to painful motion and weakness, with the range of extension unaffected. X-rays of the right knee revealed degenerative changes, and the examiner diagnosed the Veteran with right knee chondromalacia and degenerative joint disease, status post meniscal repair, with mild right knee instability. Analysis The most limited range of flexion demonstrated by the Veteran throughout the course of this appeal, that is either prior to or after September 22, 2011, including after repetitive range of motion testing, was 90 degrees (100 degrees of flexion without pain during the 2011 VA examination, which was further limited by 10 degrees after repetitive range of motion testing), which does not nearly approximate or equate to flexion limited to 45 degrees. Thus, the criterion for a 10 percent rating for limitation of flexion under Diagnostic Code 5260, considering functional loss due to pain, weakness, excess fatigability, swelling, deformity, atrophy, or painful movement, under 38 C.F.R. §§ 4.40 , 4.45, 4.59, and repetitive motion, have not been met. As the Veteran did not demonstrate any limitation of right knee extension during the entirety of this appeal, the limitation of extension findings do not more nearly approximate or equate to extension to 10 degrees. Thus, the criterion for a 10 percent rating for limitation of extension under Diagnostic Code 5261, considering functional loss due to pain, weakness, excess fatigability, swelling, deformity, atrophy, or painful movement, under 38 C.F.R. §§ 4.40 , 4.45, 4.59, and repetitive motion, had not been met. While the Veteran does experience pain, the pain does not raise to the level of functional loss to 45 degrees of flexion or 10 degrees of extension of the right knee, the criteria for a compensable rating under Diagnostic Codes 5260 and 5261. See Mitchell v. Shineski, 25 Vet. App. 32, 43 (2011) (pain must affect some aspect of normal movement in order to constitute functional loss under 38 C.F.R. § 4.40). However, under Diagnostic Code 5258 for a dislocated semilunar cartilage (meniscus), prior to the post-surgical follow-up on September 27, 2010, there is evidence of stiffness, swelling or effusion, locking pain, positive McMurray's testing for a meniscal tear, and MRI findings of changes in the posterior horn of the medial meniscus. Thus, the findings more nearly approximates the criteria for a 20 percent rating , which is the maximum rating under Diagnostic Code 5258, for the rating period prior to September 27, 2010. The assigned 20 percent rating for this rating period is more than the minimum compensable rating, which is a 10 percent rating, for a knee disability. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1 (2011) (painful motion under 38 C.F.R. § 4.59 does not require arthritis for a minimum rating for the specific joint). After September 27, 2010, the evidence reflects that the Veteran's right knee was productive of symptomatic removed semilunar cartilage, evidenced by pain, warranting a 10 percent rating pursuant to Diagnostic Code 5259. Thus, a 10 percent rating under Diagnostic Code 5259 for symptomatic removed cartilage. While the Veteran is in receipt of a 10 percent rating under 38 C.F.R. § 4.40 and 4.45 as of September 22, 2011, her symptoms are more closely approximated by the rating criteria under Diagnostic Code 5259. In sum, a 20 percent rating under Diagnostic Code 5258 is warranted prior to September 27, 2010, and a 10 percent rating under Diagnostic Code 5259 is warranted after September 27, 2010. Right Knee Instability In a February 2013 rating action, the AMC awarded a separate 10 percent rating for right knee instability pursuant to Diagnostic Code 5257, and determined the effective date of this rating to be September 22, 2011. Accordingly, it follows that before September 22, 2011, the Veteran is essentially in receipt of a noncompensable rating for instability under Diagnostic Code 5257. The criteria for higher ratings require evidence of slight, moderate, or severe recurrent subluxation or lateral instability, warranting 10, 20, and 30 percent ratings, respectively. Facts Service treatment records show that in September 2005 an assessment of right knee medial instability was made. In October 2005, the Veteran complained of right knee pain, but not right knee instability, and on examination, there was no evidence of medial or lateral instability. On VA examination in February 2007, the Veteran described experiencing flare-ups of her right knee disability that produced stiffness, pain, fatigability and instability, which occurred once or twice bi-weekly. The VA examiner noted that the Veteran had a normal gait and did not use any ambulatory aids. The right knee was stable to varus and valgus stress and evidenced no ligamenta laxity. VA treatment records show that in March 2007 the Veteran reported that she had been experiencing right knee instability after a recent misstep while walking. In April 2007, stability testing, namely anterior/posterior drawer and cruciate ligament testing, was negative, revealing no laxity. In June 2007, the Veteran reported right knee instability with frequent episodes of giving way. After reviewing the results of an April 2007 MRI study, an assessment of right knee meniscus rotational laxity was noted, and the Veteran was fitted for a knee brace. In February 2008, the Veteran denied a history of episodes of right knee locking or giving way. Anterior and posterior drawers testing and valgus/varus stress testing were negative. In March 2008, drawer and varus/valgus stress testing revealed normal results. In July 2009, all ligamental testing, designed to detect joint instability, was within normal limits. In September 2009, the Veteran denied any episodes of right knee locking of giving way, and instability testing of the right knee was negative. In July 2010, the Veteran underwent right knee surgery that revealed a meniscal tear and chondromalacia, but an intact ACL, and in September 2010, she was noted to have continued instability of the right knee, which was assessed as likely due to a strain of her medial collateral ligament (MCL). On VA examination in September 2011, the Veteran complained of right knee pain, but reported no right knee instability, and the right knee was stable to varus and valgus stress. McMurray's testing (designed to identify meniscal tears) was negative, and Lachman's testing (designed to identify the stability of the ACL) was mildly positive. Accordingly, the examiner characterized the Veteran's right knee as productive of mild instability due to ACL and medial cruciate ligament strain. Analysis Throughout this rating period, that is, both before and after September 22, 2011, the Veteran has intermittently reported experiencing right knee instability, or has been assessed with mild right knee instability. On this basis, the criterion for a 10 percent rating for slight recurrent subluxations or lateral instability throughout the rating period have been met. However, on the basis of evidence reflecting either mild or no instability, the findings do not more nearly approximate or equate to moderate recurrent subluxation or lateral instability, the criterion for the next higher rating under Diagnostic Code 5257, at any point throughout the rating period. Therefore, a staged rating is also not for application. In summary, the preponderance of the evidence supports the assignment of an initial 10 percent rating, but not higher, for right knee instability throughout appeal. See Fenderson at 119; see Hart at 505. Left Knee Disability The Veteran's left knee disability, currently referred to as left knee degenerative joint disease, has been assigned a noncompensable rating prior to September 11, 2011, and a 10 percent rating after September 11, 2011, under Diagnostic Codes 5003 and 5260. The rating criteria applicable to the right knee, as set forth above, are also applicable to the determination of the appropriate rating for the Veteran's left knee. Facts Service treatment records show that in April 2005, a left knee MRI study revealed an MCL sprain and joint effusion, but normal menisci. No evidence of degenerative arthritic changes was noted. In June 2005, the Veteran demonstrated left knee flexion to 126 degrees and extension to plus 3 degrees (indicating hyperextension). In September 2005, the Veteran was noted to have recently sustained a left valgus injury and was demonstrating MCL laxity on valgus stress, as well as medial meniscus pain and joint effusion. In October 2005, the Veteran demonstrated 120 degrees of active flexion and 0 degrees of active extension, with no pain on motion. The left knee demonstrated medial instability, but no evidence of effusion, popliteal cyst, or lateral instability, and McMurray's testing was negative. An October 2005 physical therapy treatment record notes an assessment of left collateral ligament knee sprain. On VA examination in February 2007, the Veteran stated that her left knee pain is elicited by activity and increased by cold weather. She experiences flare-ups of left her knee disability bi-weekly, manifested by pain, stiffness, and mild fatigability. On examination, the Veteran's left knee did not evidence any instability or ligament laxity, and her left knee range of motion was 0 degrees of extension to 145 degrees of flexion, without pain. There was no additional limitation of motion on repetitive testing due to pain, weakness, impaired endurance, incoordination, instability, or flares. A left knee x-ray was ordered but not obtained. The examiner diagnosed the Veteran with left knee chondromalacia patella. On VA examination in September 2011, the Veteran reported that she has experienced ongoing, consistent left knee symptoms since service, with episodes of left knee pain once or twice per week. On examination, the Veteran demonstrated 0 degrees of extension and 135 degrees of flexion, with no pain and no additional limitation on repetitive testing due to painful motion, incoordination, weakness, impaired endurance, or instability. Lachman's, McMurray's, and instability testing were negative. X-rays of the left knee revealed mild degenerative spurring in the intercondylar eminence, and the examiner diagnosed the Veteran with left knee degenerative joint disease without evidence of instability. Analysis The most limited range of flexion demonstrated by the Veteran throughout the course of this appeal, that is either prior to or after September 22, 2011, including after repetitive range of motion testing, was 120 degrees, which does not nearly approximate or equate to flexion limited to 45 degrees. Thus, the criterion for a 10 percent rating for limitation of flexion under Diagnostic Code 5260, considering functional loss due to pain, weakness, excess fatigability, swelling, deformity, atrophy, or painful movement, under 38 C.F.R. §§ 4.40 , 4.45, 4.59, and repetitive motion, have not been met. As the Veteran did not demonstrate any limitation of left knee extension during the entirety of this appeal, the limitation of extension findings do not more nearly approximate or equate to extension to 10 degrees. Thus, the criterion for a 10 percent rating for limitation of extension under Diagnostic Code 5261, considering functional loss due to pain, weakness, excess fatigability, swelling, deformity, atrophy, or painful movement, under 38 C.F.R. §§ 4.40 , 4.45, 4.59, and repetitive motion, have not been met. While the Veteran reports that her left knee is painful, no objective evidence of pain was observed during clinical evaluations throughout the appeal. Accordingly, while the Veteran is competent to report experiencing left knee pain, the objective findings of the lack of evidence of pain on movement are accorded more probative value that the Veteran's reports. See Mitchell v. Shineski, 25 Vet. App. 32, 43 (2011) (pain must affect some aspect of normal movement in order to constitute functional loss under 38 C.F.R. § 4.40). The Veteran is in receipt of a 10 percent disability rating effective September 22, 2011 under Diagnostic Code 5003 for noncompensable limitation of motion coupled with x-ray evidence of arthritis. As the first evidence of left knee arthritis was discovered during the Veteran's September 2011 VA examination, a rating under Diagnostic Code 5003 before September 22, 2011 is not warranted. Notably, the Veteran's 2005 left knee MRI study did not find evidence of degenerative changes, and the Veteran's arthritis diagnosed in September 2011 was characterized as mild and only involving the intercondylar eminence. With regard to left knee instability, the Veteran's left knee was noted to be productive of medial instability in the initial portion of this appeal, that is, shortly after she sustained her left MCL sprain. However, there is no evidence of recurrent subluxation or lateral instability throughout the entirely of the appeal, and therefore the findings do not more nearly approximate or equate to slight recurrent subluxation or lateral instability, the criterion for a compensable rating under Diagnostic Code 5257. There is also no evidence of a left meniscal injury, i.e. dislocated semilunar cartilage, or any symptomatic removed left semilunar cartilage, and therefore ratings under Diagnostic Codes 5258 and 5259 are not warranted. In sum, the evidence of record does not reflect a basis for awarding a compensable rating prior to September 22, 2011or a rating higher than 10 percent after September 22, 2011. See Fenderson at 119; see Hart at 505. Rating the Low Back Disability Rating Criteria Before September 22, 2011, the lumbar spine disability was rated noncompensable, and from September 22, 2011, the lumbar spine disability has been rated 10 percent. A lumbar spine disability is rated under either the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating Intervertebral Disc Syndrome), whichever method results in the higher rating. Any associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code depending on the particular nerve or nerve group that is affected. Note (1). Under the General Rating Formula, the criteria for a 10 percent rating are forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, where the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, where there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. The criteria for a 20 percent rating are forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, where the combined range of motion of the thoracolumbar spine is less than 120 degrees; or, where there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The criteria for a 40 percent are for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. The rating criteria are to be applied irrespective of whether there are symptoms such as pain (whether or nor it radiates), stiffness, or aching in the affected area of the spine. For rating purposes, normal forward flexion of the thoracolumbar spine is from 0 to 90 degrees, extension is from 0 to 30 degrees, left and right lateral flexion are from 0 to 30 degrees, and left and right lateral rotation are from 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the criteria for a 10 rating are incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. The criteria for a 20 rating are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. The criteria for a 40 percent rating are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. An "incapacitating episode" is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. Note (1). Facts The Veteran's service treatment records reflect that in April 2005, a diagnosis of chronic coccydynia was noted. In June 2005, the Veteran demonstrated lumbar flexion to 100 degrees, extension to 30 degrees, and bilateral lateral rotation to 20 degrees. A provisional diagnosis of back strain of the sacroiliac region was noted. In August 2005, the Veteran's history of coccydynia, with x-ray evidence of acute angulation of the coccyx, resulting in buttocks pain, was recorded, and the Veteran reported that a prior steroidal injection into her coccygeal joint had provided only limited relief. On VA examination in February 2007, the Veteran reported that she began experiencing low back pain in service and was informed that she had an improperly healed broken tailbone. The Veteran stated that she experiences increased low back pain with prolonged walking or sitting, but that she did not experience any radiating back pain. She stated that she had no incapacitating episodes of back pain requiring physician-ordered bedrest in the prior year. She described her flare-ups of back pain as occurring daily and lasting from a few minutes to a few hours. On physical examination, no muscle spasm or midline tenderness was observed, and the Veteran demonstrated flexion to two inches above her toes, and extension, bilateral lateral flexion, and bilateral lateral rotation all to 30 degrees. The Veteran displayed no further limitation of motion on repetitive testing. X-rays of the Veteran's sacrum and coccyx were obtained, but visualization of the coccyx was not optimal due to overlying bowel gas; however, no acute fracture was identified. The examiner accordingly diagnosed the Veteran with lumbago and musculoskeletal strain. On VA examination in September 2011, the Veteran reported injuring her tailbone in 1999 when falling down several stairs and that x-rays taken during service revealed a fractured tailbone. She reported experiencing pain in the area of her tailbone and low back two to three times per month, which is elicited or aggravated by prolonged walking or standing. She affirmed experiencing low back stiffness, bet denied experiencing related weakness, fatigue, lack of endurance, flare-ups within the past year, any incapacitating episodes requiring physician-ordered bed rest, or any bowel or bladder incontinence. Motor and sensory examinations of the Veteran's upper and lower extremities were normal (with the exception of sensory findings related to her right carpal tunnel syndrome). There was also no evidence of lordosis, scoliosis, kyphosis, or muscle spasm, and straight leg raise testing revealed negative results bilaterally. On range of motion testing, the Veteran demonstrated lumbar flexion to 80 degrees, with pain beginning at 50 degrees; extension to 30 degrees with pain beginning at 20 degrees; bilateral lateral flexion to 40 degrees, with pain beginning at 35 degrees; and bilateral lateral rotation to 50 degrees, with pain beginning at 40 degrees. Rating Prior to September 22, 2011 To receive a higher disability rating under the General Rating Formula for the Spine the evidence must show forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. Either full range of flexion (nearly touching her toes) or flexion to 100 degrees, and a combined range of motion greater than 235 degrees, do not more nearly approximate or equate to forward flexion less than 85 degrees or a combined range of motion less 235 degrees. Additionally, there was no evidence of muscle spasm, guarding, or tenderness. As the low back disability was noncompensable under the General Rating Formula, a rating of 10 percent may be assigned if there was satisfactory evidence of painful motion. Although the Veteran had subjective complaints of pain, painful motion during testing of range of motion was not evident on VA examination, and a compensable rating under this provision of Diagnostic Code 5003 is not warranted. While the Veteran did complain of pain, painful motion was not shown. See Mitchell v. Shineski, 25 Vet. App. 32, 43 (2011) (pain must affect some aspect of normal movement in order to constitute functional loss under 38 C.F.R. § 4.40). To this extent, the Board places greater weight on the objective findings of the examination than the Veteran's subjective complaint of pain. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Also, in the absence of painful motion, a 10 percent rating under Diagnostic Code 5003 may be assigned where there is x-ray evidence of involvement of two or more major joints. Inasmuch as the 2007 x-rays may have revealed degenerative changes if visualization of the coccyx had not been obscured, the lumbar vertebra are considered to be one major group under 38 C.F.R. § 4.45. In the absence of x-ray evidence of involvement of two or more major joints, a compensable rating under this provision of Diagnostic Code 5003 is not warranted. Also, in the absence of painful motion, the minimum compensable rating, that is a 10 percent rating, for a low back disability under 38 C.F.R. § 4.59 is not warranted. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (painful motion under 38 C.F.R. § 4.59 does not require arthritis for a minimum rating for the specific joint). In the absence of objective neurologic abnormalities, the criteria for a separate compensable rating on the basis of objective neurologic abnormalities before September 22, 2011, had not been met. As there is no evidence of incapacitating episodes, namely, a period of acute signs and symptoms that require bed rest prescribed by a physician and treatment by a physician, having a total duration of at least 1week, but less than 2 weeks during a 12 month period, the criteria for a compensable rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes had not been met. For these reasons, the Board finds that the criteria for a compensable disability rating for the low back disability have not been met before September 22, 2011. Rating After September 22, 2011 To receive a higher disability rating under the General Rating Formula for the Spine the evidence must show forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, where the combined range of motion of the thoracolumbar spine is less than 120 degrees; or, where there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. While the Veteran demonstrated 80 degrees of flexion, she was only able to forward flex to 50 degrees before objective evidence of pain was observed; thus, her range of flexion more nearly approximates the criteria for a 20 percent rating, namely forward flexion greater than 30 degrees but not greater than 60 degrees or a combined range of motion of not greater than 120 degrees. See Mitchell v. Shineski, 25 Vet. App. 32, 43 (2011) (pain must affect some aspect of normal movement in order to constitute functional loss under 38 C.F.R. § 4.40). Accordingly, a 20 percent rating is warranted. However, in the absence of flexion limited to 30 degrees or less, including as due to pain, the criteria for the next higher rating under the General Rating Formula have not been met. Additionally, there was no evidence of incapacitating episodes, namely, a period of acute signs and symptoms that require bed rest prescribed by a physician and treatment by a physician, having a total duration of at least 4 weeks, but less than 6 weeks during a 12 month period; thus, the criteria for a rating higher than 20 percent under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes had not been met. In the absence of objective neurologic abnormalities, the criteria for a separate compensable rating on the basis of objective neurologic abnormalities after September 22, 2011, had not been met. In summary, an initial compensable rating for a low back disability before September 22, 2011, is denied. An initial rating of 20 percent for a low back disability with scoliosis of the lumbar spine and degenerative changes from September 22, 2011, is granted. Extraschedular Consideration While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether a claim should be referred to the VA Director of the Compensation and Pension Service for consideration of an extraschedular rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for a service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is encompassed by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the rating criteria reasonably describe the disability levels and symptomatology, inasmuch as the Veteran's right carpal tunnel syndrome rating contemplates the Veteran's symptoms of pain, numbness, and weakness; the Veteran's bilateral knee disability ratings contemplate her symptoms of painful motion, limitation of motion, instability, and dislocated or removed semilunar cartilage; and her low back disability rating contemplates painful movement and limitation of motion. Moreover, the rating criteria provide, in each instance, for higher disability ratings for increased symptoms. In other words, the Veteran does not experience any symptomatology not already encompassed in the rating criteria, and the assigned schedular ratings are therefore adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). With regard to whether an implicit claim for entitlement to a total disability rating based on individual unemployability has been raised by the record, as part and parcel of the Veteran's increased rating claims, see Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), the Board acknowledges the Veteran's reports of unemployment throughout this appeal. Specifically, during her 2007 VA examination, the Veteran reported that she was unemployed, and during her 2011 VA examination, she reported that while she had been employed in the interim since her 2007 VA examination, at the time of the 2011 VA examination she was again unemployed. However, the Veteran has not asserted that her prior or present unemployment is due to her right carpal tunnel syndrome, bilateral knee disabilities, or low back disability. Rather, in 2007 she reported that she was unemployed as the result of stress-related issues, and in 2011, she reported that she was able to and actively seeking work, and that her wrist, knee, and back disabilities did not preclude her from functioning in her usual occupation. Accordingly, the Board concludes that a claim seeking entitlement to a total disability rating based on individual unemployability has not been raised in the context of this appeal. ORDER An initial rating higher than 10 percent for right carpal tunnel syndrome is denied. An initial 20 percent for a right knee disability, currently referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair, before September 27, 2010, is granted. An initial 10 percent rating for a right knee disability, currently referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair, from September 27, 2010, is granted. An initial 10 percent rating for right knee instability, referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair with instability, prior to September 22, 2011, is granted. An initial rating higher than 10 percent for right knee instability, referred to as right knee chondromalacia and degenerative joint disease status post meniscal tear repair with instability, from September 22, 2011, is denied. An initial compensable rating for a left knee disability, currently referred to as left knee degenerative joint disease, before September 22, 2011, is denied. An initial rating higher than 10 percent for a left knee disability, currently referred to as left knee degenerative joint disease, from September 22, 2011, is denied. An initial compensable rating for a low back disability, currently diagnosed as lumbar spine strain with mild degenerative joint disease, before September 22, 2011, is denied. (The Order continues on the next page.). An initial 20 percent rating for a low back disability, currently diagnosed as lumbar spine strain with mild degenerative joint disease, after September 22, 2011, is granted. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs