Citation Nr: 1313169 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 08-18 816 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee. 2. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from November 1978 until November 1998. This appeal to the Board of Veterans' Appeals (Board) arose from a June 2010 rating decision. In the June 2010 rating decision, the RO denied service connection for arthritis of the feet and continued 10 percent ratings for degenerative joint disease of each knee. In June 2010, the Veteran filed a notice of disagreement (NOD) with respect to the denial of these claims. A statement of the case (SOC) was issued in November 2010, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in December 2010. In November 2011, the Board denied service connection for arthritis of the feet, denied higher ratings for service-connected degenerative joint disease of the right and left knees, and remanded the claim for service connection for erectile dysfunction (which had been separately appealed from a January 2008 rating decision). The Veteran, in turn, appealed the Board's denial of entitlement to higher ratings for the knees to the United States Court of Appeals for Veterans Claims (Court). In August 2012, the Court granted a Joint Motion for Partial Remand filed by representatives for both parties, vacating the Board's decision as to the issues of the knees only, and remanding the knee claims to the Board for further proceedings consistent with the Joint Motion. On remand of the claim involving erectile dysfunction, in a September 2012 rating decision, the Appeals Management Center (AMC) awarded special monthly compensation based on loss of use of creative organ. As the September 2012 rating action represents a full grant of the benefits sought with respect to that issue, it is no longer before the Board for consideration (see Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977)), and the matters remaining on appeal are limited to those reflected on the title page. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. As explained in more detail below, review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. Pertinent to the September 2009 claim for increase, the Veteran's service-connected right knee degenerative joint disease has been manifested by objective findings of normal range of motion, with pain and crepitus, but no locking, ankylosis, subluxation, instability, impairment of the tibia or fibula, genu recurvatum or dislocated or removed semilunar cartilage; and subjective complaints of buckling and instability. 3. Pertinent to the September 2009 claim for increase, the Veteran's service-connected left knee degenerative joint disease has been manifested by objective findings of normal range of motion, with pain and crepitus, but no locking, ankylosis, subluxation, instability, impairment of the tibia or fibula, genu recurvatum or dislocated or removed semilunar cartilage; and subjective complaints of buckling and instability. 4. The applicable rating criteria are adequate to rate each of the Veteran's knee disabilities at all pertinent points. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for service-connected degenerative joint disease of the right knee are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). 2. The criteria for a rating in excess of 10 percent for service-connected degenerative joint disease of the left knee are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for a separate, 10 percent rating for instability of the right knee are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321,4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5257 (2012). 4. Resolving all reasonable doubt in the Veteran's favor, the criteria for a separate, 10 percent rating for instability of the right knee are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. A December 2009 pre-rating letter provided notice to the Veteran regarding what information and evidence was needed to substantiate the claims for increased ratings for degenerative joint disease or the right and left knees, as well as what information and evidence must be submitted by the appellant, and what information would be obtained by VA. It further specifically informed the Veteran to submit any evidence in his possession pertinent to the claim (consistent with Pelegrini and the version of 38 C.F.R. § 3.159 then in effect). This letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. The June 2010 rating decision reflects the initial adjudication of the claims after issuance of the December 2009 letter. Thereafter, the November 2010 SOC included the pertinent rating criteria for evaluating knee disabilities (the timing and form of which suffices, in part, for Dingess/Hartman). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of service, VA and private treatment records, and the VA examination report. Also of record and considered in connection with the appeal are various written statements provided by the Veteran, and by his representative, on his behalf. The Board finds that no additional RO action on either claim, prior to appellate consideration, is required. In a June 2010 NOD, the Veteran essentially argued that the December 2009 VA joints examination was inadequate. Notwithstanding this assertion, however, as explained in more detail below, the Board finds that this medical examination-along with other pertinent evidence-provides sufficient evidence for evaluation of the disabilities for which higher ratings are sought, and that no further examination in connection with these claims is required. See 38 U.S.C.A. § 5103A (2002); 38 C.F.R. § 3.159 (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board further notes that medical evidence was added the Veteran's Virtual VA electronic claims folder in December 2011-after the issuance of the November 2010. Such evidence consists of VA treatment records dated from September 2009 until April 2010. Additional VA treatment records, dated from February 2012 to December 2011 were also added to the Veteran's paper claims file. The RO/AMC has not considered all this evidence in connection with the claim for increased ratings for the right and left knees and the Veteran has not waived initial RO consideration of the evidence. However, no further RO action in this regard is required. The additional VA treatment records contain no information not previously of record pertaining to the claimed increased ratings. As this evidence thus has no bearing on the disposition of these is matter, the evidence does not constitute additional, relevant evidence, and a remand for initial RO consideration of the evidence in connection with these claims is unnecessary. See 38 C.F.R. §§ 19.37, 20.1304 (2012). In summary, the duties imposed by the VCAA have been considered and satisfied. Through notice of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claims decided herein, the avenues through which he might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of any of the matters herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Rating Claims Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted (for each knee) for different time periods. Historically, by rating action issued in June 1999, the RO granted service connection for patellofemoral syndrome of each knee, and assigned a 0 percent (noncompensable) rating for each knee, effective December 1, 1998. The Veteran filed a claim for a higher rating for each knee in August 2002. By April 2003 rating action, the RO recharacterized the right and left knee disabilities as degenerative joint disease of the right and left knee, and assigned a 10 percent rating for each knee disability, effective August 26, 2002. The Veteran filed the current claim for a higher rating for each knee in September 2009. The 10 percent rating for each knee disability, characterized as degenerative joint disease, has been assigned under DC 5099-5003, which is indicative of a disability not specified in the rating schedule that is evaluated, by analogy, as degenerative arthritis. See 38 C.F.R. §§ 4.20, 4.27. Here, however, the reference to DC 5099 is unnecessary. As the Veteran actually has been diagnosed with degenerative joint disease, which is degenerative arthritis, so evaluation pursuant to Diagnostic Code 5003 is wholly appropriate. Under DC 5003, degenerative arthritis established by X-ray findings is evaluated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved (here, DCs 5260, and 5261). Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating is assignable each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. See also 38 C.F.R. § 4.71a, Diagnostic Code 5010 (prescribing that arthritis due to trauma, substantiated by x-ray findings, should be evaluated as degenerative arthritis). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under DC 5260, a noncompensable rating is assigned for flexion limited to 60 degrees. A rating of 10 percent requires limitation of flexion to 45 degrees. A rating of 20 percent requires limitation of flexion to 30 degrees, and a rating of 30 percent requires limitation of flexion to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a rating of 10 percent requires limitation of extension to 10 degrees. A rating of 20 percent requires limitation of extension to 15 degrees. A rating of 30 percent requires limitation of extension to 20 degrees. A rating of 40 percent requires limitation of extension to 30 degrees, and a rating of 50 percent requires limitation of extension to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. The VA General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Standard range of knee motion is from 0 degrees (on extension) to 140 degrees (on flexion). See 38 C.F.R. § 4.71, Plate II. The Board also notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying scheduler criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2012); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Pertinent to the 2009 claim for increase, a June 2009 VA medical report notes the Veteran's complaints of bilateral knee pain for three years. He complained of constant knee aching and throbbing and daily right knee buckling. It was noted that a 2007 x-ray of the right knee revealed mild narrowing of the medial joint compartment. In 2008, MRI of the right knee revealed mild medial degenerative changes, small joint effusion, and a small cyst or enchondroma in the lateral femoral condyle; MRI of the left knee revealed mild medial degenerative changes with minimal joint effusion. The Veteran complained of worsening pain and used a single point cane. He took Tylenol which provided partial pain relief. On examination, range of motion of the knees was within normal limits with tenderness. Crepitus was noted in the right knee without evidence of effusion or ligamentous instability. McMurray's was positive and a patellar compression test was negative. The assessment was bilateral knee pain secondary to osteoarthritis. A September 2009 report indicates that there had been no change in the Veteran's bilateral knee disability since his last visit. He wore knee braces which improved pain, helped him go upstairs, and slightly improved popping and buckling. Pain was rated a seven out of ten on the pain scale. Examination of the knees did not indicate any muscle atrophy, swelling, or patellar deviation with a full range of motion. There was evidence of crepitance and tenderness at the center of the medial joint space. Ligaments were stable and McMurray's was negative. On December 2009 VA joints examination, the Veteran complained of weakness, stiffness, swelling, giving way, lack of endurance, locking, tenderness, effusion, and pain. He denied any heat, redness, fatigability, deformity, drainage, subluxation, or dislocation. Flare-ups occurred spontaneously as often as three times per day with each one lasting one hour. He rated his pain as an eight out of ten on the pain scale and pain was alleviated by Tramadol. The Veteran indicated that he had difficulty going up and down stairs and pain when bending his knees. He also had difficulty with standing, ambulated with a cane, and wore a brace on each knee with a shoe insert in his right shoe. The Veteran complained of morning stiffness in his knees and denied ever being hospitalized or undergoing surgery for his bilateral knee disability. He also denied any incapacitation within the past twelve months. The examiner stated that the Veteran required the use of a brace on his knees and a cane for support, but did not require the use of crutches, corrective shoes, a wheelchair, a prosthesis, or a walker. On examination of the right knee, there was guarding of movement and evidence of crepitus. However, there was no evidence of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, genu recurvatum, or locking pain. On examination of the left knee, there was evidence of crepitus. However, there was no evidence of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, guarding of movement, genu recurvatum, locking pain, or ankylosis. Range of motion of the right knee was described as normal, with pain at 110 degrees on flexion and at -10 degrees on extension. Repetitive range of motion was possible without any additional degree of limitation of motion. Joint function of the right knee was additionally limited by pain after repetitive use, but was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. Range of motion of the left knee was also described as normal, and repetitive range of motion was possible without any additional degree of limitation of motion. Joint function of the left knee was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. For both knees, the results of medial/lateral collateral ligaments stability testing, anterior/posterior cruciate ligaments stability testing, and medial/lateral meniscus stability testing were all within normal limits. The Veteran was diagnosed with degenerative joint disease of the right and left knees. With regard to the Veteran's argument that the examination was inadequate because the examiner did not perform a range of motion examination on either knee, the Board finds that this argument is not supported by the objective record, including the examination report itself, which contains a summary of the Veteran's medical history and subjective complaints, as well as pertinent clinical findings. Considering the pertinent facts in light of the above, the Board finds that, at no point pertinent to the current claim for increase has either the right or knee left arthritis warranted a rating higher than the 10 percent rating assigned. With regard to limitation of motion of the right knee under Diagnostic Code(s) 5260 and/or 5261, the evidence shows that the Veteran's service-connected right knee arthritis has been manifested by normal range of motion with pain at 110 degrees flexion and at -10 degrees. The Veteran has reported daily pain in the right knee with swelling, popping, locking, effusion, giving way, and difficulty with prolonged walking and standing. On December 2009 VA examination, joint function of the right knee was additionally limited by pain after repetitive use, but was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. In addition, there is no lay or medical indication that his right knee manifestations have ever been so disabling as to result in flexion limited to 45 degrees, or extension limited to 10 degrees, as to warrant the assignment of even the minimum 10 percent rating under Diagnostic Code 5260 or 5261, respectively. It follows, then, that the criteria for an even higher rating under either diagnostic code is not met. With regard to the left knee, the evidence shows that the disability has been manifested by normal range of motion. The Veteran has reported daily pain in the left knee with swelling, popping, locking, effusion, giving way, and difficulty with prolonged walking and standing. On December 2009 VA examination, repetitive range of motion was possible without any additional degree of limitation of motion. In addition, joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. There is no lay or medical indication that his left knee manifestations of arthritis, to include during flare-ups, have been so disabling as to result in flexion limited to 45 degrees (so as to warrant even the minimum, compensable rating under Diagnostic Code 5260) or extension limited to more than 10 degrees (so as to warrant more than a 10 percent rating under Diagnostic Code 5261). Hence, even with consideration of sections 4.40 and 4.45 and DeLuca, the record presents no basis for the assignment of any higher rating for the left knee under Diagnostic Code 5260 or 5261. Accordingly, no higher rating is assignable, on the basis of limited and/or painful motion, due to arthritis in either knee. The Board notes that, however, that separate ratings may be assignable for arthritis and instability. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997) and VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Under Diagnostic Code 5257, pursuant to which recurrent subluxation and lateral instability of the knee are evaluated, a 10 percent rating is warranted for slight disability, a 20 percent rating is warranted for moderate disability, and a 30 percent rating is warranted for severe disability. Here, upon further review of the record, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that a separate 10 percent disability rating is warranted for slight lateral instability of each knee under DC 5257. The medical evidence does not include findings of right or left knee instability by any of the Veteran's VA medical providers or his December 2009 VA examiner. The June and September 2009 VA medical providers found the knees to have stable ligaments, but noted the Veteran's complaints of knee buckling, and ordered treatment of the knees through the use of an upright metal brace to the right knee and elastic splint to the left knee. Although the Veteran reported that his knees give way during the December 2009 VA examination, he also denied having subluxation and dislocation. The examiner noted that the Veteran required a brace on both knees and a cane for ambulation, for support. The December 2009 VA examiner found no instability or subluxation of the right or left knee. The examiner also noted that medial/lateral collateral ligaments, anterior/posterior cruciate ligaments and medial/lateral meniscus stability tests for both knees were within normal limits. The examiner diagnosed the Veteran with degenerative joint disease of both knees and noted that the Veteran's use of medications and metal brace were consistent with that diagnosis. Thus, the collective evidence of record is equivocal on the question of whether the Veteran actually experiences instability of either the right or left knee. The Veteran has consistently reported knee buckling. Although his VA medical providers and the December 2009 VA examiner did not find instability on examination, VA medical providers did recommend the use of knee braces and the December 2009 VA examiner noted that knee brace use was consistent with the Veteran's knee disabilities. As such, and giving the Veteran the benefit of the doubt, the Board finds that separate 10 percent disability ratings are warranted for each knee, under DC 5257 for instability. Subluxation is not indicated by the record, as the VA medical providers and December 2009 VA examiner did not make such findings and the Veteran denied having subluxation during the December 2009 VA examination. The Board notes that, in the August 2012 Joint Motion for Partial Remand pointed out that the June 2009 VA medical record documented a positive McMurray's test (indicating a tear in the meniscus/semilunar cartilage) and "[s]mall joint effusion" and the December 2009 VA examination report documented symptoms of locking, effusion and pain, which are possibly indicative of a tear in the meniscus, locking, effusion and pain, which could provide for a separate rating under DC 5258 for cartilage, semilunar, dislocated with frequent episodes of "locking," pain and effusion into the joint. As the Board has already granted the Veteran separate ratings under DC 5257, consideration of separate ratings under 5258 is not necessary, although the Board has considered whether a maximum 20 percent rating is warranted under DC 5258. However, upon careful review of the record, the Board finds that such a rating is not warranted, as there is no evidence of record indicating that the semilunar cartilage of either knee is, or has been, dislocated. As regards the right knee, the February 2008 MRI report documents normal medial and lateral menisci, mild narrowing of the cartilage in the medial compartment, but no evidence of significant patellofemoral cartilage abnormality. The impression was mild medial degenerative changes of the right knee, small joint effusion and small cyst or enchondroma in lateral femoral condyle. However, no findings of dislocated cartilage were made. Furthermore, although the June 2009 VA medical record documented a positive McMurray's test, the examiner also found no effusion on examination. Additionally, the September 2009 VA medical provider performed a negative McMurray's test. The December 2009 VA examiner similarly noted that ligament and meniscus stability tests were normal for the right knee and found no effusion at that time. As such, the majority of the evidence of record does not indicate that the Veteran has dislocated cartilage knee and there is no evidence of semilunar cartilage removal. Indeed, the objective MRI report of the right knee included no findings of cartilage dislocation or removal. As regards the left knee, the February 2008 MRI report similarly documents normal medial and lateral menisci, mild thinning of the cartilage in the medial compartment, and no evidence of significant patellofemoral cartilage abnormality. The impression was mild medial degenerative changes of the left knee and minimal joint effusion. No findings of dislocated cartilage were made. Additionally, as previously noted, although the June 2009 VA medical record documented a positive McMurray's test, the examiner found no effusion on examination. The September 2009 VA medical provider also performed a negative McMurray's test and the December 2009 VA examiner noted normal ligament and meniscus stability tests and no effusion on examination. The majority of the evidence of record does not indicate that the Veteran has dislocated cartilage of the left knee and there is no evidence indicates cartilage removal. Indeed, the objective MRI report of the left knee included no findings of cartilage dislocation or removal. The Board further points out that, while, for each knee, a 10 percent rating for arthritis, and a 10 percent rating for instability is appropriate, no other provision of VA's rating schedule provides a basis for any higher rating for any knee disability. There have been no medical findings of ankylosis, symptomatic removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. In the absence of such findings, evaluating either knee under Diagnostic Codes 5256, 5259, 5262, or 5263 is not appropriate. See 38 C.F.R. § 4.71a. As for the lay assertions of record, the Board notes that the Veteran is certainly competent to report matters within his personal knowledge, to include his own symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In this case, the Veteran has not complained of moderate or more severe instability. Even if so, however, the Board points out that, as a layperson without appropriate medical training and expertise to competently render the medical findings needed to support a higher rating, his assertions would not be considered more persuasive than the findings of a qualified medical professional-here the VA examiner and VA medical providers. See 38 C.F.R. § 3.159 (a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). The above determinations are based upon consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point pertinent to this appeal has any service-connected knee disability been shown to be do exceptional or unusual to warrant any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the November 2010 SOC). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability and the established criteria found in the rating schedule to determine whether the veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as 'governing norms.' Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) governing norms include marked interference with employment and frequent periods of hospitalizations). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether the claimant's disability picture requires the assignment of an extra-schedular rating. Id. at 116. The Board finds that schedular criteria are adequate to rate each disability at all times pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and there is no medical indication or argument that the applicable criteria are inadequate to rate the disability under consideration at any pertinent point. The Veteran has not asserted that he has difficulty working due to his knee disabilities at any time pertinent to this appeal, and the June 2009 VA medical provider found him to be capable of activities of daily living. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As a final point, the Board notes that, although a claim for a total disability rating based on individual unemployability (TDIU) may be raised in the record as a component of a claim for higher rating (see e.g., Rice v. Shinseki, 22 Vet. App. 447 (2009)), here, there is no indication that the Veteran is unemployed, nor is there evidence or argument that service-connected disability of one or both knees renders him unemployable. As such, a claim for a TDIU due to any service-connected knee disability has not reasonably been raised, and need not be addressed. For all the foregoing reasons, the Board concludes that there is no basis for staged rating of any right or left knee disability, pursuant to Hart, and that, although a separate 10 percent rating is being assigned for instability of each knee, the claims for higher ratings for degenerative joint disease of the right and left knees must be denied. In reaching the decision to award separate rating for right and left knee instability, the Board has favorably applied the benefit-of-the-doubt doctrine, but finds that the preponderance of the evidence is against assignment of any higher rating for any knee disability. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER A rating in excess of 10 percent for degenerative joint disease of the right knee is denied. A rating in excess of 10 percent for degenerative joint disease of the left knee is denied. A separate 10 percent rating for right knee instability is granted, subject to the legal authority governing the payment of compensation. A separate 10 percent rating for left knee instability is granted, subject to the legal authority governing the payment of compensation. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs