Citation Nr: 1313253 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 05-17 971 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to a rating higher than 10 percent for post-traumatic arthritis of the left knee prior to March 7, 2008, and since May 1, 2008. (In the interim, the Veteran had a temporary 100 percent convalescent rating for this left knee disability under the provisions of 38 C.F.R. § 4.30 ("Paragraph 30").) REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Appellant ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1974 to August 1998. This appeal to the Board of Veterans' Appeals (Board/BVA) is from a March 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran twice testified at hearings, initially in January 2005 before local RO personnel and more recently in July 2006 before this Veterans Law Judge of the Board using videoconferencing technology, though not specifically in regards to this claim. The transcripts nonetheless have been associated with the claims file. The Veteran's November 2006 and March 2008 VA Form 9s included requests for an additional hearing before the Board, but in March 2013 the representative informed the Board that the Veteran was withdrawing this additional hearing request. Therefore, the Board may proceed with its adjudication of this claim. See 38 C.F.R. §§ 20.700, 20.703, 20.704 (2012). This case previously was before the Board in May 2009 and April 2012, at which time the claim was remanded to allow the RO or Appeals Management Center (AMC), as the Agency of Original Jurisdiction (AOJ), to further assist the Veteran in the development of this claim, including by obtaining outstanding treatment records and providing her another VA compensation examination reassessing the severity of her left knee disability. To this end, her most recent treatment records were obtained from the VA Medical Center (VAMC) and associated with the claims file for consideration. She also was afforded a VA compensation examination in April 2012 reassessing the severity of her left knee disability. So there was compliance with these remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board itself errs as a matter of law when it fails to ensure compliance). FINDING OF FACT The Veteran's left knee disability is manifested by subjective complaints of pain with objective symptoms of flexion limited to 85 degrees and X-ray evidence of post-traumatic arthritis. She also has at times complained of instability of this knee, but for the most part this has not been objectively confirmed. CONCLUSION OF LAW The criteria are not met for a rating higher than 10 percent for this left knee disability either prior to March 7, 2008, or since May 1, 2008. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5010, 5260, 5261 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION In deciding this claim, the Board has reviewed all of the evidence in the Veteran's claims file, both her physical claims file and electronic ("Virtual VA") claims file. Although the Board has an obligation to review the entire record, the Board does not have to discuss each and every piece of evidence reviewed, certainly not in exhaustive detail. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran must not assume the Board has overlooked pieces of evidence that are not explicitly discussed. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, this doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists that does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist obligations in response to this increased-rating claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran was notified of how to substantiate this increased-rating claim in June 2008. For an increased-compensation claim, the Veteran must be notified that she must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect the worsening has on the claimant's employment and daily life. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant DCs, which typically provide for a range in severity of a particular disability from 0 percent, i.e., noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (Vazquez-Flores I). The U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) subsequently held that the notice described in 38 U.S.C. § 5103(a) need not be Veteran specific, i.e., it need not notify the Veteran of alternative DCs, and the statutory scheme does not require "daily life" evidence for proper claim adjudication. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (Vazquez-Flores II) (vacating and remanding in part Vazquez-Flores I). Most recently, the Court clarified that the notice must advise the Veteran to submit evidence demonstrating the effect that the worsening of her disability has on her employment. Vazquez-Flores v. Shinseki, No. 05-0355 (U.S. Vet. App. October 22, 2010) (Vazquez-Flores III). The notice provided the Veteran satisfies these requirements. She has not alleged that VA failed to comply with the notice requirements of the VCAA, and she was afforded a meaningful opportunity to participate effectively in the processing of her claim and has, in fact, provided additional arguments at every stage of the appeal. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). VA also, as mentioned, has a duty to assist her in fully developing her claim, including by obtaining potentially relevant records. To this end, her service treatment records (STRs) and post-service VA treatment records were obtained and placed in the file for consideration. VA also obtained her private treatment records and associated them with the claims file as well. She has not indicated there are any additional records still needing to be obtained. The duty to assist her in obtaining relevant medical records therefore has been satisfied. This duty to assist her with her claim also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of her disability. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of her disability, a VA examination must be performed reassessing the severity of the disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a). The Veteran was provided a VA compensation examination in May 2012 reassessing the severity of her left knee disability. The medical opinion consequently rendered concerning this was based on the results of a comprehensive clinical evaluation and interview of her and review of the claims file. The examiner obtained an accurate history and, most importantly, provided a detailed explanation for the conclusions reached regarding the severity of this disability. There is no suggestion there has been a material change in the severity of this service-connected disability since it was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the mere passage of time since an otherwise adequate VA examination was performed, so not merely as a matter of course. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). See also VAOPGCPREC 11-95. Therefore, the Board finds that the examination is adequate to rate this disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (requiring that VA ensure the adequacy of an examination and opinion). In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to this claim is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Increased Rating Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where however, as in the present case, entitlement to compensation already has been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of that generated during the appeal period - the relevant temporal focus being from one year prior to the receipt of the claim. In making this assessment, the Board must "stage" the rating if there have been occasions since when the disability has been more severe than at others, which will compensate the Veteran for this variance See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (concerning an initial-rating claim, from which this practice arose). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This directive to assign a minimally compensable rating in the presence of pain applies to joint pain generally and is not limited to pain only associated with arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 1-2 (2011). Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. If, however, a Veteran already has the maximum rating assignable based on limitation of motion, it is not necessary to consider these provisions. Johnston v. Brown, 10 Vet. App. 80 (1997). Moreover, the Court has clarified that, although pain may be a cause or manifestation of functional loss, pain itself does not constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Initially, the Board observes that an April 2012 Board decision denied entitlement to a temporary total convalescent rating under 38 C.F.R. § 4.30 following the Veteran's December 2005 surgery. She more recently, however, had additional surgery in March 2008 and resultantly was awarded a temporary total convalescent rating under 38 C.F.R. § 4.30 from March 7, 2008 to April 30, 2008. So this decision contemplates the appropriateness of her rating at times other than when she had that temporary 100 percent convalescent rating - hence, for the periods prior to March 7, 2008 and since May 1, 2008. Her left knee disability is currently rated as 10-percent disabling under 38 C.F.R. § 4.71a, DCs 5010-5260, so on the premise that she has post-traumatic arthritis causing limitation of motion (specifically, on flexion). According to 38 C.F.R. § 4.71a, DC 5010, arthritis due to trauma, i.e., post-traumatic arthritis, if confirmed by X-ray, is rated as degenerative arthritis under DC 5003. DC 5003 indicates degenerative arthritis (hypertrophic or osteoarthritis) will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved - which, here, since concerning the knee, are DC 5260 for limitation of knee and leg flexion and DC 5261 for limitation of knee and leg extension. Further according to DC 5003, when the limitation of motion of the specific joint or joints involved is noncompensable (i.e., 0 percent) under the appropriate DCs, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. Moreover, according to DC 5003, in the absence of limitation of motion, a 10 percent rating is warranted when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A higher 20 percent rating requires X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. For purposes of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 0 percent evaluation is awarded when flexion is limited to 60 degrees. A 10 percent evaluation is awarded when flexion is limited to 45 degrees. A 20 percent evaluation is warranted when flexion is limited to 30 degrees. A 30 percent evaluation is assigned when flexion is limited to 15 degrees. Under DC 5261, a 0 percent rating is warranted when extension is limited to 5 degrees. Compensable ratings for limitation of extension are assigned when extension is limited to 10 degrees (10 percent), 15 degrees (20 percent), 20 degrees (30 percent), 30 degrees (40 percent) or 45 degrees (50 percent). VA's General Counsel has held that when a knee disability is rated under 38 C.F.R. § 4.71a, DC 5257, for "other" knee impairment including recurrent subluxation and lateral instability, and a Veteran also has limitation of knee motion that at least meets the criteria for a noncompensable evaluation under DC 5260 or 5261, separate evaluations may be assigned under DC 5257 for the recurrent subluxation and lateral instability and under DC 5003 for the arthritis causing limitation of motion under DC 5260 and/or 5261. If a Veteran does not meet the criteria for a noncompensable rating under either DC 5260 or 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997), published at 62 Fed. Reg. 63,604 (1997). However, if a rating is assigned under the provisions for "other" knee impairment (38 C.F.R. § 4.71a, DC 5257), a separate 10 percent rating may be assigned where there is X-ray evidence of arthritis and evidence of painful motion. See VAOPGCPREC 9-98 (August 14, 1998), published at 63 Fed. Reg. 56,704 (1998); 38 C.F.R. § 4.59. This is because, read together, 38 C.F.R. § 4.59 and DC 5003 provide that painful motion of a major joint (and, again, for purposes of rating disability from arthritis, the knee is considered a major joint, see 38 C.F.R. § 4.45(f)), arthritis is deemed to be limited motion and entitled to a minimum 10 percent rating even though there is no actual limitation. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Separate ratings under DC 5260 (limitation of leg and knee flexion) and DC 5261 (limitation of leg and knee extension) also may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Specifically, where a Veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. Turning now to the relevant facts of this particular case. In an April 2005 private treatment record the Veteran was noted to have a Baker's cyst, presumably on her left knee. See also May 2005 private treatment record. According to a December 2005 private treatment record she had flexion of this knee to 120 degrees. As already alluded to, she also underwent surgery on her left knee in December 2005 for removal of loose bodies. During her February 2006 VA examination she reported improvement in her range of motion since her then recent surgery, but she still experienced occasional pain, especially with squatting. She reported taking Tylenol to help with the pain. She could walk about a mile and reported walking three times a week for exercise. On objective physical examination there was no redness, swelling, or deformity. She had flexion to 140 degrees, without pain or crepitus. There was no evidence of instability and no flare ups of pain unless she was squatting. In an April 2006 private treatment record she had normal range-of-motion testing for flexion and extension of the left knee, so from 0 to 140 degrees. In a July 2006 VA treatment record she had left knee flexion slightly less, to 120 degrees. She had negative anterior drawer, posterior drawer, and Lachman's tests. She was diagnosed with osteoarthritis, knee sprain of the medial collateral ligament, and acute meniscal tear medial. In March 2007 she was receiving hyalgan injections for her left knee pain. During her August 2007 VA examination she reported having pain in her knee every day with swelling, popping, and grinding. She also said she could not walk more than 30 minutes and could not stand more than 3 hours. She reported taking Tylenol or Advil for relief. On range-of-motion testing she had flexion to 95 degrees and full extension. On repetitive testing the range of motion did not change. There was no instability, tenderness, crepitus, or warmth. Her motor strength was normal. The examiner reviewed X-rays that confirmed left knee osteoarthritis. As also already alluded to, she had additional surgery in March 2008 for anteromedial osteoarthritis of her left knee. In an August 2008 private treatment record she reported having left knee pain off and on for the previous 2 weeks, so still despite her surgery. However, the eventual temporary 100 percent convalescent rating she received under 38 C.F.R. § 4.30 compensated her for that. X-rays from a May 2009 VA treatment record show she had no fractures or other acute osseous or articular abnormalities. In a December 2010 VA treatment record she reported having left knee pain and bursitis of both knees. See also October 2011 VA treatment record. And, indeed, service connection also is in effect for traumatic arthritis of her right knee, so not just for her left knee. She had another VA compensation examination in May 2012. During this most recent examination she reported receiving three injections to help with her knee pain. She also presented wearing a knee brace. On range-of-motion testing she had flexion to 85 degrees and still full extension. On repetitive testing her range of motion did not change. She also had normal strength in her left knee, no objective indications of instability, and no evidence of subluxation or dislocation. X-rays revealed status post medial compartment hemiarthroplasty; there was no evidence of hardware failure or other complication. There was mild patellofemoral compartment osteoarthritis. In a June 2012 VA treatment record she reported pain and swelling in her left knee when exercising. In a December 2012 VA statement she reported that her left knee had gotten worse in that it gave out and was painful most of the time. She reported taking pain medication for 8 years or more. There is no competent and credible evidence supporting the assignment of a rating higher than 10 percent for this left knee disability either prior to March 7, 2008, or since May 1, 2008. As explained, she has been assigned a 10 percent rating for traumatic arthritis of this knee causing limitation of motion, particularly on flexion under DC 5260 since her extension according to DC 5261 has at all times been completely normal to 0 degrees. And even accepting that at least at times she has had considerably less than normal flexion, especially when considering the extent of her pain, her flexion still is not shown to be sufficiently limited - even on prolonged or repetitive-use testing - as to warrant assigning a rating higher than 10 percent. Considering all of the times her range of motion has been tested, the greatest amount her flexion has been limited is to 85 degrees, even again when considering her associated pain, which does not warrant even the most minimum rating of 0 percent under DC 5260, requiring flexion limited to at least 60 degrees. So the fact that she has a 10 percent rating under this DC is meant to compensate her for the additional limitation of flexion she has when factoring in the extent of her pain. As such, there is no suggestion an even higher rating is warranted for limitation of motion, either on flexion or extension. Her left knee arthritis also does not involve 2 or more major joints (instead just one major joint) or 2 or more minor joint groups, with occasional incapacitating exacerbations, so a higher rating also cannot otherwise be granted under DC 5003. Further concerning the extent of the pain and its affect on the range of motion, the February 2006 VA examiner indicated the Veteran did not have any of the DeLuca factors for functional impairment, including limitation by pain, fatigue, weakness, or lack of endurance following repetitive use. The August 2007 VA examiner similarly noted no additional limitation due to pain, fatigue, weakness, or lack of endurance, as did also the most recent May 2012 VA examiner who equally found no evidence of weakened movement, excess fatigability, incoordination, or functional impairment other than pain. The Board acknowledges the Veteran's complaints of chronic pain in her left knee which has required the use of pain medication to try and alleviate some measure of her discomfort. But the objective evidence of record indicates this pain does not for the most part cause additional functional impairment, meaning above and beyond that shown, including additional limitation of motion over and above what is contemplated at the 10-percent level, especially, as explained, seeing as though she does not have sufficient limitation of motion to warrant assignment of a 10 percent rating unless her pain is considered. Else, she would only be entitled to a 0 percent rating based on the results of her range-of-motion testing. See again Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system.) The Board also has considered the potential applicability of other DCs for rating the Veteran's left knee disability. However, no higher or separate evaluation is warranted under any of the other DCs concerning knee disabilities. The Board observes that there is no evidence she has ankylosis of this knee, so DC 5256 is not for application. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999). See, too, Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)]. This clearly is not the situation here, however, since the mere fact that the Veteran continues to have considerable range of motion in this knee on both flexion and extension, even if less than normal range of motion on flexion, in turn means that, by definition, this knee is not ankylosed. DCs 5258 and 5259 pertain to dislocated and removal of semilunar cartilage, which the Veteran has not been noted to have. There also is no objective confirmation of recurrent subluxation or lateral instability, despite her at times complaining of this and most recently wearing a brace of this knee, so as to in turn invoke consideration of DC 5257. Far more often than not, indeed, virtually without exception, the tests specifically to determine whether there is instability (e.g., Lachman's, McMurray's, varus and valgus stress, etc.) repeatedly have been negative for confirmation of this, so grossly unrermarkable. Moreover, there is no indication she has nonunion or malunion of her tibia or fibula; DC 5262 therefore also is inapplicable. Furthermore, there is no suggestion she has genu recurvatum as to warrant application of DC 5263. In addition to the medical evidence, the Board has considered the Veteran's lay statements in support of her claim. As a lay person, she is competent to report on that as to which she has personal knowledge, such as experiencing pain, locking, and limitation of motion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). Since the allegations of these particular symptoms appear to be uncontradicted, even by medical findings of record, the Board also finds them to be credible and, thus, probative. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Rucker v. Brown, 10 Vet. App. 67 (1997) (indicating competency to make these type proclamations must be distinguished from the weight and credibility of this lay testimony, which are factual determinations going to the ultimate probative value of this evidence). As a lay person without the appropriate medical training and expertise, however, she is not further competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of her left knee disability in relation to the applicable rating criteria. An examiner, including the VA compensation examiners, takes into consideration her subjective complaints and the results of the objective testing, including the range-of-motion testing, as well as X-rays and other objective clinical findings in determining the overall severity of her left knee disability. This determination is multi-factorial, not just predicated on lay statements and other testimony, rather, all of the relevant medical and other evidence. The Federal Circuit Court has recognized the Board's 'authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence.' Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board finds that the Veteran is not entitled to a rating higher than 10 percent for her left knee disability at any point during the appeal period, again, either prior to March 7, 2008, or since May 1, 2008. The Board has considered whether the benefit of the doubt rule applies. However, a preponderance of the evidence is against a higher evaluation, this rule does not apply and the claim for an increased evaluation must be denied.38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Extra-Schedular Consideration There is no evidence of exceptional or unusual circumstances to warrant referring this claim for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1). The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). And although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). The Board finds no such evidence in this particular instance, however. The Veteran's complaints related to her left knee disability are considered under the appropriate DCs. Her primary symptoms are arthritic pain and consequent limitation of motion. All of her symptoms are accounted for in the regular schedular rating criteria. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Indeed, in Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993), the Court reiterated this, noting the disability rating, itself, is recognition that industrial capabilities are impaired. Moreover, although she has twice had surgery on her left knee since service, the overwhelming majority of the evaluation and treatment she has received for this disability has been on an outpatient basis, not instead as an inpatient, certainly not frequent inpatient. Thus, as the assigned schedular evaluation for this service-connected left knee disability is adequate, referral for an extra-schedular rating is unnecessary. Thun, supra. See also Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER The claim of entitlement to a rating higher than 10 percent for the left knee disability prior to March 7, 2008, and since May 1, 2008 is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs