Citation Nr: 1313707 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 08-11 861 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for sinusitis. 2. Entitlement to increased rating for the service-connected right knee disability, currently rated 30 percent disabling. 3. Entitlement to increased rating for the service-connected left knee disability, currently rated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from June 1979 to October 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama that in relevant part denied the Veteran's request to reopen a previously-denied claim of entitlement to service connection for sinusitis; increased the rating for the right knee disability from 0 percent to 20 percent effective from October 21, 2005; and, continued a current 10 percent rating for the left knee disability. The Veteran testified in a hearing before the RO's Decision Review Officer (DRO) in June 2009, and in March 2011 he testified before the undersigned Veterans Law Judge by videoconference from the RO. Transcripts of both hearings are of record. During the course of the appeal the RO increased the rating for the right knee disability from 20 percent to 30 percent, effective from March 1, 2008 (see rating decision in February 2008). The RO also increased the rating for the left knee disability from 10 percent to 20 percent, effective from November 1, 2007; reduced the rating for the left knee from 20 percent to 10 percent effective from April 21, 2009; and, increased the rating for the left knee disability from 10 percent to 30 percent effective from June 1, 2010 (see rating decision in November 2009). In May 2012 the Board issued a decision that reopened the claim for service connection for sinusitis. The Board's action remanded the claims on appeal to the Originating Agency for further development, which has been accomplished. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. The Veteran does not have chronic sinusitis that is etiologically related to service. 2. During the period between April 20, 2006, to June 1, 2006, and from October 3, 2006, to April 1, 2008, the Veteran's right knee was rated as 100 percent disabling due to surgery and convalescence. 3. Prior to April 20, 2006, and during the period June 1, 2006, to October 2, 2006, the Veteran's right knee disability was manifested by moderate instability and painful motion due to arthritis. 4. From April 1, 2008, following convalescence from total right knee replacement, the Veteran has not had chronic residuals consisting of severe painful motion or weakness. 5. During the period from July 18, 2008, to September 1, 2008, and from April 21, 2009 to June 1, 2010, the Veteran's left knee was rated as 100 percent disabling due to surgery and convalescence. 6. Prior to November 1, 2007, the Veteran's left knee disability was manifested by slight instability and painful motion due to arthritis. 7. From November 1, 2007, to July 17, 2008, and from September 1, 2008, to April 20, 2009, the Veteran's left knee disability was manifested by moderate instability and painful motion due to arthritis. 8. From June 1, 2010, following convalescence from total left knee replacement, the Veteran has not had chronic residuals consisting of severe painful motion or weakness. CONCLUSIONS OF LAW 1. Sinusitis is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The criteria for evaluation of 30 percent, but not more, for right knee disability prior to April 19, 2006, and for the period June 1, 2006, to October 2, 2006, are met; this is determined to be based on a 20 percent rating for instability and a separate 10 percent rating for arthritis with painful but noncompensable limitation of motion. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a including Diagnostic Codes 5003, 5010, 5259, 5260, 5261 (2012). 3. The criteria for evaluation higher than 30 percent for right knee disability from April 1, 2008, are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a including Diagnostic Codes 5003, 5010, 5259, 5260, 5261 (2012). 4. The criteria for evaluation of 20 percent, but not more, for left knee disability prior to November 1, 2007, are met; this is determined to be based on a 10 percent rating for instability and a separate 10 percent rating for arthritis with painful but noncompensable limitation of motion. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a including Diagnostic Codes 5003, 5010, 5259, 5260, 5261 (2012). 5. The criteria for evaluation of 30 percent, but not more, for left knee disability for the period November 1, 2007, to July 17, 2008, and from September 1, 2008, to April 20, 2009, are met; this is determined to be based on a 20 percent rating for instability and a separate 10 percent rating for arthritis with painful but noncompensable limitation of motion. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a including Diagnostic Codes 5003, 5010, 5259, 5260, 5261 (2012). 6. The criteria for evaluation higher than 30 percent for left knee disability from June 1, 2010, are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a including Diagnostic Codes 5003, 5010, 5259, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The notification obligation in this case, to include the disability-rating and effective date elements of a service-connection claim, was accomplished by way of letters from the RO to the Veteran dated in January 2006 and March 2006; the Veteran had ample opportunity to respond prior to issuance of the rating decision on appeal. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing that an error is harmful or prejudicial normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. Service treatment records (STRs) are on file, as are records from those VA and non-VA medical providers the Veteran identified as potentially having relevant treatment records. The Veteran received appropriate VA medical examinations, and he was afforded hearings before the RO's DRO and before the Board. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and has not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of this appeal. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Entitlement to Service Connection Applicable Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Factual Background Service treatment records (STRs) demonstrate a fractured nose during service (for which the Veteran was granted service connection) but do not demonstrate a chronic sinus disorder. The Veteran was treated in March 1981 for a cold and sinus congestion, which was treated at the time as a viral syndrome. Following service, the Veteran presented to the VA outpatient clinic in September 1992 complaining of chronic ear infection, ear pain and sinus pressure. The provisional diagnosis was chronic rhinosinusitis. He had a VA sinus series in October 1992 that confirmed a diagnosis of mild bilateral maxillary sinusitis. The Veteran was treated at the VA ear/nose/throat (ENT) clinic in December 1992 for symptoms of audio and sinus congestion; the clinical impression was rule out ethmoid sinusitis. VA computed tomography (CT) scan in March 1993 showed an impression of bilateral maxillary sinusitis. The Veteran submitted a Statement in Support of Claim in July 1993 asserting that after surgery on his nose during service he developed sinus problems, becoming severe in 1992. He disavowed problems prior to service. In March 1995 the Veteran was treated at USA Hospital, a private provider, for respiratory problems. The Veteran describes his disorder at the time as having been due to sinusitis (see Veteran's statement dated May 1995). A supporting statement by Mr. CLS, dated in May 1995, states the Veteran at the time appeared to have flu-like symptoms (chills, high fever and speaking incoherently). Similarly, a May 1995 supporting statement by Rev. MY asserts the Veteran had a high fever and was disoriented. The Veteran has submitted appointment reminders showing that he had scheduled appointments at the VA ear/nose/throat (ENT) clinic in February, August and September 1994; February and October 1996; February 1997; and, January and February 1998. The Veteran was treated by the VA clinic for sinusitis in May 2005 (noting history of sinus surgery in 1993 and subsequent frequent sinus infections). He was treated for allergies and for allergic laryngitis/sinusitis in April 2009. The Veteran testified before the RO's DRO in June 2009 that he had a deviated nasal septum in service, for which he had been granted VA disability benefits, but he also developed sinusitis. He had sinus surgery by VA in 1997, and the VA surgeon at the time told the Veteran his sinusitis was due to the facial trauma in service. His current VA attending physicians had also told him that his chronic sinusitis was due to the facial trauma in service. The Veteran had a VA sinus examination in December 2009, performed by an examiner who reviewed the claims file. The Veteran recounted the history of fractured sinus cavity during service when hit in the face by a softball, and that surgery in 1983 was successful until the cavity closed again in 1991, necessitating another surgery. The Veteran described recurrent nasal congestion and discharge with associated headaches and breathing difficulties; episodes which would occur every 90 days. Current examination of the sinuses including X-rays was normal. The examiner was unable to diagnose current sinusitis and accordingly opined current sinusitis was not caused by or related to the service-connected nose fracture. The Veteran testified before the Board in March 2011 that he was treated for sinusitis during service; sinus symptoms began after the fracture of his nose but prior to discharge from service. After discharge from service he had surgery in 1991 or 1992. All his doctors agreed that his chronic sinus condition is due to the sinus cavity being closed so long and then reopened in the early 1990s. The Veteran had a VA examination of the sinuses in April 2012, performed by an ENT physician. The examiner reviewed the claims file; the examiner also reviewed the Veteran's VA treatment records on the Computerized Patient Records System (CPRS), including an operative report from 1993 and imaging reports from 1993 through 2012. The examiner also found an ENT consult he had authored in June 2002 that concerned acute and chronic sinusitis (the examiner reviewed the clinical findings of that visit in detail), followed shortly by another ENT note showing the acute sinus infection had resolved. There was also a "regular" (non-C&P) ENT note in October 2002 that was mostly for earache and documented that sinus problems had not recurred since June. Review of CPRS showed that the Veteran's PCP had added "acute and chronic sinusitis" to the Veteran's active problems list in April 1998; the same PCP removed "acute sinusitis" from the active problems list in January 2001 and he removed "chronic sinusitis" from the active problems list in January 2006. The Veteran described having a nasal fracture in service while playing softball, after which he began having recurring sinus infections. The examiner performed a physical examination and noted observations in detail. The examiner stated the Veteran had current conditions of sinusitis (ethmoid and maxillary), rhinitis and deviated nasal septum. The examiner stated the Veteran's testimony before the Board showed he was confusing symptoms and treatment for allergic rhinitis with symptoms of sinusitis, and that softball trauma to the nose would not cause allergies in the nose. The examiner stated that review of the STRs showed the Veteran had two softball-related injuries in 1985, the first of which showed a deviated septum but no fracture by X-ray; the second showed a slightly depressed fracture by X-ray but the nasal bones were intact. The clinical impression after the second trauma was significantly displaced traumatic nasal septum and non-displaced nasal fracture. Surgery was performed in service, and although the maxillary sinuses were air-filled immediately after surgery the VA examiner stated an opinion that this was simply due to the nose having been packed for a few days after surgery. Based on review of post-service clinical records, the examiner stated an opinion that the Veteran did sustain a non-displaced nasal fracture and deviated septum in service in 1985, but this was hardly the degree of trauma that the examiner would professionally expect to lead to any sinus problems, particularly with such mild radiological abnormalities as were documented in 1992. The examiner stated the Veteran did appear to have a chronic, recurring sinus condition in March 1993, but there was no supporting evidence showing a chronic sinus problem prior to that date. The examiner could also find no competent medical opinion of record that asserted the Veteran's nasal fracture in service had led to, caused or contributed to his subsequent development of sinus problems. Analysis On review of the evidence above, the Board finds that although he did not have sinusitis during the most recent examination there is sufficient evidence of record to demonstrate that he has chronic recurrent sinusitis. He also had a documented nasal fracture during service. He has accordingly demonstrated a prima facie case for service connection for sinusitis. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). Where an opinion is used to link the current disability to a cause during service, a competent opinion of a medical professional is required. Caluza, 7 Vet. App. 498 (1995). In this case, there is no competent medical opinion of record showing a relationship between the diagnosed sinusitis and service, and in fact the only medical opinions of etiology documented in the claims file - those of the VA examiner in December 2009 and the VA examiner in April 2012 - agree that the Veteran does not have sinusitis due to the in-service fracture. These two medical opinions, and especially the very detailed opinion of the VA examiner in April 2012, satisfy all three elements of probative value cited in Nieves-Rodriguez. (i.e., both a medical experts were fully informed of the pertinent factual premises of the case, both medical experts provided fully-articulated opinions and both medical opinions were supported by reasoned analyses). Given that the uncontroverted medical opinion of record is against a relationship between the claimed disorder and service, the Board has no basis on which to grant service connection. The Veteran asserted during testimony that he had been informed by several physicians that his sinusitis is due to the nasal fracture during service, this assertion was discounted by the VA examiner in April 2012. Further, even if arguably one or more physicians did tell the Veteran his sinusitis was due to in-service injury, there is no indication of how such a conclusion was reached, whereas both VA examiners demonstrably reviewed the Veteran's subjective and objective medical history and performed an examination of the Veteran prior to reaching a conclusion. The verbal opinions cited by the Veteran cannot be assessed for probative value under the inquiries cited in Nieves-Rodriguez, whereas the opinions of the VA examiners are shown to satisfy those inquiries. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence above the Board has carefully considered the lay evidence offered by the Veteran in the form of his testimony, his correspondence of record and his statements to various medical providers and examiners. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). The Veteran is accordingly competent to describe recurring episodes of sinusitis since his discharge from service. However, the Veteran does not assert, and the evidence of record does not show, continuous symptoms since discharge from service. To the degree that the Veteran's lay testimony is intended to show his personal belief that sinusitis is due to the in-service nasal fracture, this is a medical conclusion the Veteran is not competent to make. See Jones v. Brown, 7 Vet. App. 134, 137 (1994) ([i]t is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation). Further, as demonstrated by the VA examiner, symptoms of sinusitis are easily confused with rhinitis or other disorders; accordingly, the Board finds that the etiology of the Veteran's sinusitis is too complex an issue, one typically determined by persons with medical training, to lend itself to lay opinion evidence. Kahana, 24 Vet. App. 428. In sum, the Board has found the Veteran's sinusitis is not shown to be due to or aggravated by service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the evidence preponderates against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Evaluation of Bilateral Knee Disabilities Applicable Laws and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). 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. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and 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. The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1, 1997); VAOPGCPREC 9-98 (August 14, 1998). The VA General Counsel has also held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code (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. VAOGCPREC 9-2004 (September 17, 2004). Painful motion of a major joint or groups caused by degenerative arthritis, where the arthritis is established by X-ray, is deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even though there is no actual limitation of motion. VAOPGCPREC 09-98 (August 14, 1998). Recurrent subluxation or lateral instability of the knee warrants a 10 percent evaluation for impairment to a slight degree, a 20 percent evaluation for impairment to a moderate degree, and a 30 percent evaluation for impairment to a severe degree. 38 C.F.R. § 4.71a, DC 5257. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. In turn, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. 38 C.F.R. § 4.71a, DC 5003. Limitation of flexion of a leg warrants a noncompensable evaluation if flexion is limited to 60 degrees, a 10 percent evaluation if flexion is limited to 45 degrees, a 20 percent evaluation if flexion is limited to 30 degrees or a 30 percent evaluation if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Limitation of extension of a leg warrants a noncompensable evaluation if extension is limited to 5 degrees, a 10 percent evaluation if extension is limited to 10 degrees, a 20 percent evaluation if extension is limited to 15 degrees, a 30 percent evaluation if extension is limited to 20 degrees, a 40 percent evaluation if extension is limited to 30 degrees or a 50 percent evaluation if extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Normal range of motion (ROM) of the knee is extension to 0 degrees and flexion to 140 degrees. 38 C.F.R. § 4.71a, Plate II. Also applicable is DC 5258, which provides for a rating of 20 percent for dislocated semilunar cartilage, and DC 5259, which provides for a rating of 10 percent for symptomatic removal of semilunar cartilage. Also applicable is DC 5055 (prosthetic knee replacement). A minimum rating of 30 percent is assigned after replacement of the knee joint. A rating of 60 percent is assigned with chronic residuals consisting of severe painful motion or weakness in the affected extremity. A rating of 100 percent is assigned during the year following implantation of the prosthesis. Intermediate ratings between 30 percent and 60 percent are assignable by analogy under DCs 5256, 5261 or 5262. Other diagnostic codes pertaining to the knee are DC 5256 (ankylosis), DC 5262 (nonunion or malunion of tibia and fibula) and DC 5263 (genu recurvatum). These DCs are not applicable because the Veteran does not exhibit the relevant pathologies. In any increased rating claim, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Factual Background In accordance with 38 C.F.R. §§ 4.1, 4.2 (2011) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities under review. The instant claim for increased rating was received in January 2006. At that time, the Veteran's right and left knee disabilities were each evaluated as 10 percent disabling. In September 2005 the Veteran presented to the VA specialty clinic complaining of pain and swelling of the right knee. X-ray showed no bone changes, and the knee was tapped to withdraw excess fluid. The clinical impression was acute exacerbation of chronic knee pain. The Veteran had a VA orthopedic consult in October 2005 for reported persistent patellar instability of the right knee. He reported having recently twisted the knee and reported it had been aspirated and painful since then. Examination of the right knee showed trace effusion and positive patellofemoral grind test. The patella was hypermobile and could almost be dislocated. There was apprehension test medially as well as crepitation. There was no medial or lateral laxity; ROM was full extension and 120 degrees of flexion. X-ray of the right knee showed degenerative changes. The clinical impression was right patellar instability with patellofemoral degenerative changes. During VA orthopedic evaluation in December 2005 the Veteran stated he could walk less than 50 yards and not stand for prolonged periods due to knee pain. Examination of the right knee showed ROM of 0-110 degrees with no effusion although trace crepitus was noted; the left knee was not examined. Clinical impression was patellofemoral bilateral knee pain secondary to patellofemoral degenerative joint disease (DJD). During VA orthopedic follow-up in January 2006 the Veteran stated the left patellar realignment was working fairly well, but the right was obviously loose. Magnetic resonance imaging (MRI) showed primarily chondral defects on the patella and no obvious meniscus tear; examination was otherwise unremarkable and the clinical evaluation was patellofemoral arthrosis with instability on the right. The Veteran was fitted with bilateral braces to replace the previous neoprene sleeves. The Veteran had a VA examination in February 2006 in which he complained of pain in both kneecaps with daily painful flare-ups. He reported taking ibuprofen for pain, applying heat during flare-ups and wearing knee braces for alignment. He stated he had difficulty kneeling, climbing stairs and ladders and sitting on the floor, all due to painful knees. He did not report any specific changes in his job duties as a clergyman. Examination showed normal-appearing knees with full extension and with flexion to 140 degrees, both without pain. No additional limitation was shown on repetitive motion. The knees were stable, gait was normal and there was no swelling. X-ray of the left knee showed postsurgical change but was otherwise normal. X-ray of the right knee showed mild lateral subluxation of the patella with spurring, and magnetic resonance imaging (MRI) of the right knee showed intact ligaments and post-surgical change from meniscectomy with cartilage loss from the patella. The examiner's diagnosis was bilateral maltracking patellae with mild chronic strain. The Veteran submitted a letter in March 2006 asserting that in late 2003 his knee popping and pain had increased dramatically and caused him to be taking prescription-strength pain medication without relief. He was scheduled to undergo knee surgery in April 2006. The record reflects the Veteran underwent right surgery (arthroscopic lateral release with removal of loose body) on April 20, 2006; the operative notes are of record. The right knee disability was rated at 100 percent during the period April 21, 2006, to May 31, 2006, due to surgery and convalescence. In May 2006 the Veteran submitted a letter stating his right knee surgery had progressed from minor surgery (orthoscopic) to major surgery (reconstructive) and that he was informed by the surgeon he would need a knee replacement in the very near future. The Veteran stated his left knee was just as bad as the right knee. In July 2006, three months post-surgery, the Veteran presented to the VA orthopedic clinic with continued complaint of diffuse right knee pain. ROM was observed to be 5-120 degrees with joint line tenderness and the Veteran was observed to walk with a moderate limp. The clinician stated the Veteran's symptoms were likely due to arthrosis of the patellofemoral joint and lateral joint compartment. Later the same month the Veteran complained that the right knee felt "like it had a rock in it" and that the associated pain and burning kept him awake at night. The Veteran had a VA examination in August 2006 to determine the severity of the right knee after surgery. The Veteran complained of dull, constant ache with no reported periods of flare-up. The Veteran endorsed using a brace and cane. The Veteran reported being no longer able to work at his previous occupation as an appliance repairman because he could no longer kneel; he was therefore looking for alternative employment. The Veteran endorsed pain when negotiating stairs and stated his wife did the driving; he also stated he could only walk for about 10 minutes at a time. Physical examination showed ROM of full extension and flexion to 100 degrees, limited by pain and stiffness. There was pain through the ROM but no additional functional limitation with repetitive use. There was no evidence of current instability (negative McMurray sign and negative Lachman test) and no evidence of fatigue, weakness, lack of endurance or fatigability of the right knee. There was no evidence of abnormal weightbearing, ankylosis, heat or abnormal movement. There was some guarding of movement and no history of falls. The clinical assessment was status post surgery to the left knee [sic] with mild-to-moderate functional limitation related to pain. The Veteran had a total right knee replacement in October 2006 at the University of South Alabama (USA) Orthopedic Department; operative and post-operative records are associated with the claims file. He was rated at 100 percent for the right knee from October 3, 2006, to March 30, 2008, after which he was assigned a 30 percent rating, the minimum rating under DC 5055 after total knee replacement. A VA clinic note in February 2007 stated the Veteran would have to have another right knee surgery because the previous knee replacement by USA was too small. The Veteran currently complained of right knee pain and swelling. Clinical observation showed reduced ROM, swelling and scar as well as left knee discomfort. The Veteran had revision surgery on the right knee in February 2007, and a March 2007 treatment note by the USA Orthopedic Clinic stated that the Veteran was "doing great" postoperatively, with ROM of 0-115 degrees and no laxity. The Veteran's wife submitted a letter in April 2007 asserting that the Veteran's right knee surgeries in April 2006 and October 2006 had been ineffective in resolving his problems, and that he would probably need another right knee surgery because the previous operation was defective. The Veteran had gone from being very active to being unable to carry out normal activities. The Veteran's brother submitted a similar letter in April 2007 asserting the Veteran's quality of life had deteriorated to the point where he was unable to engage in any physical activity or basically any activity that would require him to be on his feet. The Veteran had to dissolve his heating and air conditioning business because he was unable to perform the basic functions associated with the trade. The file contains similar statements from others in April 2007 attesting that the Veteran had suffered with leg and knee problems for a number of years, especially in the previous two years. The Veteran's livelihood depended on being able to get up and down and to climb and crawl underneath buildings, but his knee problems prevented him from doing so. The Veteran's wife had to go to work to help support the family. The Veteran had a strong work ethic and strong desire to return to work but was physically unable to do so. Treatment notes in August 2007 by the USA show ROM of the right knee as 0-110 degrees and the left knee as 0-115 degrees; the Veteran denied right knee pain but complained of left knee pain and patellar laxity. X-rays of the bilateral knees showed an impression of status post right total knee arthroplasty and left knee with a screw in the anterior aspect of the proximal medial metaphysis. The Veteran was advised to get an MRI of the left knee. A VA orthopedic note in September 2007 shows the Veteran's private provider (USA) requested an MRI of the left knee due to patellar instability. The resultant MRI showed a metal screw causing some metallic susceptibility artifacts, and it was difficult to tell whether there was thinning of the lateral facet of the patellar cartilage; there was also evidence of a very small tear in the medial meniscus. The Veteran had another VA examination in October 2007 primarily to determine whether the Veteran's service-connected bilateral knee disabilities rendered him unemployable. The Veteran reported he was pending an imminent total left knee replacement; he complained of current bilateral knee pain and swelling, right worse than left. He used a walking stick but not a cane or crutch, and did not currently use a knee brace. The Veteran reported problems standing longer than 20 minutes and sitting more than 30 minutes unless he could get up and move around. He reported daily flare-ups associated with activity. He stated he was able to perform activities of daily living (ADLs) including driving but stated he was unemployed. On examination the Veteran was observed to walk with antalgic gait and right limp; he could tandem-walk, heel-walk and toe-walk without difficulty. The right knee had a well-healed scar, no heat or erythema but mild swelling. There was laxity of the right knee to both varus and valgus stress. ROM of the right knee was 0-120 degrees after repetitive motion, with pain at all ranges of motion but no tenderness to palpation. The left knee had a well-healed scar and no swelling or laxity; ROM of the left knee was 0-130 degrees without pain on motion or tenderness to palpation. The examiner noted X-rays in 2006 and MRI in September 2007. The examiner's assessment was status post right knee replacement with residual traumatic arthritis and instability, and status post multiple surgeries of the left knee with residual traumatic arthritis. In regard to employability, the examiner stated the Veteran would have difficulty doing physical labor but should be able to perform sedentary employment without difficulty despite the service-connected disabilities. A November 2007 treatment note by USA Orthopedic Clinic shows the left knee with ROM of 0-120 degrees and X-ray impression of minimal narrowing of the joint line. The Veteran's current complaint was left knee pain with patellar dislocation and laxity. The treatment plan was to schedule left patellofemoral arthroplasty (which was performed in July 2008 as noted below). The Veteran had another VA examination in March 2008 for the purpose of reevaluating the right knee, status post total knee replacement surgery. The Veteran reported being independent in ADLs, but the right knee surgeries required extended convalescence and that prevented employability. The Veteran complained of current right knee pain with walking or standing more than 15 minutes; he also reported occasional knee pain when driving. He reported pain severity as 5-6/10 on average and no significant flare-ups, but daily swelling. He reported instability but no locking or falls. Visual inspection showed moderate swelling of the right knee but no erythema. The Veteran was observed to ambulate with a walking stick, not a cane. Gait was normal and without limp. ROM after repetitive motion was 0-125 degrees without instability or tenderness to palpation. X-ray showed status post right total knee arthroplasty. The clinical diagnosis was status post total right knee replacement #2 with mild knee joint effusion. The Veteran had left knee arthroplasty by USA Orthopedic Clinic in July 2008; operative and post-operative records are associated with the claims file. The Veteran was rated 100 percent for the period July 18-October 31, reverting to 10 percent thereafter. Per a VA physician's note in March 2009, this arthroplasty in July 2008 was not the same as a total knee replacement. The Veteran had total left knee replacement in April 2009, performed at Mobile Infirmary Medical Center. His left knee was rated 100 percent until June 1, 2010, reverting thereafter to 30 percent under DC 5055. The Veteran had a VA examination in November 2009 for the purpose of reevaluating the left knee, status post total arthroplasty surgery. The Veteran reported no impediments to ADLs and stated he could drive. Reported impediments to his usual occupation were bilateral knee traumatic arthritis and right knee replacement surgery. The Veteran stated his left knee was actually worse than prior to surgery, because although instability was resolved he now had constant pain of 3-4/10 severity. He reported flare-ups of 8-9/10 severity associated with protracted standing or walking and also at night, causing him to awaken. On examination the Veteran was observed to limp on his right leg and to use a walking stick. Repetitive motion showed ROM of 0-110 degrees without instability; additional limitation with flare-ups could not be determined. X-ray showed satisfactory postoperative appearance of the arthroplasty. The examiner's diagnosis was status post patellofemoral arthroplasty. The Veteran testified before the RO's DRO in June 2009 that he was unable to drive more than 20 minutes because his right knee, which operates the gas pedal, would cramp and jerk. His right knee instability had occasionally caused him to fall. He rated his right knee pain at 5+/10 routinely and sometimes rising to 10/10. In regard to the left knee, the Veteran felt that since the left knee was as painful as the right it should also be rated at least 20 percent. The Veteran stated his left knee surgery in July 2008 resulted in pain and swelling, and the left knee had to be drained of fluid on four occasions prior to having a corrective total left knee replacement in April 2009. The Veteran reported he last worked in April 2006 as a self-employed heating and air conditioning specialist, a trade he had learned through VA vocational training, but his knee disabilities made it impossible to continue that trade; however, the Veteran believed he would improve and be able to return to gainful employment with time. In terms of ADLs, the Veteran's wife did the driving and helped him to dress, and his daughters helped with driving and helped him to put on his shoes. The Veteran testified before the Board in March 2011 that he was currently taking pain medications and wearing knee braces due to continuing postoperative problems with both knees. Both knees continued to be unstable, and he would occasionally fall to the ground because of that instability; he stopped using a walking stick because he tended to trip over it. Both knees hurt constantly. The right knee was less stable than the left knee and had about an inch of movement all around. The Veteran had been unemployed since 2006; he had to close his business due to his knee problems and could not subsequently find alternative work because he kept going into and out of hospitals for knee treatment. However, the Veteran did not want to be unemployed and wanted to return to being a productive citizen. The Veteran had a VA examination of the knees in May 2011. There were no reported affects of the Veteran's knee disabilities on his activities of daily living (ADLs) other than needing help putting on his shoes and socks and difficulty driving long distances. In terms of occupational impairment, the Veteran described difficulty bending, kneeling and working in small enclosed spaces. The examiner noted clinical reference to relative instability of the right knee, which could necessitate revision of previous surgery (four previous right knee surgeries were noted). The Veteran described his right knee as currently worse than his left. He complained of current right knee symptoms of constant daily pain at 7/10 level with daily flare-ups to 8-9/10 level; the left knee had constant daily pain at 6/10 severity with daily flare-ups the same as the right knee. He endorsed continued instability of both knees. The Veteran stated the right knee was worse than in the previous examination, but the left knee has some improvement in terms of pain and stiffness since the last surgery in April 2009. On physical examination, the Veteran was noted to walk with a slight limp and to be wearing bilateral hinged knee braces. The Veteran needed assistance in putting on and removing his shoes. Motor strength of the lower extremities was normal, but heel-walk and toe-walk were difficult due to knee pain. ROM of the right knee was 0-80 degrees, and ROM of the left knee was 0-95 degrees. Both knees had slight anterior laxity. There was no additional loss of function due to repetitive use. Additional loss of function due to flare-ups could not be estimated. The examiner diagnosed bilateral total knee arthroplasties with residual anterior instability and effusion, causing moderate functional limitation. The Veteran submitted a letter to VA in December 2012 asserting that he had a right knee replacement in December 2011, representing his third knee replacement in less than five years. The Veteran complained that he had not received a 100 percent convalescent payment for the 13 months after that surgery. Analysis Schedular evaluation of right knee disability As indicated above, when the Veteran filed his claim for increase, his right knee disability was evaluated as 10 percent disabling. In the appealed July 2006 rating action, his right knee evaluation was increased to 20 percent, effective from his October 2005 claim. Thereafter, his right knee disability was rated as 20 percent disabling to April 21, 2006 and from June 1, 2006, to October 2, 2006. Evaluation was increased to 30 percent from April 1, 2008, to the present. (During the intervening periods of April 21, 2006, to May 31, 2006, and from October 3, 2006 to March 30, 2008, the right knee was rated at 100 percent due to surgery and convalescence). Prior to October 2006, the RO rated the Veteran's right knee disability under DC 5258, which allows a maximum 20 percent rating. However, the provisions of DC 5257 apply in regard to possible higher rating for instability, and DCs 5260 and 5261 apply for limitation of motion. The evidence cited above shows that prior to April 19, 2006, the Veteran's right knee was clinically characterized as unstable in treatment notes in October 2005 and January 2006. Because the examination in February 2006 showed the knee to be stable and the gait to be normal, the Board concludes that the degree of instability that was shown in October 2005 and January 2006 was moderate rather than severe; accordingly, rating in excess of 20 percent is not appropriate under DC 5257. During the same period the Veteran's ROM was not compensable under either DC 5260 or 5261 because his extension was consistently 0 degrees and his flexion was consistently better than 45 degrees. However, the Veteran had DJD and showed pain with motion; he is accordingly entitled to a separate 10 percent evaluation for those symptoms. VAOPGCPREC 23-97; VAOPGCPREC 09-98. The surgery in April 2006 was for arthroscopic lateral release with removal of loose body; it was not a knee replacement. Accordingly, the minimum 30 percent post-knee replacement rating under DC 5055 is not applicable following this surgery. During the period from June 1, 2006, to October 2, 2006, following convalescence from surgery in April 2006, the Veteran's right knee extension was at worst 5 degrees (July 2006) and his flexion was at worst 100 degrees (August 2006), neither of which is compensable limitation of motion; however, separate minimum 10 percent for painful motion with DJD remained warranted during the period. There is no clinical notation of instability during the period, and the treatment note in August 2006 in fact stated the knee was stable, so increased rating is not warranted under DC 5257 or 5258. Finally, since April 1, 2008, following convalescence from total knee replacement in October 2006, the Veteran has not had compensable limitation of motion although he has continued to complain of pain. He complained in March 2008 of subjective instability but there was no clinical instability on examination and gait was normal, without limp; during examination in May 2011 there was clinical evidence of "slight" anterior laxity. The Veteran is entitled to minimum 30 percent under DC 5055 for total knee replacement, but there is no indication of chronic residuals showing entitlement to a 60 percent rating under that DC (severe painful motion or weakness), nor were such residuals shown during the March 2008 or May 2011 VA examinations. In sum, the Board has found the Veteran's right knee disability should be rated as 30 percent disabling prior to October 3, 2006 (except for the period of 100 percent evaluation in April 20 - May 31, 2006), based on moderate instability and painful but noncompensable limitation of motion due to arthritis; his claim is granted to that extent. Rating higher than 30 percent is denied. Schedular evaluation of left knee disability During the period on appeal the left knee disability was rated as 10 percent disabling prior to October 31, 2007, and as 20 percent disabling from November 1, 2007 to July 17, 2008. Evaluation was reduced to 10 percent from September 1, 2008 to April 20, 2009. Evaluation was increased to 30 percent from June 1, 2010 to the present. (During the intervening periods of July 18, 2008 to August 31, 2008, and from April 21, 2009, to May 31, 2010, the left knee was rated at 100 percent due to surgery and convalescence). Prior to April 2009 the RO rated the left knee under the provisions of DC 5257, based on instability. Prior to October 31, 2007, the Veteran complained several times of subjective instability, and a treatment note in September 2007 requested MRI for possible patellar instability, but the resultant MRI was silent in regard to instability and the subsequent examination in October 2007 stated no laxity was found. The Board accordingly finds the Veteran's instability during the period was "slight" rather than "moderate" and that rating higher than 10 percent under DC 5257 is not warranted. During the period the Veteran's left knee extension was consistently 0 degrees and his flexion was at worst 115 degrees, so compensable rating under DCs 5260 and 5261 was not warranted; however, since the clinician in February 2005 noted pain secondary to DJD, a separate rating of 10 percent is warranted for painful motion. During the period from November 1, 2007, to July 17, 2008 the RO increased the rating to 20 percent based on the treatment note showing complaint of dislocation and laxity. Rating of 20 percent for dislocation is appropriate under DC 5258, which provides for a maximum rating of 20 percent. The evidence does not show "severe" subluxation or lateral instability to warrant a 30 percent rating under DC 5257. The Veteran's left knee ROM of 0-120 degrees does not show compensable limitation of motion, but as before, painful motion with arthritis warrants a continued separate 10 percent rating. During the period from September 1, 2008, to April 20, 2009, following convalescence from surgery in July 2008, the RO assigned a 10 percent rating. There is no evidence whatsoever regarding the severity of the left knee disability during the period. Accordingly, the previous rating (20 percent under DC 5258 and separate 10 percent for limitation of motion) should remain in place. Finally, since June 1, 2010 and following convalescence from total knee replacement in April 2009, the Veteran is entitled to minimum 30 percent under DC 5055 for total knee replacement. There is no indication of chronic residuals showing entitlement to a 60 percent rating under that DC (severe painful motion or weakness). During examination in November 2009 and May 2011 the Veteran's ROM was noncompensable under the appropriate DCs, and although he asserted pain on motion separate rating cannot be assigned in conjunction with DC 5055 due to pyramiding. The Veteran had "slight" instability in May 2011, but there is no schedular provision for instability rating higher than the currently-assigned 30 percent, so alternative rating for instability would present no benefit to the Veteran. There is no provision in the rating schedule for concurrent ratings under DC 5055 (knee replacement) and DC 5257 (instability). In sum, the Board has found the left knee disability should be rated as 20 percent disabling prior to November 1, 2007, based on slight instability and painful but noncompensable limitation of motion due to arthritis. The Board has also found that the disability should be rated as 30 percent disabling from November 1, 2007, to April 21, 2009 (except for the period of 100 percent evaluation from July 18, 2008, to August 31, 2008), based on moderate instability and painful but noncompensable limitation of motion due to arthritis. The Veteran's claim is granted to that extent. Rating higher than 30 percent is denied. Lay evidence VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence above the Board has considered the lay evidence submitted by the Veteran in the form of his testimony, his correspondence to VA and his statements to various medical providers and examiners; the Board has also considered the lay statements submitted on the Veteran's behalf. As noted above, a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer, 7 Vet. App. 379, 384; Falzone, 8 Vet. App. 398, 403. Similarly, a layperson can certainly provide an eyewitness account of a veteran's visible symptoms; Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board finds the lay evidence offered by the Veteran to be credible, and has based its grant of increased evaluation based in part on that lay evidence. Even affording full competence and credibility to the lay evidence in reporting the Veteran's symptoms, however, the evidence does not show entitlement to schedular evaluations higher than that granted by the Board above, in that the lay evidence does not demonstrate either compensable limitation of motion or severe instability, nor does it show or allude to qualifying chronic residuals of total knee replacement. The Veteran has offered lay evidence that he has severe knee pain, as per his subjective report to the VA examiner in May 2011. However, as the examiner noted a clinical impression of "moderate" limitation of function, and as the Veteran's motor strength was intact on examination, the Board cannot find that the Veteran has "severe" painful motion or weakness as defined by the rating criteria of DC 5055. As the examiner did not find increased limitation of function on repetitive motion, consideration of DeLuca does not result in a higher schedular rating. Other considerations The Board's action above represents "stage rating" allowing increased schedular evaluations for distinct periods during the entire period under review. Hart, 21 Vet. App. 505 The Board has also considered whether referral for extraschedular consideration is warranted. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the rating schedule reasonably describes both the Veteran's disability level and his symptomatology (i.e., painful limitation of motion and instability), so referral for extra-schedular consideration is not appropriate. Thun, id. The Court has recently held that a request for a TDIU, whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). In this case an RO rating decision in February 2008, during the course of this appeal, denied the Veteran's formal claim for TDIU. The Board has considered whether the evidence after February 2008 raises a new claim for TDIU, but during hearings before the DRO and before the Board the Veteran stated he did not believe himself to be permanently unemployable. The Board accordingly finds that a new claim for TDIU is not raised by the rating issues herein adjudicated. ORDER Service connection for sinusitis is denied. Subject to the criteria applicable to the payment of monetary benefits, a separate 10 percent evaluation for right knee painful motion with arthritis for the period prior to April 2006, and for the period from June 2006 to October 2006, is granted. Schedular evaluation for right knee disability in excess of 30 percent, combined or otherwise, is denied. Subject to the criteria applicable to the payment of monetary benefits, a separate 10 percent evaluation for left knee painful motion with arthritis for the period prior to July 2008, is granted. Subject to the criteria applicable to the payment of monetary benefits, a 20 percent evaluation for left knee instability, and a 10 percent evaluation for left knee painful motion with arthritis for the period from September 2008 to April 2009, is granted. Schedular evaluation for left knee disability in excess of 30 percent, combined or otherwise, is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs