Citation Nr: 1314006 Decision Date: 04/26/13 Archive Date: 05/03/13 DOCKET NO. 07-05 714 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to an initial compensable evaluation for left knee patellofemoral syndrome prior to June 30, 2008. 2. Entitlement to an evaluation in excess of 10 percent for left knee patellofemoral syndrome, based upon limitation of flexion, for the period beginning on June 30, 2008. 3. Entitlement to a separate evaluation for left knee patellofemoral syndrome, based upon limitation of extension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran had active service from September 1989 to August 2005. This matter initially came before the Board of Veterans' Appeals (Board) from a September 2006 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Buffalo, New York. In that decision, the RO, in relevant part, granted service connection and assigned a noncompensable evaluation for a left knee disability, effective on August 10, 2005. The Veteran appealed the initial evaluation. Jurisdiction of the Veteran's claims file was subsequently transferred to the RO in Oakland, California. In a July 2008 rating decision, the RO granted an increased evaluation for the left knee disability and assigned a 10 percent rating, effective on June 30, 2008. As a higher rating for this disability is assignable before and after this date, and the Veteran is presumed to seek the maximum available benefit, the issue remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In August 2010 and April 2012, the Board remanded the appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further development. As will be discussed further, the RO substantially complied with the remand directives, and no further action is necessary as to the issue being decided herein. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in the file reveals VA treatment records pertinent to the issue on appeal. As noted in the April 2012 remand, the issue of service connection for the residuals of a right hand or right finger injury has been raised by the record. It has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is, again, referred to the AOJ for appropriate action. FINDINGS OF FACT 1. For the period prior to June 30, 2008, the Veteran's left knee disability manifested as flexion to 130 degrees, and extension to 0 degrees, without objective evidence of pain. 2. For the period beginning on June 30, 2008, the Veteran's left knee disability manifests as flexion to 100 degrees with remaining functional flexion greater than 45 degrees, and full extension. 3. Effective April 27, 2012 extension was limited to -7 degrees with subjective complaints and objective evidence of pain. CONCLUSIONS OF LAW 1. The criteria for a 10 percent evaluation for the service-connected left knee disability have been met for the period prior to June 30, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2012). 2. The criteria for a disability rating in excess of 10 percent for the service-connected left knee disability based upon limitation of flexion have not been met for the period beginning on June 30, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2012). 3. The criteria for a separate 10 percent disability rating for the service-connected left knee disability based upon limitation of extension have been met for the period beginning on April 27, 2012. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial disability-rating and effective-date elements of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006), the Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, the Veteran is challenging the initial evaluation assigned following the grant of service connection for patellofemoral syndrome of the left knee. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied with respect to the issue of entitlement to a higher initial evaluation for his left knee disability. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In connection with the current appeal, available service and private treatment records have been obtained. The Board further observes that this case was remanded in August 2010 and April 2012 in order to obtain VA joints examinations. Thereafter, the Veteran was afforded the requested examinations in December 2010 and April 2012. The AMC also associated VA treatment records dated through November 2012 with the Virtual VA paperless claims file. In the August 2010 Remand, the RO was also directed to clarify the basis for the use of Diagnostic Code 5257 for subluxation or instability of the left knee. Although the issue was addressed in a December 2011 Supplemental Statement of the Case (SSOC) instead of a rating decision, there was substantial compliance with the Remand directives. Therefore, the Board finds that the RO has substantially complied with the August 2010 and April 2012 Remand directives such that no further action is necessary in this regard. See D'Aries, supra. With respect to VA examinations, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The most recent VA examination provided in April 2012 is based on review of the claims file, taking a relevant history from the Veteran, and clinical evaluation of the Veteran. The examination report is adequate; the information provided by the VA examiner is supported by a thorough history, fully reasoned explanations and clinical findings, as will be discussed at length below. A new examination is not required as the examiner's opinions are well-supported, and the opinion addressed the Board's April 2012 Remand directives. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim. The evidence of record provides sufficient information to adequately evaluate the claim, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. No further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Accordingly, the Board will address the merits of the claim. Laws and Regulations Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is a higher initial rating since the grant of service connection, and in any rating case, "staged ratings" (assignment of different ratings for distinct periods of time, based on the facts found) must be considered. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, there has been a significant change and a staged rating is warranted. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in a Diagnostic Code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2012). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several Diagnostic Codes; however, the critical element in permitting the assignment of several ratings under various Diagnostic Codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2012) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). 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 which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2012). VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, in Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the Diagnostic Code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the Diagnostic Code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). The Veteran's service-connected left knee patellofemoral syndrome is currently rated under Diagnostic Code 5260. Diagnostic Codes 5260 and 5261 are utilized to rate limitation of flexion and extension of the knee joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, limitation of flexion of the knee to 60 degrees warrants a noncompensable disability rating, limitation of flexion to 45 degrees warrants a 10 percent disability rating, limitation of flexion to 30 degrees warrants a 20 percent disability rating, and limitation of flexion to 15 degrees warrants a maximum 30 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the knee to 5 degrees warrants a noncompensable disability rating, limitation of extension of the knee to 10 degrees warrants a 10 percent disability rating, limitation of extension to 15 degrees warrants a 20 percent disability rating, and limitation of extension to 20 degrees warrants a 30 percent disability rating. Limitation of extension of the knee to 30 degrees warrants a 40 percent disability rating and limitation of extension of the knee to 45 degrees warrants a maximum 50 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Schedule provides that the normal range of motion of the knee is zero degrees on extension to 140 degrees on flexion. 38 C.F.R. § 4.71, Plate II. Evaluations of the knee are not limited to limitation of motion under the Rating Schedule. Under Diagnostic Code 5257, other impairment of the knee, a 10 percent disability rating requires slight recurrent subluxation or lateral instability. A 20 percent disability rating requires moderate recurrent subluxation or lateral instability. A 30 percent disability rating requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5258, dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint, warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability, and a 20 percent disability rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, a 10 percent disability rating is assigned for acquired, traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. 38 C.F.R. § 4.71a, Diagnostic Code 5263. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, 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 and not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. VA's General Counsel has held that a veteran who has arthritis and instability of the knee could receive separate ratings under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97 (1997); 62 Fed. Reg. 63,604 (1997). When a knee disorder is already rated under Diagnostic Code 5257, the Veteran must also have limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a noncompensable rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98 (1998); 64 Fed. Reg. 52,376 (1999), the VA General Counsel further explained that, when a veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. In the alternative, a compensable rating may be granted by virtue of 38 C.F.R. § 4.59. In VAOPGCPREC 9-2004 (2004); 69 Fed. Reg. 59,990 (2004), the VA General Counsel held that when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a Veteran may receive a rating for limitation in flexion only, limitation of extension only, or separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion), and Diagnostic Code 5261 (leg, limitation of extension). Where a veteran has both a limitation of flexion, and 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. Factual Background In this case, the Veteran claims that his left knee disability is more severe than reflected by the assigned noncompensable disability rating prior to June 30, 2008, and the assigned 10 percent disability rating from June 30, 2008. Upon receipt of the Veteran's service connection claim, he was afforded a January 2006 VA general medical examination. He complained of a left knee bone spur injury with intermittent pain. He denied locking, giving way, or swelling of the joint, but he indicated that he had flare-ups of pain, lasting two days, approximately twice per year. He stated that he used Tylenol as needed to relieve his left knee pain. He reported that his left knee pain bothered him while he was golfing and pivoting on the knee. He denied the use of any assistive devices and stated that it did not provide difficulty ambulating. He indicated that the left knee disability did not affect his ability to perform activities of daily living or his usual occupation. In a September 2006 VA examination report addendum, the examiner who conducted the January 2006 VA examination noted that the Veteran's left knee range of motion testing showed extension to 0 degrees and flexion to 130 degrees without pain. A December 2006 VA treatment note included knee arthralgia in the Veteran's medical history. No description, including which knee was affected or when arthralgia was diagnosed, was included in the notation. In a January 2007 Notice of Disagreement, the Veteran reported that his left knee pain forced him to favor the right side in weight bearing. In a February 2007 VA treatment note, the Veteran reported that his left knee pain was "tolerable." In a September 2007 VA treatment note, the Veteran reported that his chronic knee pain felt like a strain. He indicated that his knee was stiff, but he denied any giving way. An October 2007 x-ray study of the left knee showed "very small" intracondylar notch spurs. The medial and lateral compartments and the patellofemoral joint space appeared well-preserved. In a June 2008 VA treatment note, the examining physician noted that a recent x-ray of the left knee showed degenerative joint disease. A June 2008 VA magnetic resonance imaging (MRI) study of the left knee showed pes anserine bursitis and a mild increased signal within the anterior cruciate ligament compatible with a sprain. In a June 2008 VA treatment note, the Veteran complained of lateral and anterolateral left knee pain that was aggravated by running on asphalt and ascending or descending steps. He reported a couple of episodes of locking every year and occasional swelling. He indicated that he wore a soft knee strap that seemed to help. He noted that he had pain in the lateral knee with twisting of his knee while playing golf. A physical examination of the left knee showed no effusion. The Veteran was tender to palpation over the anterior and posterolateral joint lines. He had range of motion from 0 to 130 degrees with pain at full flexion along the lateral joint line area. He had a stable ligamentous examination to varus and valgus, negative anterior and posterior drawer, negative Lachman, negative pivot shift, and negative patellar grind. X-rays of the left knee were negative for any arthritis. An MRI study of the left knee showed some irregularity at the lateral meniscus primarily on the sagital views. The examiner noted that there was possibly a small peripheral tear. During a March 2009 VA joints examination, the Veteran reported that he had worn a brace since he originally injured his left knee in 1994 during service. He noted that his left knee pain worsened with increased activity, such as walking, trying to run, climbing stairs, squatting, kneeling, or playing golf. He reported that he had periodic stiffness of the knee depending on his activity level. He also indicated that his knee pain flared periodically. He was unable to state how often it flared or the duration of the flares, but he stated that it limited him from activities. The examiner noted that the Veteran walked with a mildly antalgic gait and used a neoprene brace on his left knee. When the brace was removed, the knee had mild crepitus with movement. Range of motion testing revealed extension to 0 degrees and flexion to 115 degrees. Repetitive range of motion testing produced complaints of pain. There was no additional limitation of motion with repetitive range of motion testing. There was no obvious laxity of the knee and no obvious instability. During a December 2010 VA joints examination, the Veteran reported that he had increased left knee pain. He noted that the pain was achy and constant, and he rated it as 7 out of 10 in severity. He acknowledged weakness, instability, lack of endurance, stiffness, and swelling. He denied fatigue, redness, locking, or heat. He noted that his pain worsened with golfing, sitting longer than 30 minutes, and using stairs. His pain improved with rest, heat, wrapping, and Tylenol taken as needed. He indicated that he had severe flare-ups of pain twice per month, but he denied any incapacitating episodes. He did not use a cane, walker, or a wheelchair. He used braces on his knee. He denied dislocations. He reported that he had arthritis in the joint. He indicated that he worked as an information technologist. He denied any work or active daily living restrictions. He noted that he took four days off of work in the past year. Physical examination of the left knee showed no effusion, deformity, or tenderness. McMurray, Lachman, and anterior and posterior drawer tests were normal. There was crepitus. Passive range of motion testing elicited pain at the inner patella. Active range of motion testing revealed extension to 0 degrees and flexion to 100 degrees. There was an absence of pain, weakness, fatigability, incoordination, and instability. There was no loss of function upon repetition. X-rays of the left knee showed minimal medial and patellofemoral compartment degenerative change. During an April 2012 VA examination, the Veteran reported that he worked in the information technology field. He indicated that his job required him to perform some lifting of computers and equipment, but his service-connected left knee and right shoulder disabilities made it difficult to carry certain items. He rated his left knee pain as approximately 2 to 3 out of 10 in severity which increased to 7 out of 10. He reported that during the first two to three days of the work week, his knee was minimally painful; however, in the next few days, after 3 p.m., his pain significantly increased to 8 out of 10 in severity. He noted that he was able to perform independent activities of daily living and personal hygiene. He denied the use of a cane, walker, or crutches, but he acknowledged the use of orthotic devices. He noted that he could tolerate walking approximately 300 to 400 yards, but he had difficulty ascending stairs. He stated that he had flare-ups of pain approximately three to four times per week that were usually the result of prolonged walking and standing. He related that he treated the flares with heating pads and he tried to stay off of his feet. He denied any bed rest prescribed by a physician during the past year, and he stated that he missed no work due to his knee. On physical examination, the examiner noted that the Veteran had minimal antalgia with his gait and that there was no evidence of weakness. There was no significant swelling or effusion or significant joint line tenderness. There was some mild, generalized tenderness, mainly centered around the patellar and peripatellar area. Patellar compression was positive and patellar laxity was not present. The examiner noted that moving the patella from side-to-side caused some discomfort. Range of motion testing revealed -7 degrees of extension and flexion to 105 degrees. The Veteran had pain beginning at approximately 40 degrees of flexion and pain when he extended from the flexed position at 40 degrees. There was no decrease in range of motion due to pain, weakness, fatigue, or lack of endurance. There was no subluxation or instability and the ligaments were stable. The examiner also noted that the Veteran did not have dislocated, semilunar cartilage with frequent episodes of locking with pain and effusion to the joint. The examiner noted that x-rays of the left knee showed no significant abnormality and that the impression of the radiologist was "unremarkable" as well. Analysis As discussed above, Diagnostic Codes 5260 and 5261 pertain to limitation of flexion of the knee and limitation of extension of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Prior to June 30, 2008 The Veteran has been assigned a noncompensable evaluation based upon limitation of motion for the period prior to June 30, 2008. As noted above, the Veteran was previously evaluated under Diagnostic Code 5257 for other impairments of the knee; however, in a December 2011 SSOC, the RO determined that his symptoms were better evaluated under Diagnostic Code 5260 for limitation of flexion. Under Diagnostic Code 5260, the assigned noncompensable evaluation contemplates leg flexion limited to 60 degrees or when there is a diagnosed disability with no compensable symptoms. A 10 percent evaluation is not warranted unless flexion is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. In considering the foregoing criteria of Diagnostic Code 5260, there is no evidence that the Veteran demonstrated a functional restriction in flexion limited to 45 degrees. However, in regard to limitation of flexion, the Board is not convinced that the Veteran's left knee flexion became worse on June 30, 2008. The 10 percent evaluation assigned effective on June 30, 2008 was based upon the examination finding flexion to 130 degrees with pain at full extension. During the examinations prior to June 2008, the Veteran also demonstrated flexion to 130 degrees, credible lay evidence of pain, and a report of arthralgia. Since full flexion is to 140 degrees, the Board is willing to accept that motion beyond 130 degrees would have been painful. In light of limitation of full flexion, and a report of arthralgia, the Board concludes that the provisions of 38 C.F.R. § 4.59 are applicable. Therefore, the Board finds that the Veteran has periarticular pathology productive of painful motion warranting a 10 percent evaluation for the period prior to June 30, 2008. In addition, separate evaluations may be assigned for instability or subluxation, or compensable limitation of extension. In considering the foregoing criteria of Diagnostic Code 5261, the Veteran demonstrated full extension to zero degrees throughout the period prior to June 30, 2008. As noted above, limitation of extension to 10 degrees warrants a 10 percent disability rating. Id. The Veteran does not warrant a separate 10 percent disability rating for instability of the left knee under Diagnostic Code 5257 for the period prior to June 30, 2008. Diagnostic Code 5257 provides a 10 percent evaluation for slight recurrent subluxation or lateral instability. There is no credible evidence to show that the left knee was not stable. In fact, during the January 2006 VA examination and during VA treatment in September 2007, the Veteran stated that his knee did not give way. Diagnostic Code 5258 provides the rating criteria for dislocation of semilunar cartilage and Diagnostic Code 5259 provides the rating criteria for symptomatic removal of semilunar cartilage. There is no evidence of dislocation or symptomatic removal of semilunar cartilage for this period. In essence, a separate evaluation is not warranted under Diagnostic Codes 5258 or 5259. The Board also finds that Diagnostic Code 5262 (impairment of the tibia and fibula) and Diagnostic Code 5263 (genu recurvatum) are not applicable here, as the medical evidence does not show that the Veteran has any of these disabilities. 38 C.F.R. § 4.71a, Diagnostic Codes 5262, 5263. In sum, the Board finds that the weight of the credible evidence demonstrates that the Veteran's service-connected left knee disability supports the criteria of a 10 percent evaluation for limited or painful motion of a major joint for the period prior to June 30, 2008. Beginning on June 30, 2008 The Veteran has been assigned a 10 percent evaluation based upon limitation of motion for the period beginning on June 30, 2008. The evaluation contemplates periarticular pathology productive of painful motion. It is also consistent with limitation of flexion to 45 degrees. In order to warrant a higher evaluation, the Veteran must have the functional equivalent of limitation of flexion to 30 degrees. See 38 C.F.R. § 4.7; DeLuca, supra. In addition, separate evaluations may be assigned for instability or subluxation, or compensable limitation of extension. In considering the foregoing criteria of Diagnostic Code 5260, there is no evidence that the Veteran demonstrated a functional restriction in flexion in excess of 45 degrees. He demonstrated some limitation of motion during VA treatment in June 2008 (with limitation of flexion to 130 degrees with pain at full flexion), during the March 2009 VA joints examination (with limitation of flexion to 115 degrees with complaints of pain with repetitive range of motion), during the December 2010 VA joints examination (with flexion to 100 degrees), and during the April 2012 VA examination (with flexion to 105 degrees with pain starting at approximately 40 degrees of flexion). Even if the Board were to accept that flexion was functionally limited to 40 degrees, such impairment would not warrant an evaluation in excess of 10 percent. See 38 C.F.R. § 4.7. While limitation of flexion fell far short of that required for a 20 percent disability rating under Diagnostic Code 5260, as the evidence shows that he retained greater remaining function than 45 degrees of flexion of the left knee, the RO assigned a 10 percent evaluation based on painful motion of the knee under 38 C.F.R. § 4.59. 38 C.F.R. § 4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. While the Veteran did not demonstrate limitation of flexion to a compensable degree under Diagnostic Code 5260, he demonstrated painful motion sufficient to grant a 10 percent evaluation under 38 C.F.R. § 4.59. In considering the foregoing criteria of Diagnostic Code 5261, the Veteran demonstrated full extension to zero degrees throughout the period on appeal, with the exception of during the April 2012 VA examination where he demonstrated overextension of the knee to -7 degrees. In VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004), the VA General Counsel clearly established that limitation of flexion and limitation of extension are to be separately rated. The rating decision on appeal is limited to discussing Diagnostic Code 5260 which does not contemplate limitation of extension under Diagnostic Code 5261. The RO could have modified the rating decision, but did not. Since extension is limited to 7 degrees, a separate 10 percent evaluation is warranted effective that date of eviodence demonstrating a marked change in the disability. April 27, 2012. See 38 C.F.R. § 4.7. The Veteran does not warrant a separate 10 percent disability rating for instability of the left knee under Diagnostic Code 5257. Diagnostic Code 5257 provides a 10 percent evaluation for slight recurrent subluxation or lateral instability. The Veteran has not asserted that he had any instability and there is no medical evidence suggesting that he had any instability during this period. In fact, the March 2009, December 2010, and April 2012 VA examiners all noted that there was no evidence of instability on examination of the left knee. Diagnostic Code 5258 provides the rating criteria for dislocation of semilunar cartilage and Diagnostic Code 5259 provides the rating criteria for symptomatic removal of semilunar cartilage. However, in a June 2008 VA treatment note, the examiner noted a stable ligamentous examination. Therefore, a separate evaluation is not warranted under Diagnostic Codes 5258 or 5259. The Board also finds that Diagnostic Code 5262 (impairment of the tibia and fibula) and Diagnostic Code 5263 (genu recurvatum) are not applicable here, as the medical evidence does not show that the Veteran has any of these disabilities. 38 C.F.R. § 4.71a, Diagnostic Codes 5262, 5263. The Board has considered the testimony and statements of the Veteran as to the extent of his current symptoms. He is certainly competent to report that his symptoms have worsened. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). In sum, the Board finds that the weight of the credible evidence demonstrates that the Veteran's service-connected left knee disability supports the criteria of a disability rating no greater than 10 percent for limitation of flexion that contemplates periarticular pathology productive of painful motion, and a separate 10 percent evaluation for limitation of extension. Extra-schedular Consideration Finally, the Board finds that the Veteran's left knee disability does not warrant referral for extra-schedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board finds that the evidence does not warrant referral of the Veteran's claim for extra-schedular consideration. The level of severity of the Veteran's left knee disability is adequately contemplated by the applicable diagnostic criteria. The criteria provide for a higher rating, but as has been thoroughly discussed above, the rating assigned herein is appropriate. In view of the adequacy of the disability rating assigned under the applicable diagnostic criteria, consideration of the second step under Thun is not for application in this case. Accordingly, the claim will not be referred for extra-schedular consideration. ORDER A 10 percent evaluation for left knee patellofemoral syndrome based on limitation of flexion, prior to June 30, 2008, is granted. An evaluation in excess of 10 percent for left knee patellofemoral syndrome based upon limitation of flexion is denied. A separate 10 percent evaluation for left knee patellofemoral syndrome based upon limitation of extension for the period beginning on April 27, 2012, is granted. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs