Citation Nr: 1314159 Decision Date: 04/29/13 Archive Date: 05/15/13 DOCKET NO. 04-19 458 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a higher evaluation for service-connected left knee chondromalacia, currently evaluated as 20 percent disabling. 2. Entitlement to a higher evaluation for service-connected left knee instability, currently evaluated as 20 percent disabling. 3. Entitlement to an effective date prior to November 25, 2009 for a separate 20 percent evaluation for left knee instability. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney at Law WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD R.N. Poulson, Counsel INTRODUCTION The Veteran served on active duty from January 1967 to January 1971 and from March 1971 to March 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which continued a 20 percent evaluation for left knee chondromalacia. In December 2006, the Board denied an evaluation in excess of 20 percent for left knee chondromalacia. The Board also granted a separate 10 percent evaluation for arthritis and instability of the left knee. The Veteran appealed the December 2006 decision to the United States Court of Appeals for Veterans Claims (Court). In January 2007, the RO assigned a 10 percent evaluation for left knee instability, effective December 8, 2003. In a January 2009 Memorandum Decision, the Court vacated the Board decision that denied a rating in excess of 20 percent for left knee chondromalacia and remanded the matter to the Board. In August 2009 and August 2010, the Board remanded the issue of entitlement to an increased rating for left knee chondromalacia for additional development. A review of the record indicates compliance with the Board's directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In May 2010, the RO increased the evaluation for left knee instability to 20 percent, effective November 25, 2009. In October 2012, the RO granted an earlier effective date of July 8, 2000 for the 10 percent evaluation for left knee instability. The Board notes that this issue was not in appellate status prior to October 2012, and the Veteran has not filed a notice of disagreement. Therefore, this claim is not on appeal. In November 2003 and July 2004, the Veteran testified at a hearing before a Decision Review Officer (DRO). Transcripts of the hearings are associated with the claims folder. FINDINGS OF FACT 1. The Veteran's left knee chondromalacia has been manifested by painful motion with functional loss equating to no worse than limitation of flexion to 30 degrees, occasional stiffness and swelling, and weakness. There is no evidence of malunion or nonunion of the left tibia. 2. The Veteran's left knee instability is no more than moderate. 3. From December 8, 2003 to November 24, 2009, the Veteran's left knee disability was manifested by extension limited to 10 degrees. 4. From November 25, 2009 to February 28, 2012, the Veteran's left knee disability was manifested by normal extension. 5. Since February 29, 2012, the Veteran's left knee disability has been manifested by extension limited to 15 degrees after repetitive testing. 6. The Veteran's claim for an increased rating for his service-connected left knee disability was received on July 20, 2001. 7. The record does not establish entitlement to a 20 percent rating for left knee instability prior to November 25, 2009. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for left knee chondromalacia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5260 (2012). 2. The criteria for a rating in excess of 20 percent for left knee instability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2012). 3. From December 8, 2003 to November 24, 2009, the criteria for a separate initial evaluation of 10 percent, but no higher, for left knee limitation of extension were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261 (2012). 4. Since February 29, 2012, the criteria for a separate initial evaluation of 20 percent, but no higher, for left knee limitation of extension have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261 (2012). 5. The criteria for an effective date prior to November 25, 2009 for the assignment of a 20 percent rating for left knee instability have not been met. 38 U.S.C.A. § 5110(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant was must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of the specific diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores, 580 F.3d at 1270. Here, a letter dated in January 2002 apprised the Veteran of what the evidence must show to establish entitlement to the benefit sought, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. A letter dated in October 2009 informed the Veteran that an increase in his left knee disability may be shown by physical and clinical evaluation results, such as range of motion tests, and statements from individuals who are able to describe from their knowledge and personal observations the manner in which the disability has worsened. A January 2007 letter notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board acknowledges that the January 2007 and October 2009 letters were furnished to the Veteran after the RO's initial adjudication of his appeal. This timing defect was cured, however, by the RO's subsequent readjudications of the Veteran's appeal and issuance of a statement of the case and multiple supplemental statements of the case, most recently in January 2013. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). Moreover, the Board finds that VA has complied with its duty to assist the Veteran in the development of his claims. VA has obtained VA and private treatment records. Although the claims file indicates that the Veteran applied for disability benefits from the Social Security Administration (SSA), those records are not in the claims file. The duty to assist extends to obtaining SSA records where they are relevant to the issue under consideration. Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010). Here, the Board finds that the SSA records are not relevant because it has not been indicated that left knee disability was the basis for any SSA claim filed by the Veteran. Specifically, December 2000 and March 2001 VA treatment records indicate that the Veteran planned to apply for SSA benefits due to a nonservice-connected right above-the-knee amputation (AKA). Furthermore, unemployability is not at issue. Additionally, pertinent VA examinations with respect to the issues on appeal were obtained in March 2002, December 2003, September 2004, November 2009, and February 2012. To that end, 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 VA examinations obtained in this case are sufficient when taken together, as they considered all of the pertinent evidence of record, including the statements of the Veteran, and provided the medical information necessary to apply the appropriate rating criteria. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. See 38 C.F.R. § 3.159(c)(4). The Veteran also was provided an opportunity to set forth his contentions during the November 2003 and July 2004 hearings before a DRO. The requirements of 38 C.F.R. § 3.103(c)(2) impose a duty on a VA hearing officer to fully explain the issues and suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that the DROs set forth the issues to be discussed at the hearing, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearings. II. Increased Schedular Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and 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. 38 C.F.R. §§ 3.102, 4.3, 4.7 (2012). In addition, the Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether or not they were raised by the veteran, as well as the entire history of the veteran's disorder in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation already has been established and an increased disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Different percentage ratings for different periods of time can be applied based on the evidence of record. Hart v. Mansfield, 21 Vet. App. 505 (2007). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. The RO granted service connection for left knee chondromalacia in July 1975 and assigned a noncompensable (zero percent) evaluation under DC 5299, effective March 22, 1975. In March 1987, the RO increased the evaluation to 10 percent and changed the DCs to 5010-5260, effective October 21, 1986. In August 2000, the RO increased the evaluation to 20 percent, effective May 9, 2000, and changed the DCs to 5010-5257. In March 2002, the RO continued the 20 percent evaluation under DCs 5010-5257. In December 2006, the Board granted a separate evaluation for arthritis and instability of the left knee. Subsequently, in January 2007, the RO awarded a 10 percent evaluation under DC 5257 and changed the left knee chondromalacia DCs to 5010-5260. In May 2010, the RO increased the evaluation of left knee instability to 20 percent under DC 5257. Although the RO has most recently listed DCs 5010-5260 for the Veteran's left knee chondromalacia, the Board has considered all potentially applicable DCs. The record contains x-ray evidence of degenerative joint disease. DC 5010 provides that arthritis that is due to trauma and substantiated by X-ray findings is to be evaluated as degenerative arthritis. DC 5003 provides that degenerative arthritis established by x-ray findings is to be evaluated on the basis of limitation of motion under the appropriate DC 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 DC, an evaluation of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups. A 20 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a, DC 5003 (2012). Lateral instability and limitation of motion of the knee may be rated separately under DCs 5257 and 5003. VAOPGCPREC 23-97 (July 1, 1997). Under DC 5257, a 10 percent evaluation is assigned for slight recurrent subluxation or lateral instability. A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability. A 30 percent disability rating is assigned under for severe recurrent subluxation or lateral instability. The average normal range of motion of the knee is zero to 140 degrees. 38 C.F.R. § 4.71a, Plate II (2012). DC 5260 addresses limitation of flexion of the leg. Flexion limited to 60 degrees warrants a noncompensable rating. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. DC 5261 addresses limitation of extension of the leg. Extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Extension limited to 45 degrees warrants a 50 percent rating. Separate ratings may be assigned under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg). VAOPGCPREC 9-2004 (Sept. 17, 2004). When rating disabilities of the joints, the degree of actual functional impairment must be considered. Factors such as pain, fatigue, lack of endurance, incoordination, and weakness are evaluated to determine the functional impact on the involved joint, particularly with repeated movements. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Historically, the Veteran was diagnosed with chondromalacia of the left knee during service. VA treatment records dated from July 2000 to September 2012, as well as several VA examinations, demonstrate that the Veteran has had ongoing treatment and evaluation for the left knee. In November 2000, the Veteran sustained a gunshot wound to the right thigh that resulted in an AKA. A skin graft was removed from the left anterior thigh at the time of the operation, and a portion of the saphenous vein in the left thigh was removed in anticipation of a vein harvest. A March 2001 VA treatment record shows that strength and motor testing of the left lower extremity were normal. In April 2001, a clinician indicated that the left knee pain was due to osteoarthritis. A May 2001 physical examination was normal. Left leg edema was noted, but it was found to be caused by the Veteran's anti-hypertensive medication. X-rays showed demineralization, but otherwise the left knee was within normal limits. The clinician diagnosed degenerative joint disease (DJD) based on pain and effusion. In June 2001, it was noted that the demineralization was probably due to inactivity. A physical examination in July 2001 was normal. A July 2001 physician statement from Dr. P.B.A. contains diagnoses of right AKA and diabetes mellitus, mild, diet controlled. He indicated that the Veteran was housebound due to the right AKA. The Veteran underwent extensive rehabilitation subsequent to the right AKA, to include physical therapy to improve the endurance of his left lower extremity. In October 2001, it was noted that the Veteran exhibited a poor gait pattern due to posture and dysfunction in the left knee. In November 2001, he reported improved endurance and strength in the left leg and more flexibility in the left knee. Flexion was within normal limits, and extension was to -6 degrees. He was issued a knee brace. A January 2002 physical therapy note indicates that the Veteran's left knee had improved and that extension was to -4 degrees. The Veteran submitted to a March 2002 VA examination. He complained of pain and slight swelling, especially when walking up stairs. He wore a brace, which seemed to help. Celebrex also helped somewhat. The examiner noted that the Veteran "has progressive pain in the knee because he has to use it since the right-sided amputation." The Veteran stated that prior to the right AKA he was employed as an electrical technician, however, he had not worked since that time. Upon physical examination, range of motion of the left knee was zero to 120 degrees. There was no fluid, laxity, or crepitus. There was slight tenderness about the left knee and slight periarticular thickening. The examiner noted that the May 2001 x-rays showed degenerative joint disease. A June 2002 VA treatment record indicates that there was a minimal loss of extension. In December 2002, the Veteran complained of "left-sided leg stiffness" with a neuropathic component, as well as left knee pain. He stated that he was independent in his activities of daily living. Upon physical examination, there was no joint stiffness or swelling. The Veteran was able to walk with his prosthesis and crutches. The left lower extremity was warm. Good +1 pulses were noted. Strength and reflex testing were normal. A February 2003 MRI revealed a small effusion and a probable horizontal tear of the posterior horn lateral meniscus. A May 2003 physical examination showed no edema and good pulses, however, trace edema of the left leg was noted in August 2003. During the November 2003 DRO hearing, the Veteran testified that his left knee had collapsed on several occasions. The Veteran submitted to a December 2003 VA examination. He claimed that the weakness in the right lower extremity had put extra strain on the previously present arthritis in the left knee. The examiner wrote: "I really don't doubt that, however, neither can I explain the tear in the lateral meniscus." He suspected left lower leg instability secondary to deconditioning and muscle atrophy. He noted that the Veteran "apparently [] remains in a wheelchair most of the time." Upon physical examination, there was extension to 10 degrees and flexion to 120 degrees. McMurray's and Lachman's testing was negative. There was no valgus or varus instability. The examiner noted that there was pain and apparently some mild fluid collection. He opined that weight shifting and exogenous obesity, plus narcotic medicine dependency, had resulted in strain on the previously service-connected left knee. The Veteran submitted to another VA examination in September 2004. He complained that his left leg seemed unstable and reported "giving way." He also reported occasional swelling. He reportedly had fallen several times, landing on his left knee. He used a wheelchair for long distances and a single crutch otherwise. The examiner noted that the Veteran's knee complaints were "just the same" since the December 2003 VA examination. He noted that use of the prosthesis had caused stress to the left knee. Upon physical examination, a small effusion was noted. Range of motion was from 10 to 120 degrees. McMurray's and Lachman's testing were negative. There was no instability upon varus and valgus testing. The examiner noted that the pain appeared to be mainly parapatellar and medial joint line. A patellar grind test was negative. X-rays showed marginal spurs. The diagnosis was minimal DJD with patellofemoral syndrome. A February 2007 VA treatment record shows that there was no change in the Veteran's DJD. In June 2007, the Veteran was in a wheelchair but indicated that he was ambulatory. In August 2007, he complained of left knee discomfort. In December 2007, he complained of left leg pain. The Veteran's DJD was found to be stable in January 2008, July 2008, and February 2009. The Veteran submitted to a November 2009 VA examination. He complained of daily intermittent left knee pain that was dependent on how much weight he put on the knee. He denied flare-ups. He reportedly caught himself from falling several times a day. He wore a knee brace. He walked with crutches and also used a wheelchair. Upon physical examination, there was no joint line tenderness or effusion. Flexion was to 110 degrees and extension was to zero degrees without pain. Lachman's and McMurray's testing were negative. There was moderate shift of the joint with valgus and varus pressure. The cruciate appeared to be intact. The examiner noted that there was instability, lack of endurance, and fatigue partly due to the amputated right leg. However, there was no change in range of motion, coordination, fatigue, endurance, or pain after repetitive testing. X-rays showed mild bicompartmental DJD with narrowing, tiny posterior patellar osteophytes, and osteoporosis. The diagnoses included left knee chondromalacia, moderate instability, and DJD. In August 2010, it was noted that the Veteran lived alone in a first floor apartment, had full ambulation, and was independent in activities of daily living. Left knee range of motion was within normal limits. No edema was noted. Pulses were well-felt. There was no joint deformity or subluxation. Left knee and ankle reflexes were 1/4. In July 2011, the Veteran reported difficulty walking upon awakening. The Veteran submitted to a February 2012 VA examination. He complained of daily pain, stiffness, instability, and decreased range of motion. He denied flare-ups. He used a wheelchair whenever he left the house. He used a brace and crutches on a constant basis for support. Upon physical examination, there was tenderness to palpation. Flexion was to 130 degrees, with pain at 110 degrees, and extension was to 10 degrees with no objective evidence of pain. Repetitive testing resulted in additional range of motion limitation, less movement than normal, excess fatigability, pain on movement, instability, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. Specifically, flexion was to 125 degrees and extension was to 15 degrees. Strength testing was normal. Lachman's and medial-lateral instability testing were 1+. Posterior instability testing was normal. There was slight patellar subluxation/dislocation. With respect to the Veteran's ability to work, the examiner noted that he could sit for 60 minutes, stand for 20 minutes, and ambulate 20 yards on his own. He could not lift and carry. He could write and type without restriction. Finally, the examiner noted that the Veteran was clinically stable. In March 2012, strength testing of the left lower extremity was normal. An August 2012 treatment record also described the Veteran's medical issues as stable. Upon review of the evidence, the Board finds that the Veteran is not entitled to a rating greater than the currently assigned 20 percent under DC 5260. On examination in November 2009, flexion was recorded to be 110 degrees. Flexion was limited to 125 degrees on account of pain on examination in February 2012. Thus, even considering the Veteran's left knee pain, he is able to achieve flexion beyond that which would be considered noncompensable under DC 5260 (flexion limited to 60 degrees). Nevertheless, it appears that the RO assigned the 20 percent rating due to moderate knee disability. The Board will not disturb this rating. Instead, the Board finds that the evidence does warrant a 20 percent rating under DC 5260 due to functional loss. The February 2012 examiner noted the following after repetitive testing: additional fatigability; instability; disturbance of locomotion; and interference with sitting, standing, and weight-bearing. From a functional standpoint, it was noted that the Veteran was unable to stand or sit for a prolonged period of time and could not lift and carry. Accordingly, even though the evidence fails to reveal that the Veteran's left knee flexion is limited to even a noncompensable degree, the Board finds the 20 percent rating for left knee chondromalacia is warranted on the factors as described in Deluca. The Board also finds that a rating in excess of 20 percent under DC 5257 is not warranted. The highest possible rating of 30 percent is applicable only where severe instability is found. While examination findings have noted instability of the Veteran's knee, it has not been characterized as severe. Indeed, the most recent examination found no instability. A 30 percent rating for instability of the knee is therefore not warranted. Finally, the Board determines that a staged rating is warranted based on limitation of extension. As noted previously, separate ratings may be assigned under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg). VAOPGCPREC 9-2004 (Sept. 17, 2004). In this regard, the Board notes that extension of the Veteran's left knee was limited to 10 degrees at the December 2003 and September 2004 VA examinations, warranting a 10 percent evaluation pursuant to DC 5261. A separate compensable evaluation is not warranted from November 25, 2009 to February 28, 2012, as extension was normal at the November 2009 examination. This finding is confirmed by the August 2010 treatment record, which also indicates that extension of the left knee was normal. However, a separate 10 percent evaluation is warranted from February 29, 2012, as extension after repetitive testing was limited to 15 degrees during the VA examination. The dates of the examination reports represent the best evidence for determining when the level of disability changed given the variable severity of the Veteran's disability. The Board notes that, because of the Veteran's dynamic symptoms, a rating stage is less than a previous stage for limitation of extension. However, because the Veteran's disability rating was never reduced below the level that was originally appealed (no separate rating), the reduction procedures of 38 C.F.R. § 3.105(e) are not for application. See O'Connell v. Nicholson, 21 Vet. App. 89, 94 (2007). The Board notes the conflicting findings with respect to objective evidence of medial joint line tenderness. See December 2003 and November 2009 VA Examination Reports. However, there has been no x-ray or MRI evidence of dislocation of semilunar cartilage such that a separate rating or higher rating under DCs 5258 and 5259 would be applicable. The remaining DCs allowing for ratings for the knees are inapplicable. DC 5256 does not apply, as the medical records do not show any finding of ankylosis in the left knee. DC 5262 for malunion of the tibia and fibula is not relevant, as X-rays show no evidence of this kind of impairment. DC 5263 is not applicable as the medical evidence does not show that the Veteran has genu recurvatum. Consideration has been given regarding whether the schedular evaluation is inadequate, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra- schedular evaluation where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating, otherwise, the schedular evaluation is adequate, and referral is not required. Id. at 116. The schedular ratings here are adequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected disorder, but the evidence reflects that those manifestations are not present in this case. The Veteran's service-connected left knee disability is contemplated and reasonably described by the rating criteria. See 38 C.F.R. § 3.321(b); Thun, 22 Vet. App. at 114. As shown in the above discussion, the Veteran's left knee disability has been manifested by pain, weakness, occasional swelling and stiffness, some limitation of motion, and instability, resulting in difficulty walking and standing for prolonged periods and difficulty lifting and carrying. The Board finds that these symptoms are contemplated under the relevant rating criteria and under the Deluca criteria, including §§ 4.40 and 4.45, which compensate for limitation of motion, and symptoms such as pain, weakness, and instability producing functional limitations. The Veteran does not have symptoms associated with this disability that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. The treatment records and VA examination reports do not reflect findings by medical professionals that indicate the Veteran's left knee disability is unusual or exceptional. Thus, the Veteran's disability picture is contemplated by the rating schedule, and no extraschedular referral is required. Finally, the Board does not find that this case raises a claim for total disability evaluation based upon individual unemployability (TDIU) due to service-connected disabilities. See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Briefly, the RO denied the Veteran's TDIU claim in September 2012 and he did not appeal. Furthermore, the record reflects that the Veteran is disabled due to the nonservice-connected right AKA. Therefore, a new claim for TDIU has not been raised. In reaching the above conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against higher or separate ratings than what has been detailed, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. 49 at 53-56. III. Effective Date Unless specifically provided in 38 U.S.C.A. § 5100 et seq., the effective date of an award of benefits based on an original claim, a claim re-opened after final disallowance, or a claim for an increase shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012). VA law and regulation provide that unless otherwise provided, the effective date of an award of increased evaluation shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application therefor. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(o)(1) (2012). The Board notes that the effective date of an award of increased compensation may, however, be established at the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application for an increased evaluation is received within one year from that date. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). In a January 2007 rating decision, the RO granted a separate 10 percent rating for instability of the left knee, effective December 8, 2003. The Veteran did not file a notice of disagreement. [The Board notes that, in October 2012, the RO granted an effective date of July 8, 2000 for the separate 10 percent rating.] In a May 2010 rating decision, the RO increased the rating of the Veteran's left knee instability to 20 percent. The Veteran seeks an effective date prior to November 25, 2009 for the separate 20 percent rating for his left knee instability. The Veteran filed his increased rating claim for left knee chondromalacia on July 20, 2001. This date is the proper date of claim for increase, which would include any separate rating for a left knee problem other than chondromalacia. However, the evidence does not show moderate left knee instability or worse prior to the November 2009 VA examination. Although the December 2003 VA examiner suspected left lower leg instability, he opined that this was secondary to deconditioning and muscle atrophy as opposed to the Veteran's service-connected left knee chondromalacia. More importantly, no valgus or varus instability was found upon physical examination. As such, the proper effective date for the separate 20 percent rating for left knee instability is November 25, 2009. See 38 C.F.R. § 3.400. The date of the examination is the best evidence for determining when it was factually ascertainable that the Veteran's instability resulted in a level of disability equating to moderate severity. There is no doubt to be resolved; and an effective date prior to November 25, 2009 is not warranted. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 53-56. ORDER An evaluation in excess of 20 percent for left knee chondromalacia rated under DC 5260 is denied. An evaluation in excess of 20 percent for left knee instability rated under DC 5257 is denied. From December 8, 2003 to November 24, 2009, a separate initial evaluation of 10 percent for left knee limitation of extension under DC 5261 is granted, subject to the laws and regulations governing the payment of monetary benefits. Since February 29, 2012, a separate initial evaluation of 20 percent for left knee limitation of extension under DC 5261 is granted, subject to the laws and regulations governing the payment of monetary benefits. An effective date prior to November 25, 2009 for the assignment of a 20 percent rating for left knee instability is denied. ____________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs