Citation Nr: 1314449 Decision Date: 05/02/13 Archive Date: 05/15/13 DOCKET NO. 10-48 167 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for status post fasciotomy of the left calf, muscle group XI. 2. Entitlement to an initial rating in excess of 10 percent for right knee disability, status post arthroscopic meniscectomy with residual scars. ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran had active service from March 1988 to March 2008. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in August 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. In a VA Form 9 dated in June 2011, the Veteran raised the issue of entitlement to service connection for type II diabetes mellitus. This matter is REFERRED to the RO for appropriate action. FINDINGS OF FACT 1. For the period of time from April 2008 forward, the Veteran's right knee disability, status post arthroscopic surgery in October 2007, is characterized by symptoms of tenderness to pain on palpation of the joint line and soft tissue, and right knee pain on activities such as prolonged standing, walking, climbing stairs, repetitive kneeling, squatting, and running. 2. For the period of time from April 2008 forward, range of motion of the right knee is flexion to 140 degrees with onset of pain at 130 degrees, and extension to 0 degrees with no pain; there is no instability; there is some additional functional limitation due to pain, in the form of limitation of motion on repetitive use testing. 3. For the period from April 2008 forward, impairment of muscle group XI is shown, with fatigue and pain, a lowered threshold of fatigue, and impaired prolonged ambulation; however, there is normal muscle strength, and no evidence of muscle atrophy, fascial defects, or impairment of muscle tonus; and the condition does not affect the muscle substance or function. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for right knee disability are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.71a, Diagnostic Codes 5259 (2012). 2. The criteria for an initial disability rating in excess of 10 percent for status post fasciotomy of the left calf, muscle group XI, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.56, 4.73, Diagnostic Code 5311 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (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); 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 or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper 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. 38 C.F.R. § 3.159(b)(1). A May 2008 VCAA notice letter explained the evidence necessary to substantiate the claims for service connection for right knee disability and left calf disability. This letter also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In August 2008 the RO granted the Veteran's claims for left calf disability and right knee disability. The RO assigned initial noncompensable evaluations for these disabilities. This appeal arises from an August 2009 notice of disagreement with the initial ratings assigned in August 2008 for left calf and right knee disabilities. As the August 2008 rating decision on appeal granted the Veteran's claims of entitlement to service connection for left calf and right knee disability, the claims are now substantiated. As a result, the Veteran's filing of a notice of disagreement as to these determinations does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). With the grant of service connection the Veteran's claim was not only substantiated, it was proven, so that the purpose of VCAA notice, originally provided to the Veteran in May 2008, had been fulfilled. Thus no further VCAA notice was required with respect to these claims. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises upon receipt of a notice of disagreement). With regard to the duty to assist, the claims file contains service treatment records, identified records of private of private treatment, and reports of VA examinations. See 38 U.S.C.A. § 5103A(a)-(d). With respect to the adequacy of VA examinations, the Board notes that an August 2012 VA examination reflects a review of the Veteran's claims file and treatment records, includes all required findings for rating of the Veteran's right knee and left calf disabilities, and sets forth reasoned explanations for the opinions provided. The examination report is therefore adequate for adjudication of the claims on appeal. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims. Essentially, all available evidence that could substantiate the claim has been obtained. There is no indication in the claims file that there are additional available relevant records that have been identified but not yet been obtained. Law and Regulations-Ratings Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See 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. 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the severity of a particular disability it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). A claim such as this one, placed in appellate status by disagreement with the initial rating award and not yet ultimately resolved, is an original claim as opposed to a new claim for increase. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. 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. 38 C.F.R. § 4.59. When assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Right Knee Service treatment records and records of private treatment during service show that in June 2007 the Veteran was seen for pain in the right knee with no recent trauma. Private records of in-service treatment show that the Veteran was diagnosed in October 2007 by an MR arthrogram as having a tear of the posterior horn of the right knee medial meniscus. The Veteran underwent arthroscopic surgery and repair of the right knee in October 2007. As noted, the Veteran was discharged from active service in March 2008. On VA examination in May 2008, the Veteran described recurrent intermittent pain of the right knee. He stated that the pain was aching and sharp, ranging on a level of 2 to 6 on a pain scale of 1 to 10, with 10 being the highest. He indicated he usually functions without medication. On examination, range of motion of the knees was normal, zero to 140 degrees, bilaterally. After repetitive use, range of motion was not limited by pain, fatigue, weakness, lack of endurance or incoordination. There was no laxity in medial and lateral or anterior and posterior cruciate ligaments. On examination, posture and gait were normal. X-rays did not show any abnormality. There were no meniscal clicks on the right or left. The diagnosis was status postoperative arthroscopy without visible scar. At the August 2012 VA examination, the Veteran reported being limited by right knee pain in activities such as prolonged standing, walking, climbing stairs, repetitive kneeling, squatting, and running. On examination, the range of motion of the right knee on examination was as follows: 140 degrees of flexion (140 degrees is considered normal or full range of motion, see 38 C.F.R. § 4.71a, Plate II) with pain at 130 degrees, and 0 degrees of extension (0 degrees is considered normal or full range of motion, see 38 C.F.R. § 4.71a, Plate II) without pain. The examiner noted that the joint stability tests were all within normal limits for the right knee. There was tenderness to pain on palpation of the joint line and soft tissue of the right knee. There was normal muscle strength of the right knee. The examiner stated that the Veteran was able to perform repetitive-use testing with three repetitions, but that there was pain and additional limitation in range of motion of the right knee following repetitive-use testing. The examiner stated there was a meniscal tear of the right knee, status post meniscectomy, with frequent episodes of joint pain. There were no episodes of joint locking or effusion. The examiner also described three linear arthroscopy scars on the right knee, each measuring 0.7 centimeters. The scars were described as not painful, and as not resulting in limitation of function. An August 2012 report of a VA X-ray of the right knee indicated all findings to be normal. The impression was no significant findings. The August 2012 VA examiner's diagnosis was status post arthroscopic meniscectomy, right knee, with residual scars x 3. Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257, recurrent subluxation or lateral instability is rated as 10 percent disabling if slight, 20 percent disabling if moderate, and 30 percent disabling if severe. Under Diagnostic Code 5258, dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint is rated as 20 percent disabling, while under Diagnostic Code 5259, removal of cartilage with symptomatic residuals is rated as 10 percent disabling. Under Diagnostic Code 5260, limitation of flexion of the leg to 15 degrees is rated as 30 percent disabling; to 30 degrees is rated as 20 percent disabling; to 45 degrees is rated as 10 percent disabling; and to 60 degrees is rated as 0 percent disabling. Under Diagnostic Code 5261, limitation of extension of the leg to 45 degrees is rated as 50 percent disabling; to 30 degrees is rated as 40 percent disabling; to 20 degrees is rated as 30 percent disabling; to 15 degrees is rated as 20 percent disabling; to 10 degrees is rated as 10 percent disabling; and to 5 degrees or less is rated as noncompensably disabling. A veteran may receive separate ratings under Diagnostic Code 5260 (leg, limitation of flexion), and DC 5261 (leg, limitation of extension) for disability of the same joint. VAOPGCPREC 9-2004. A claimant who has arthritis and instability of the knee may be rated separately for these aspects of disability under diagnostic codes 5003 and 5257. VAOPGCPREC 23-97. The knee disability has been reclassified by the AOJ. Initially, a non-compensable evaluation was assigned under diagnostic code 5260, effective April 1. 2008. That code was amended to diagnostic code 5259 and assigned a 10 percent evaluation effective April 1, 2008. Clearly, the appellant was not prejudiced by the assignment of a higher evaluation. A 10 percent evaluation is the maximum assignable under DC 5259. That evaluation contemplates symptomatic residuals. However, a higher evaluation may be assigned if there is greater functional impairment due to limited motion. A separate evaluation may be assigned if there is instability. As the August 2012 VA examination results are generally equally or more favorable than the May 2008 VA examination results, the Board will afford the benefit of the doubt in applying the August 2012 VA examination findings to the rating criteria. Unlike that August 2012 VA examiner, the May 2008 VA examiner found that range of motion was not limited by pain after repetitive use of the right knee. The May 2008 VA examiner found no scars of the knee, but the August 2012 VA examiner found three .7 cm linear scars on the knee. The August 2012 VA examiner also noted tenderness to palpation along the joint line. The August 2012 VA examination results demonstrate that the condition is symptomatic, characterized by symptoms of tenderness or pain on palpation of the joint line and soft tissue, and right knee pain on activities such as prolonged standing, walking, climbing stairs, repetitive kneeling, squatting, and running. As shown at the August 2012 VA examination, range of motion of the right knee is flexion to 140 degrees with onset of pain at 130 degrees, and extension to 0 degrees with no pain; there is no arthritis or instability shown. The August 2012 VA examination report is based on an accurate review of the Veteran's history, review of the medical evidence in the claims file, and a physical examination of the right knee sufficient for ascertaining the level of disability as applied to the VA rating code. The examiner's findings are well-explained and consistent with other evidence of record. The findings and conclusions contained in the examination report are therefore of a very high probative weight and value. For the period of time from March 2008 forward, range of motion of the right knee is flexion to 140 degrees with onset of pain at 130 degrees, and extension to 0 degrees with no pain. Thus, the preponderance of the evidence shows that no additional or greater disability rating is warranted for limitation of extension or flexion, even with consideration of factors such as pain on motion or on repetitive use. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5260. Pain on motion is indicated to start at 130 degrees flexion, still well short of what would be required for a compensable rating for limitation of flexion. There is no limitation of extension shown. VA examination results indicate no additional functional impairment due to incoordination or fatigue. However, there is additional limitation of range of motion due to pain on repetitive testing. Still, range of motion is to 0 degrees extension and 140 degrees flexion; even taking into consideration additional functional limitation due to pain, range of motion is not shown to approximate less than 30 degrees flexion or 15 degrees extension, as would be required to warrant the next higher rating of 20 percent for limitation of extension or flexion. See 38 C.F.R. § 4.71a, Diagnostic Code 4.71a, Diagnostic Codes 5260, 5261; DeLuca v. Brown, 8 Vet. App. 202 (1995). Additionally, the preponderance of the evidence, including the August 2012 VA examination results, shows that there is no arthritis or instability of the right knee. Thus, no additional or higher rating is assignable pursuant to Diagnostic Codes 5003 (arthritis), 5010 (traumatic arthritis), or 5257 (knee, other impairment of, to include subluxation or lateral instability). Further, as the Veteran's post-surgical symptomatic right knee is best characterized as status post removal of cartilage, rather than as involving semilunar dislocated cartilage with frequent episodes of "locking," pain, and effusion into the joint, a higher rating of 20 percent pursuant to Diagnostic Code 5258 is not warranted. There is no indication either by history or examination of locking or effusion from April 1, 2008, the date of discharge from service, forward. In light of the foregoing, the Board finds that the preponderance of the evidence is against a rating in excess of the currently assigned 10 percent rating for service-connected right knee disability. For no period from April 2008 forward are the criteria for the next higher rating of 20 percent met or approximated. Thus, a "staged" rating in excess of 10 percent for right knee disability is not warranted for any period pertinent to this appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether the three linear post-surgical scars of the right knee warrant separate ratings for a tender or painful scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804. A May 2008 VA examiner found that there was no visible scar. The August 2012 VA examiner found three residual scars, each of .7 cm each and linear, but these scars were not painful or unstable, resulted in no limitation of function, and resulted in no associated other pertinent physical findings, complications, conditions, signs or symptoms. As the scars are linear and of only .7 cm each, are not tender or painful, are not unstable, and result in no functional limitation, a separate compensable rating for the scars is not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 7802-7805, as in effect prior to October 23, 2008, or under 38 C.F.R. § 4.71a, Diagnostic Codes 7802-7805, as in effect from October 23, 2008, forward. See generally Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (separate ratings may be assigned for tender and painful scars and underlying functional loss due to muscle injury). The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected right knee disability. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the Veteran has symptoms of knee pain and tenderness, with functional impairment of the right knee on activities such as prolonged standing, walking, climbing stairs, repetitive kneeling, squatting, and running. The Veteran's symptomatic right knee, status post repair by arthroscopic surgery, is contemplated in the rating schedule. There is nothing to indicate that the disability picture is exceptional or unusual. Accordingly, referral to the Director, Compensation and Pension, is not warranted. As the preponderance of the evidence is against the claim for an initial rating in excess of 10 percent for right knee disability, the benefit of the doubt doctrine is not for application. See generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Calf Service treatment records indicate that the Veteran injured his left calf during active service, in 2003, playing basketball. September 2005 records of treatment indicate re-injury with findings of mild muscle strain of the medial head of the gastrocnemius at the musculotendinous junction area. In January 2006, thickened scar tissue was excised. In September 2006 the Veteran was treated for a gastrocnemius muscle tear. A private record of in-service treatment indicates that in October 2006 the Veteran underwent a surgical exploration of the left lower extremity with release of superficial and deep posterior compartment times two to remove scar tissue and release scar tissue of the left gastrocnemius muscle complex. As noted, the Veteran was discharged from active service in March 2008. At a VA examination in May 2008, the Veteran reported that he was unable to stand for long periods of time, unable to squat and unable to run. He denied current treatment. He described constant aching and burning pain, on a level of 5 to 6 on a scale from 1 to 10, with 10 being the most pain. Examination revealed a healed 18 by 0.5 centimeter surgical scar over the posterior aspect of the left calf gastrocnemius muscle. The scar was level and non-tender. Lower extremities muscle strength was 5/5 bilaterally. Neurological examination was normal. Based on examination results, the diagnosis was status post operative fasciotomy of the left calf with residual scar. (The Board notes that although the wording of the May 2008 VA examination report indicates that the Veteran asserted he was "unable to squat or run," this is not commensurate or consistent with the severity of examination findings or other histories provided in May 2008 and August 2012. The Veteran had muscle strength of 5/5 and other relevant physical findings were negative in May 2008. The May 2008 report of examination of the right knee, which stated that the Veteran had problems with prolonged standing, walking, climbing stairs, repetitive kneeling, squatting, and running, was better articulated to indicate difficulty with running or squatting rather than inability.) The August 2012 VA examiner's diagnosis was status post fasciotomy, left calf, with residual scar x 1. The August 2012 VA examiner indicated that the Veteran has a painful surgical scar of the left calf. The Veteran stated to the examiner that the pain on palpation of the left calf surgical scar was mild. The scar was described as a linear scar of 20 cm in length. (The Board notes that in August 2012 the RO granted service connection for a residual scar of the left calf status post fasciotomy, and assigned an evaluation of 10 percent for this disability, effective from April 1, 2008. There is no indication in the claims file that the Veteran has appealed the initial rating assigned for the residual scar.) At the August 2012 VA examination, the Veteran reported having a left calf muscle tear during service, which later developed into compartment syndrome which required fasciotomy. He indicated he had pain and frequent swelling with prolonged standing and walking. On examination, there were no fascial defects, and the condition did not affect the muscle substance or function. The examiner found that the Veteran had a lowered threshold of fatigue, as well as fatigue and pain, described as consistent. There was normal muscle strength testing, with no evidence of muscle atrophy. The examiner noted that there was impaired prolonged ambulation. The diagnosis was status post fasciotomy of the left calf, involving muscle group XI. 38 C.F.R. § 4.56 provides that slight muscle disability is found where there has been a simple wound of the muscle without debridement or infection. Clinical examination would disclose the absence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue would be present. Moderate muscle disability is found where there has been a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. There must be indications of some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. Moderately severe muscle disability is found where there has been through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. There must be indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with the sound side must demonstrate positive evidence of impairment. With severe muscle disability, there is evidence of wide damage to muscle groups in the missile track. There must be indications on palpation of loss of deep fascia or muscle substance, or soft, flabby muscles in the wound area. There must be severe impairment of function, that is, strength, endurance and coordination, of the involved muscle group. In addition, X-ray evidence of minute multiple scattered foreign bodies, or visible evidence of atrophy, may indicate a severe muscle disability. 38 C.F.R. § 4.56. 38 C.F.R. § 4.73, Diagnostic Code 5311, provides that disability of the posterior and lateral crural muscles, and muscles of the calf due to a muscle injury to Muscle Group XI, is rated as noncompensable if slight, at 10 percent if moderate, at 20 percent if moderately severe, and at 30 percent if severe. The findings of the August 2012 VA examiner reflect a review of the claims file and pertinent medical evidence, a review of the history of the Veteran's disability, a detailed examination including all findings required to evaluate the disability under the appropriate rating criteria, and an explanation for all opinions provided. As a result, the findings of the August 2012 VA examiner are of a high probative weight and value. As the findings of the August 2012 VA examiner are generally equally or more favorable than those of the May 2008 VA examiner, the Board will afford the Veteran the benefit of the doubt in utilizing the results of the August 2012 VA examination in considering whether an initial rating in excess of 10 percent is warranted for disability of muscle group XI. The May 2008 VA examiner made no physical examination findings reflecting impairment of the left lower extremity. Based on the August 2012 VA examination results, for the period from April 2008 forward, impairment of muscle group XI is shown, with fatigue and pain, a lowered threshold of fatigue, and impaired prolonged ambulation. However, there is normal muscle strength; no evidence of muscle atrophy, fascial defects, or impairment of muscle tonus; and the condition was found not to affect the muscle substance or function. As a result, the preponderance of the evidence shows that the next higher rating of 20 percent for moderately severe disability of muscle group XI is not warranted. There was not a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring, or other injury of similar initial severity. There are no indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with the sound side did not demonstrate positive evidence of impairment. The impairment shown is fatigue and pain, and a lowered threshold for fatigue, as directly contemplated under the criteria for the currently assigned rating of 10 percent, corresponding to moderate muscle disability. See 38 C.F.R. §§ 4.56, 4.73, Diagnostic Code 5311. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected disability of muscle group XI. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the Veteran has symptoms of pain and fatigue and a lower threshold of fatigue, which are contemplated in the rating schedule. There is nothing to indicate that the disability picture is exceptional or unusual. Accordingly, referral to the Director, Compensation and Pension, is not warranted. In light of the foregoing, the Board finds that the preponderance of the evidence is against a rating in excess of the currently assigned 10 percent rating for service-connected disability of muscle group XI of the left lower extremity. For no period from April 2008 forward are the criteria for the next higher rating of 20 percent met or approximated. Thus, a "staged" rating in excess of 10 percent for disability of muscle group XI is not warranted for any period pertinent to this appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). As the preponderance of the evidence is against the claim for an initial rating in excess of 10 percent for status post fasciotomy of the left calf, muscle group XI, the benefit of the doubt doctrine is not for application. See generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 10 percent for status post fasciotomy of the left calf, muscle group XI, is denied. Entitlement to an initial rating in excess of 10 percent for right knee disability, status post arthroscopic meniscectomy with residual scars, is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs