Citation Nr: 1314949 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 09-41 831 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to a disability rating greater than 20 percent prior to March 9, 2013, and greater than 30 percent thereafter for a right knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from September 1961 to October 1962. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which assigned a 20 percent rating effective September 23, 2008, for the Veteran's service-connected right knee disability (which was characterized as residuals of a fractured right patella, including traumatic arthritis). In February 2013, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the RO/AMC to contact the Veteran and ask him to provide information concerning recent treatment for his service-connected right knee disability. This letter was mailed to the Veteran and his service representative later in February 2013. There is no record of a response. The Board also directed the RO/AMC to schedule the Veteran for updated VA examination which occurred in March 2013. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board notes that, in Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim cannot be considered separate and apart from an increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Instead, the Court held that a TDIU claim is an attempt to obtain an appropriate rating for a service-connected disability. The Court also found in Rice that, when entitlement to a TDIU is raised during the adjudicatory process of the underlying disability, it is part of the claim for benefits for the underlying disability. The record evidence suggests that the Veteran's service-connected right knee disability may have affected his employability. The Veteran notified VA in November 2009 correspondence that he is not seeking entitlement to a TDIU, however. Accordingly, the Board finds that a TDIU claim is not inferred from a review of the record and Rice is inapplicable to this appeal. In a Post-Remand Brief submitted to the Board in April 2013, the Veteran's service representative argued that the Veteran was entitled to a separate disability rating for his service-connected right knee disability under 38 C.F.R. § 4.71a, DC 5257. The service representative specifically contended that, because the Veteran's service-connected right knee disability had been evaluated under DC 5257 between the initial grant of service connection for this disability in 1963 and 2003 when the RO changed the DC used to evaluate it to DC 5010-5261, an evaluation under DC 5257 was "protected." The representative also argued that the RO had "severed" this rating unlawfully (without a finding of fraud) when it changed the DC used to evaluate the Veteran's service-connected right knee disability from DC 5257 to DC 5010-5261 in 2003. In advancing this argument, the representative appears to conflate the requirements for severance of service connection with a change in the DC used to evaluate a service-connected disability. The Board notes initially that, although the DC used to evaluate the Veteran's service-connected right knee disability was changed from DC 5257 to DC 5010-5261 in a March 2003 rating decision, this was based on a change in diagnosis of this disability from residuals of a fractured patella (evaluated under DC 5257 between 1963 and 2003) to residuals of a fractured patella, to include traumatic arthritis (evaluated under DC 5010-5261 since 2003). See also 38 C.F.R. § 4.27 (discussing use of diagnostic code numbers in rating disabilities). The Board also notes that, in Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011), the Federal Circuit found that, although the grant of service connection for a particular disability may be "protected" under 38 U.S.C.A. § 1159, the choice of a particular DC in evaluating a service-connected disability is not entitled to similar protection. See also Gifford v. Brown, 6 Vet. App. 269 (1994); VAOPGCPREC 50-91 (Mar. 29, 1991) and VAOPGCPREC 13-92 (June 2, 1992). Thus, the Board finds that the service representative's argument concerning a "protected" DC for the Veteran's service-connected right knee disability is without merit. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The record evidence shows that, prior to March 9, 2013, the Veteran's service-connected right knee disability was manifested by, at worst, extension limited to 15 degrees, complaints of severe pain on ambulation, flare-ups of pain on standing, walking, or walking up and down stairs relieved by rest, no joint instability, and severe tri-compartmental arthritis. 2. The record evidence shows that, since March 9, 2013, the Veteran's service-connected right knee disability is manifested by, at worst, extension limited to 20 degrees, less movement than normal, pain on movement, tenderness to palpation on the joint line or soft tissues, and no joint instability or patellar subluxation. CONCLUSION OF LAW The criteria for a disability rating greater than 20 percent prior to March 9, 2013, and greater than 30 percent thereafter for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Code (DC) 5010-5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters issued in September and October 2008, VA notified the Veteran of the information and evidence needed to substantiate and complete his claim, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence showing that his service-connected right knee disability had worsened. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board is aware of the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) in which the Court held that, for an increased-compensation claim, § 5103(a) requires, at a minimum, VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. The Veteran was provided with appropriate Vazquez-Flores notice in the October 2008 VCAA notice letter. The Veteran has not alleged that he received inadequate VCAA notice in this case. See Goodwin v. Peake, 22 Vet. App. 128 (2008) (holding as to the notice requirements for downstream earlier effective date claims following the grant of service connection: "that where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements"). The Board concludes that, because there is no indication that there exists any evidence which could be obtained to affect the outcome of this case, no additional VCAA notice is necessary. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (finding VCAA notice not required where there is no reasonable possibility that additional development will aid the Veteran). As will be explained below in greater detail, the evidence does not support granting an increased rating for a right knee disability. Because the Veteran was fully informed of the evidence needed to substantiate this claim, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The claimant also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, all of the relevant VCAA notice was issued to the Veteran and his service representative prior to the currently appealed November 2008 rating decision which denied the benefits sought on appeal; thus, this notice was timely. Because the Veteran's claim is being denied in this decision, any question as to the appropriate disability rating or effective date is moot and there can be no failure to notify the Veteran. See Dingess, 19 Vet. App. at 473. And any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board, although he declined to do so. It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed and no relevant evidence was located there. The Veteran also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. The Veteran was afforded VA examinations in October 2008 and in March 2013. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claim adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Increased Rating For A Right Knee Disability The Veteran contends that his service-connected right knee disability is more disabling than currently evaluated. He specifically contends that his right knee disability is totally disabling and prevents him from standing for more than 10 minutes at a time. Law and Regulations In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The Veteran's service-connected right knee disability currently is evaluated as 20 percent disabling effective September 23, 2008, and as 30 percent disabling effective March 9, 2013, by analogy to 38 C.F.R. § 4.71a, DC 5010-5261 (traumatic arthritis-limitation of leg extension). See 38 C.F.R. § 4.71a, DC 5010-5261 (2012). A 20 percent rating is maximum rating available under DC 5010 for traumatic arthritis manifested by x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, DC 5010 (2012). Under DC 5261, a 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A maximum 50 percent rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a, DC 5261 (2012). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2012). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40 (2012). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2012). VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the diagnostic codes; "functional loss" may occur as a result of weakness, fatigability, incoordination or pain on motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). VA must consider any part of the musculoskeletal system that becomes painful on use to be "seriously disabled." If a Veteran has separate and distinct manifestations relating to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14 (2012). Where a Veteran has a limitation of flexion and a limitation of extension, the limitations must be rated separately to adequately compensate for functional loss, which comports with the principle underlying Esteban. See VAOPGCPREC 9-2004. The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14 (2012). The Rating Schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomatology, since such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding. See Esteban, citing Brady v. Brown, 4 Vet. App. 203 (1993). VA's General Counsel has held that limitation of motion and instability of the knee involve different symptomatology and separate ratings specifically are allowed under the Rating Schedule with x-ray evidence of arthritis. See VAOPGCPREC 23-97 and VAOPGCPREC 9-98. Under 38 C.F.R. §§ 4.40 and 4.45, a Veteran's pain, swelling, weakness, and excess fatigability must be considered when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court held in DeLuca that all complaints of pain, fatigability, etc., shall be considered when put forth by a Veteran. Therefore, consistent with DeLuca and 38 C.F.R. § 4.59, the Veteran's complaints of pain have been considered in the Board's review of the diagnostic codes for limitation of motion. Factual Background The recent evidence shows that, on VA examination in October 2008, the Veteran's complaints included difficulty with his activities of daily living, to include difficulty walking, shopping, and ambulating "within the house without pain." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran rated his right knee pain as 9/10 on a pain scale (with 10/10 as the worst imaginable pain). "He uses a cane, which helps him moderately." The Veteran was able to walk "for about 15 minutes or 1-2 blocks; he does have flare-ups whenever he is standing, walking or walking up and down stairs, this makes his pain go to 10 and will be relieved with about 15 minutes of rest." He had corticosteroid injections in his right knee "about every 3 months" which helped him "moderately." Physical examination in October 2008 showed a markedly antalgic gait and he walked with a cane. Physical examination of the right knee showed a range of motion from 15 to 85 degrees with "pain in the last 5 degrees of extension" from 15 to 20 degrees of extension, no increased pain or decreased range of motion with repetitive range of motion testing, marked crepitus with range of motion, positive patella grind, 2+ joint effusion, osteophytes readily palpated "about the knee joint," "a 5 degrees varus malalignment that is not able to be passively corrected," no instability, and a positive McMurray's sign that "would be positive with the degree of the [Veteran's] arthritis and is less likely indicative of meniscal pathology." X-rays showed severe hypertrophic arthritis "in all 3 compartments." The VA examiner stated that, although it was conceivable that the Veteran's right knee pain "could further limit function...particularly after being on his feet all day," he could not express this in terms of additional limitation of motion "with any degree of medical certainty." The assessment was severe varus hypertrophic arthritis of the right knee "that is the same as severe osteoarthritis in the right knee." On private outpatient treatment in March 2009, the Veteran complained of right knee pain "which has been ongoing for many years." He described his right knee pain as "a generalized aching pain but also has episodes of sharp catching pains with transient locking. That type of pain is located centrally behind the knee cap. He reports no swelling in the knee." A history of post-traumatic arthritis and osteoarthritis of the right knee in July 2004. The Veteran reported that he was retired and his service-connected right knee disability "does not affect his ability to be retired." Physical examination showed a 2+ effusion in the right knee "along with generalized bony hypertrophy," a curved median parapatellar surgical scar "plus some arthroscopy port incision, tenderness on the medial and lateral joint lines, "moderate restriction of motion in both flexion and extension," and no McMurray's sign. X-rays of the right knee showed advanced narrowing of the lateral joint space "almost bone on bone narrowing of the medial joint space," subchondral sclerosis and irregularity of the subchondral bone, spurs on the medial and lateral aspects of the knee, an osteochondral loose body in the suprapatellar pouch, large spurs on the distal femur posteriorly, the superior and inferior poles of the patella, and the proximal tibia anteriorly and posteriorly, and "almost bone on bone narrowing of the patellofemoral space." The Veteran was advised "that the knee is really in bad enough shape to consider knee replacement arthroplasty. Arthoscopy and removal of the loose body might diminish the sharp catching pains but certainly would not make the knee asymptomatic." The Veteran received a right knee injection. The diagnoses were post-traumatic arthritis, osteoarthritis of the right knee, and a loose body in the right knee. On VA knee and lower leg Disability Benefits Questionnaire (DBQ) in March 2013, the Veteran's complaints included recurrent right knee pain. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran had received "multiple injections in the past" in his right knee. His right knee was "painful daily and all the time, especially with walking" and decreased motion while walking. A history of right knee debridement and 2 meniscectomies was noted. The Veteran used a cane constantly for ambulation. Range of motion testing of the right knee showed flexion to 80 degrees with painful motion beginning at 80 degrees and extension to 20 degrees with painful motion beginning at 20 degrees. There were no changes on extension and no additional limitation of motion following repetitive range of motion testing. Physical examination of the right knee showed less movement than normal, pain on movement, interference with sitting, standing, and weight-bearing, tenderness to palpation on the joint line or soft tissue, 5/5 muscle strength, no joint instability, no evidence or history of recurrent patellar subluxation/dislocation, no shin splints, and scars that were not painful or unstable. X-rays showed degenerative or traumatic arthritis but no evidence of patellar subluxation. The VA examiner stated that the Veteran's right knee disability was manifested by "significantly decreased" range of motion with pain/crepitance daily and severe arthritis on x-ray. This examiner also stated that the Veteran "should avoid any prolonged standing or walking." The Veteran would be able to work in sedentary employment "provided he has a proper ergonomic workspace that allows for his limited knee flexion." The VA examiner stated further: [The Veteran] currently has severe arthritis limiting his activities of daily living. He is unable to do any prolonged standing/walking, he walks with an assist[ive] device, and has continuous pain in his [right] knee. He also has marked crepitus and decreased [range of motion] in his knee. He is unable to perform any physical work. He could perform sedentary work provided he has the proper work space for his limited knee flexion and it doesn't require significant walking or prolonged standing. There would be additional limitations in walking/standing during any acute flares. The Veteran's right knee was stable and "without significant laxity." The diagnoses were patella fracture of the right knee and arthritis of the right knee. Analysis The Board finds that the preponderance of the evidence is against assigning a disability rating greater than 20 percent prior to March 9, 2013, and greater than 30 percent thereafter for a right knee disability. The Veteran has contended that his service-connected right knee disability is more disabling than currently evaluated and is, in fact, totally disabling. His assertions regarding the severity of his service-connected right knee disability are not supported by a review of the record evidence, however. The record evidence shows instead that, prior to March 9, 2013, the Veteran's service-connected right knee disability was manifested by, at worst, extension limited to 15 degrees, complaints of severe pain on ambulation, flare-ups of pain whenever standing, walking, or walking up and down stairs relieved by rest, no joint instability, and severe tri-compartmental arthritis (as seen on VA examination in October 2008). The Veteran reported at his October 2008 VA examination that he used a cane and, although he experienced flare-ups of right knee pain whenever standing, walking or walking up and down stairs, these flare-ups were relieved by resting for 15 minutes. Physical examination showed right knee extension limited to 15 degrees with no change on repetitive range of motion testing. The Veteran was diagnosed as having severe osteoarthritis of the right knee. Private outpatient treatment in March 2009 showed a moderately restricted right knee range of motion. The Veteran was advised to consider knee replacement surgery by his private treating physician in March 2009 and received a steroid injection in the right knee. The record evidence demonstrates that, prior to March 9, 2013, the Veteran's service-connected right knee disability is manifested by, at worst, extension limited to 15 degrees, complaints of severe pain on ambulation, flare-ups of pain whenever standing, walking or walking up and down stairs relieved by rest, no joint instability, and severe tri-compartmental arthritis. Although the Veteran complained of severe pain on ambulation during this time period, he also reported that his severe knee pain was relieved by resting for 15 minutes. The right knee range of motion was only moderately restricted. The evidence does not indicate that the Veteran's right knee extension was limited to 20 degrees or more (i.e., at least a 30 percent rating under DC 5010-5261) such that a disability rating greater than 20 percent prior to March 9, 2013, is warranted for the Veteran's service-connected right knee disability. See 38 C.F.R. § 4.71a, DC 5010-5261 (2012). The Veteran appears to be compensated appropriately for the level of disability that he experienced during this time period as a result of his service-connected right knee disability. He also has not identified or submitted any competent evidence demonstrating his entitlement to an increased rating for this disability prior to March 9, 2013. Nor is there record evidence demonstrating both limitation of motion and instability of the Veteran's right knee with x-ray evidence of arthritis such that a separate rating for instability are warranted; instead, the record evidence demonstrates that the Veteran's right knee was stable when it was examined during this time period. See VAOPGCPREC 23-97 and VAOPGCPREC 9-98. In summary, the Board finds that the criteria for a disability rating greater than 20 percent prior to March 9, 2013, for the Veteran's service-connected right knee disability are not met. See 38 C.F.R. § 4.71a, DC 5010-5261 (2012). The Board also finds that the preponderance of the evidence is against assigning a disability rating greater than 30 percent effective March 9, 2013, for the Veteran's service-connected right knee disability. The record does not demonstrate right knee extension limited to 30 degrees or more such that a disability rating greater than 30 percent effective March 9, 2013, is warranted for this disability. Id. The evidence shows instead that, on VA examination on March 9, 2013, the Veteran's right knee extension was limited only to 20 degrees with painful motion beginning at 20 degrees. There was no additional limitation of motion following repetitive range of motion testing. X-rays showed severe arthritis but no patellar subluxation. There also was no evidence or history of recurrent patellar subluxation/dislocation on physical examination of the Veteran's right knee. The VA examiner stated that the Veteran's right knee disability was manifested by "significantly decreased" range of motion and daily pain. The Veteran's right knee also was stable. The record evidence demonstrates that, effective March 9, 2013, the Veteran's service-connected right knee disability is manifested by, at worst, extension limited to 20 degrees, less movement than normal, pain on movement, tenderness to palpation on the joint line or soft tissues, and no joint instability or patellar subluxation. There is no evidence that the Veteran's right knee extension is limited to 30 degrees or more (i.e., at least a 40 percent rating under DC 5010-5261) such that a disability rating greater than 30 percent effective March 9, 2013, is warranted for the Veteran's service-connected right knee disability. See 38 C.F.R. § 4.71a, DC 5010-5261 (2012). The Veteran appears to be compensated appropriately for the level of disability that he has experienced since March 9, 2013, as a result of his service-connected right knee disability as the record evidence supported assigning a 30 percent rating as of that date. He has not identified or submitted any competent evidence demonstrating his entitlement to an increased rating for this disability effective March 9, 2013. Nor does the record evidence demonstrate both limitation of motion and instability of the Veteran's right knee with x-ray evidence of arthritis such that a separate rating for instability is warranted during this time period. The Board notes in this regard that the Veteran's right knee was stable when examined on March 9, 2013. See VAOPGCPREC 23-97 and VAOPGCPREC 9-98. In summary, the Board finds that the criteria for a disability rating greater than 30 percent effective March 9, 2013, for the Veteran's service-connected right knee disability also are not met. See 38 C.F.R. § 4.71a, DC 5010-5261 (2012). The Board finally finds that consideration of additional staged ratings is not warranted for the Veteran's service-connected right knee disability. As discussed above, the Veteran is compensated appropriately for the level of disability that he experiences due to his service-connected right knee disability for each of the time periods considered on appeal. And it appears that a 30 percent rating was assigned effective March 9, 2013, for the Veteran's service-connected right knee disability because of the worsening disability he experienced as of that date. Thus, consideration of additional staged ratings is not warranted. See Hart, 21 Vet. App. at 505. Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected right knee disability. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration 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. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the 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. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluations assigned for the Veteran's service-connected right knee disability are not inadequate for either of the time periods at issue in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's service-connected right knee disability. This is especially true because the 30 percent rating currently assigned for the Veteran's right knee disability effective March 9, 2013, contemplates moderately severe disability. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The Veteran reported at his VA examination in October 2008 that he was retired and his service-connected right knee disability did not affect his retirement. The March 2013 VA examiner concluded that, although the Veteran was unable to perform any physical labor due to his service-connected right knee disability, he could perform sedentary work. As noted in the Introduction, the Veteran has informed VA that he is not pursuing a TDIU claim. The Veteran also has not been hospitalized for treatment of his service-connected right knee disability at any time during this appeal. In light of the above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a disability rating greater than 20 percent prior to March 9, 2013, and greater than 30 percent thereafter for a right knee disability is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs