Citation Nr: 1315833 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 05-18 682 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an increased evaluation for left knee strain, currently evaluated as 10 percent disabling from February 27, 2002 to February 11, 2009, and in excess of 10 percent since April 1, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R.N. Poulson, Counsel INTRODUCTION The Veteran served on active duty from February 1976 to January 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2004 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which continued a noncompensable disability rating for service-connected left knee pain. Subsequently, in April 2005, the RO characterized the disability as left knee strain and increased the evaluation to 10 percent, effective February 27, 2002. In October 2009, the RO characterized the disability as left knee pain, status post partial medial meniscectomy and superficial chondroplasty of medial femoral condyle, and continued the 10 percent evaluation. In April 2009, the Board denied entitlement to a rating in excess of 10 percent for left knee strain. The Veteran subsequently submitted a Notice of Appeal to the United States Court of Appeals for Veterans Claims (Court), indicating his disagreement with the denial of his claim. The Court issued a December 2009 Order vacating the April 2009 Board decision and remanding the appeal for readjudication consistent with the parties' Joint Motion for Remand (JMR). This matter was subsequently remanded by the Board for further development in March 2010, November 2010, June 2011, January 2012, and August 2012. As will be discussed in further detail below, the Board is satisfied that the terms of its prior remands have been complied with; thus, it may proceed with a decision at this time. See Stegall v. West, 11 Vet. App. 268 (1998). In May 2009, the RO granted entitlement to a temporary total evaluation, from February 11, 2009 to March 31, 2009, under 38 C.F.R. § 4.30 for convalescence purposes associated with left knee surgery. Additionally, in May 2012, the Appeals Management Center (AMC) granted direct service connection for a torn meniscus of the left knee and assigned a 20 percent evaluation, effective February 27, 2002. The Veteran did not file a notice of disagreement (NOD) with respect to either claim. Accordingly, these matters (to include entitlement to a separate scar rating) are not in appellate status at this time. FINDING OF FACT Left knee strain is manifested by limitation of flexion to no worse than 55 degrees in supine position and 60 degrees in a standing position, normal extension, and constant pain with occasional additional pain after repeated motion; but no convincing evidence of subluxation, instability, dislocation of semilunar cartilage, genu recurvatum, impairment of the tibia or fibula, or ankylosis. CONCLUSION OF LAW The criteria for an evaluation in excess of 10 percent for left knee strain from February 27, 2002 to February 11, 2009, and in excess of 10 percent since April 1, 2009 have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5003, 5256 - 5263 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist 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 v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). A letter dated in May 2004 informed the Veteran that an increase in his left knee disability may be shown by doctor statements, physical and clinical evaluation results, and statements from individuals who are able to describe from their knowledge and personal observations the manner in which the disability has worsened. Also, a March 2006 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). Although the March 2006 letter was provided after the initial adjudication, the Veteran has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. The claim was subsequently readjudicated in several supplemental statements of the case, most recently in January 2013. The Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claim. The evidence includes VA examination reports, VA and private treatment records, and lay statements. He has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration (SSA). See 38 C.F.R. § 3.159 (c) (2). There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was afforded VA examinations to evaluate the severity of his left knee symptomatology in July 2004, December 2007, June 2010 (with an addendum obtained in December 2010), August 2011, February 2012, and September 2012 (with an addendum obtained in January 2013). The Veteran's representative has indicated that the September 2012 opinion and January 2013 addendum are inadequate. See March 2013 and June 2012 Post-Remand Briefs. Specifically, he contends that the VA examiner failed to reconcile conflicting examination findings in the June 2010 and August 2011 VA examination reports. He further contends that the February 2012 clinician previously treated the Veteran after his September 1997 discharge, which is in conflict with the Board's January 2012 Remand Order. The Board finds that the examinations were adequate as they fully address the rating criteria. See 38 C.F.R. § 3.326 (2012); Barr v. Nicholson, 21 Vet. App. 303, 311 (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Importantly, the Board may presume that VA medical staff competently discharged their duties. See Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir 2009) (confirming that the presumption of regularity does not only apply to procedural matters, but also applies to the competency of medical professionals). Thus, the Board may presume that the VA examiners accurately transcribed the Veteran's assertions. In any event, the Veteran's representative's contentions are moot in light of the RO's May 2012 grant of direct service connection for a torn meniscus of the left knee. Furthermore, the Veteran has not asserted, and the evidence does not indicate, that his symptoms have materially increased in severity since the September 2012 evaluation. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board accordingly finds that the examiners' opinions are supported by adequate rationales and also comply with the terms of the Board's prior remands. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall, supra. In addition, the Veteran has further been given the opportunity to submit evidence, and he has provided written argument in support of his claim. The Veteran has not identified, and the record does not indicate, existing records pertinent to the claim decided herein that need to be obtained. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Increased Rating Disability evaluations are determined by comparing a Veteran's present symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where entitlement to compensation has already been established, the United States Court of Appeals for Veterans Claims has held that consideration of the appropriateness of a staged rating is required. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). In September 1997, the RO granted service connection for history of left knee pain and assigned an initial noncompensable evaluation under DC 5257, effective February 1, 1997. The noncompensable evaluation was continued by March 2000 and August 2004 rating decisions. In April 2005, the RO characterized the disability as left knee strain and increased the evaluation to 10 percent under DCs 5299-5260, effective February 27, 2002. In October 2009, the RO characterized the disability as left knee pain, status post partial medial meniscectomy and superficial chrondroplasty of medial femoral condyle, and continued the 10 percent evaluation under DCs 5299-5260. In May 2012, the RO granted service connection for torn meniscus, left knee, and assigned a 10 percent evaluation under DC 5258, effective February 27, 2002. DC 5003 (for impairment resulting from degenerative arthritis) provides that, when the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. See 38 C.F.R. § 4.71a, DC 5003. In the absence of limitation of motion, a 20 percent evaluation is granted where X-ray evidence shows involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Id. The average normal range of motion of the knee is 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II. DC 5261 addresses limitation of extension of the leg. Extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 5 degrees warrants a noncompensable 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. 38 C.F.R. § 4.71a, DC 5261. 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. 38 C.F.R. § 4.71a, DC 5260. 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. Lateral instability and limitation of motion of the knee may be rated separately under DCs 5257 and 5003. VAOPGCPREC 23-97. 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. 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; DeLuca v. Brown, 8 Vet. App. 202, (1995). April 2003 VA treatment records indicate that the Veteran complained of knee pain. He denied popping, locking, or swelling. He reportedly walked four miles each day. There was slight tenderness on the medial side and full range of motion. X-rays were normal. The assessment was left knee pain. In May 2003, the Veteran reported buckling after standing for long periods of time. He also complained of recent swelling. Ambulation and range of motion were both normal. No crepitus was noted, but there was mild edema surrounding the knee. There was no atrophy of the quadricep muscle. The impression was knee pain secondary to probable patella malalignment versus early osteoarthritis. In January 2004, the Veteran complained of pain, popping, swelling, and reduced mobility. No edema was noted, but there was swelling and tenderness with reduced range of motion. The assessment was left knee pain. A February 2004 MRI revealed a ruptured semi-membranous muscle, effusion, a healed fracture to the anterior tibial tubercle, and no internal derangement. An addendum noted that the most medial aspect of the semi-membranous muscle was still attached to the tendon. In March 2004, the Veteran reported swelling and giving way. No effusion was noted. There was some tenderness at the medial hamstrings above the joint line. The tibial tubercle was prominent, but not tender. There was flexion to 120 degrees with no instability. The impression was weakness in the left knee. The clinician prescribed physical therapy. The Veteran submitted to a July 2004 VA joints examination. It was noted that a February 2004 MRI revealed a ruptured semi membranous muscle, effusion, and heel fracture to the anterior tibial tubercle with no internal derangement of the knee. The Veteran reported a sharp pain in his knee, which increased with cold weather or prolonged standing or walking. He reported that the knee would sometimes lock and give way. Upon examination, the Veteran was tender medially and laterally on palpation of the patellae. The Veteran reported that it was too painful to have range of motion testing, McMurray's testing, or ligament testing of his left knee. X-rays were normal. The diagnosis was chronic knee strain. A November 2004 VA treatment record shows that the Veteran continued to complain of swelling and occasional giving way. The diagnosis was weakness of the left knee. No edema was noted upon examination in May 2006. February 2007 X-rays were normal. A December 2007 private treatment record contains a diagnosis of osteoarthritis. The Veteran submitted to another VA joints examination in December 2007. He reported problems with buckling and cramps around his knee; pain on both sides of the knee, as well as swelling after prolonged standing; and daily pain that was increased by walking up or down stairs. He indicated that his knee felt stiff and weak and would pop. He wore a knee brace at his job with the United States Postal Service (USPS). An antalgic gait was noted upon examination, but this was felt to be secondary to right knee problems. The left knee was tender with mild effusion and soft tissue swelling. In the supine position, flexion of the knee was 0 to 55 degrees with pain. In the standing position, flexion of the knee was 0 to 104 degrees. Following repetitive movements, left knee flexion decreased to 98 degrees. McMurray's sign was negative and there was no increase in laxity. No instability was noted. X-rays showed a nonfused ossification center involving the anterior tibial tuberosity, which was considered a developmental abnormality. The Veteran was diagnosed with the residuals of a left knee strain, and a partial rupture of the semi membranous muscle and joint effusion. The examiner was unable to determine the specific occupational impact of the left knee because the Veteran had back and right knee problems as well. An April 2008 VA examination with respect to the Veteran's right knee included range of motion testing of the left knee. Flexion was to 135 degrees, and extension was to 0 degrees. An April 2008 private treatment record shows that neurological testing of the Veteran's left knee was normal. In July 2008, the Veteran related that his job at the USPS required prolonged standing and walking. In January 2009, the Veteran complained of left knee pain and swelling. He denied any locking or collapsing. A January 22, 2009 private treatment record shows that the Veteran reported sharp left knee pain that was exacerbated by prolonged walking and standing activities. He ambulated with a left antalgic gait. There was a small effusion with no overlying erythema or increased skin temperature. There was full extension and 130 degrees of flexion. There was marked tenderness over the anterior medial joint line. McMurray's testing was positive. There was atrophy of the quadriceps muscle. There was no finding of instability at that time. The impression was left knee pain and effusion, rule out inflammatory process versus internal derangement. A January 27, 2009 MRI revealed osteoarthritis, tearing of the posterior horn of the medical meniscus, infrapatella ossicle, and a Baker's cyst. A January 29, 2009 private treatment record shows trace effusion. There was full extension and 130 degrees of flexion. There was also marked tenderness and a positive McMurray's sign along the medial joint line. The impression was medial meniscal tear. In February 2009, the Veteran underwent a partial medial meniscectomy and superficial chondroplasty of the medial femoral condyle. Private treatment records indicate that the Veteran returned to work in April 2009, but continued to complain of instability and pain. He reportedly was having a hard time standing at work. It was noted that he had made some gains in strength, but continued to be dependent on a knee brace. In May 2009, persistent left knee swelling was noted; fluid was drained from the knee and a cyst was aspirated. In June 2009, there was full extension and flexion to 125 degrees; the Veteran reported that he was "having problems getting through his work shift due to the pain and edema." A June 2009 VA treatment record shows that there was decreased range of motion in the left knee. In October 2009, the Veteran was diagnosed with degenerative joint disease. As instructed by the March 2010 Remand Order, the Veteran submitted to a VA joints examination in June 2010. He complained of giving way, instability, pain, stiffness, weakness, and effusion. He was able to stand more than one hour, but less than three hours. He could walk one-quarter of a mile. He reported intermittent, but frequent, use of a knee brace. He had not lost any time from work during the last 12 months. Upon physical examination, it was noted that the Veteran's gait was antalgic. Flexion was to 60 degrees. Extension was to 0 degrees. There was no objective evidence of pain and no additional limitations following repetitive motion. There was no joint ankylosis. The diagnosis was osteoarthritis, tearing of the posterior horn of the medical meniscus, infrapatellar ossicle, and Baker's cyst. The examiner noted that there were significant effects on the Veteran's occupation, namely decreased mobility and pain. The examiner opined that it is "less likely as not" that the Veteran's meniscus tear was caused by or a result of the service-connected left knee strain. She noted that if the meniscus tear had occurred 20 years ago, more aggressive treatment would have been necessary. She also noted that the Veteran's occupation required standing for long hours, something the Veteran would be unable to do if he had a meniscus tear that was 20 years old. The examiner emphasized that the left knee meniscus tear and the left knee strain were separate entities. In a December 2010 addendum, the June 2010 examiner reviewed the claims file and reiterated her opinion that the left knee meniscus tear "is less likely as not" caused by or a result of the service-connected left knee strain. She did not, as instructed by the November 2010 Remand Order, opine as to which of the Veteran's left knee symptoms were related to his service-connected left knee strain and which were related to his service-connected meniscal tear. As instructed by the Court's June 2011 Remand Order, the Veteran submitted to another VA joints examination in August 2011. He related that he had injured his left knee at work three years earlier and had undergone surgery with nine weeks of physical therapy. He complained of current knee pain that he rated 8/10. He reportedly had lost one week of work in the last 12 months due to left knee pain. The Veteran was able to stand 20 minutes and walk for five minutes. He was unable to run. He had a friend help with cooking and cleaning. He wore a knee brace. Upon physical examination, no effusion was noted. The patella looked normal. There was no fatigue, weakness, or instability. Flexion was to 100 degrees, and extension was to 0 degrees. Repetitive activity precipitated mild spasm, but range of motion remained the same. There was no evidence of weakened movement, incoordination, excess fatigability, or instability. The examiner noted that June 2011 X-rays revealed old stable tibial tubercle separations with otherwise normal knees that was unchanged from 2007. In an addendum dated later that month, the examiner reviewed the claims file and opined that the meniscal tear "is less likely as not" related to the service-connected left knee strain. She reasoned that the left knee strain occurred many years ago and would have healed, and that the Veteran's job at the USPS "might have put additional pressure on his meniscus." An August 2011 VA physical therapy records show that strength in the Veteran's left quadriceps and hamstring was 3+ and 3, respectively. He reportedly was able to walk more than 500 feet without an assistance device. The left knee continued to swell each day after standing eight hours at work. However, it was noted that the Veteran's baseline measures had improved. As instructed by the January 2012 Remand Order, the Veteran submitted to another VA joints examination in February 2012. At that time, he complained of a sharp throbbing pain in his left knee that occurred with prolonged standing, sitting, and sleeping in an awkward position. At times, his knee buckled and swelled, especially after increased activity. He could manage most distances by walking slowly. He denied the use of an assistive device. Upon physical examination, extension was to 0 degrees and flexion was to 120 degrees. There was no increased pain or loss of function after repetitive testing. There was no evidence of recurrent subluxation or lateral instability. There was also no anterior/posterior instability or medial instability. There was some tenderness medially more so than laterally. There was also tenderness over the tibial tuberosity and some evidence of joint effusion. McMurray's testing was negative. The scarring from the surgery, which was barely visible, was well healed and nontender. Crepitus was noted on passive motion, and patellofemoral compression caused pain. The examiner diagnosed status post arthroscopic repair of a meniscal tear and Osgood-Schlatter disease. He concluded that the Veteran's left knee condition was secondary to the arthroscopic repair of a meniscal tear, which in turn was secondary to the knee strain. He opined that "it is at least likely as not" that the Veteran's current knee symptoms are related to his service-connected left knee strain and left meniscal tear. As instructed by the August 2012 Remand Order, the Veteran submitted to yet another VA joints examination in September 2012. He complained of daily left knee pain since the previous VA examination. He denied having flare-ups. He regularly used a knee brace. The examiner wrote: "It is unclear why he requires a left brace. His 9/6/12 VA prosthetics visit notes that he was given a brace 'to be afforded a considerable sense of stability.'" Flexion was to 120 degrees, and extension was to 0 degrees. There was no change in range of motion after repetitive testing. There was, however, functional loss. Specifically, the examiner noted that there was "pain on movement." There was no tenderness or pain on palpation. Strength and stability testing were normal. There was no evidence of recurrent patellar subluxation or dislocation. There were no symptoms associated with the Veteran's meniscal tear or the meniscectomy. The examiner reviewed the claims file, to include private and VA orthopedic records, the February 2009 arthroscopic surgery report, and post-operative examinations. She noted that after the surgery the Veteran had full extension and 125 degrees flexion. In a January 2013 addendum, the examiner opined that the Veteran's current left knee disability "was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service event." She noted that the orthopedic records showed a good result from the 2009 arthroscopic surgery, and that she had not identified weakened movement, excess fatigue, instability, or incoordination during the September 2012 examination. Specifically, she noted that there was no effusion. She opined that the current symptoms in the Veteran's left knee "are more likely than not" due to the effects of aging. Based on a careful review of the evidence, the Board has determined that the Veteran is not entitled to a rating greater than 10 percent under DC 5261, based upon an analysis of the recorded ranges of motion. The Board has considered whether a separate compensable rating based on limitation of flexion under DC 5260 is warranted. See VAOPGCPREC 9-2004. Flexion has been limited to no worse than 55 degrees in a supine position and 60 degrees in a standing position. These measurements do not even warrant a compensable rating for limitation of flexion under DC 5260, as flexion limited to 60 degrees warrants a 0 percent rating. Moreover, these range of motion findings occurred on two isolated occasions over a period of several years. The remainder findings of flexion range from 100 to 135 degrees, the most recent finding being 120 degrees. The Veteran has been diagnosed by X-ray with osteoarthritis and degenerative joint disease. However, the medical evidence of record does not demonstrate incapacitating episodes as a result of the Veteran's service-connected left knee strain. Accordingly, the next higher rating of 20 percent under DC 5003 based on an absence of limitation of motion is not warranted. In addition, the Board has considered whether the Veteran is entitled to a separate compensable rating under DC 5257. See VAOPGCPREC 23-97. The Veteran has complained repeatedly that his left knee gives out. However, the objective clinical evidence does not support his claim. The Veteran's left knee has repeatedly been found to be stable upon physical examination. Stability of a knee joint can be identified by objective testing and to the extent the Veteran is competent to comment on stability of the knee joint, his statements are contradicted by objective testing and are not credible. In light of the findings of normal stability of the left knee, a separate compensable evaluation based on any instability of that joint is not warranted. 38 C.F.R. § 4.71a, DC 5257. 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. With regard to establishing loss of function due to pain, it is necessary that complaints be supported by adequate pathology and be evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. The December 2007 VA examination report reflects objective evidence of pain on motion. The August 2011 VA examination report indicates that there was mild spasm with repetitive use, but no further limitation of motion. There was some functional loss upon repetitive use noted in September 2012, but no further limitation of motion and the Veteran denied flare-ups of pain. The effects of pain due to the service-connected left knee strain are contemplated in the currently assigned 10 percent evaluation. There is no indication that pain, due to left knee strain, causes functional loss greater than that contemplated by the evaluation assigned. See 38 C.F.R. § 4.40. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. The Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's description of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In light of the holding in Hart, the Board has considered whether the Veteran is entitled to additional "staged" ratings. Based upon the record, the Board concludes that at no time during the appeal period has this disability been more disabling than as currently rated. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for an increased evaluation from February 27, 2002 to February 11, 2009, and in excess of 10 percent since April 1, 2009. Consideration has also been given regarding whether the schedular evaluations are 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). 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 Board has considered all left knee symptoms in rendering this decision. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The schedular evaluation in this case is adequate. Ratings in excess of that assigned are provided for certain manifestations of the service-connected disorder, but the medical evidence reflects that those manifestations are not present in this case. The criteria fully address and consider the signs and symptoms complained of by the Veteran and reported clinically. This includes consideration of the impact of pain, weakness, fatigue, lack of endurance, and incoordination in measuring the degree of actual functional impairment, including on flexion. The criteria also provide higher levels of compensation for symptomatology worse than that currently manifested. The Veteran has not been hospitalized for treatment for his service-connected left knee strain. The Board acknowledges that the Veteran reportedly missed one week of work in 2011 because of left knee pain. However, this evidence does not rise to the level of marked interference with employment solely due to the service-connected left knee strain. Therefore, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. As the Schedule is adequate, no further discussion of extraschedular evaluation under 38 C.F.R. § 3.321(b) is necessary. Moreover, the Board has considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) is present here. None of the VA examination reports show that the Veteran is unemployable solely due to his left knee strain. During the August 2011 VA examination, the Veteran reported that he had missed one week of work the previous year because of left knee pain. However, he has continued to work at the USPS. Therefore, any inferred TDIU claim is inapplicable in this case. ORDER Entitlement to an evaluation in excess of 10 percent for left knee strain from February 27, 2002 to February 11, 2009, and in excess of 10 percent since April 1, 2009 is denied. ____________________________________________ J.A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs