Citation Nr: 1315853 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 08-33 420 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for status post right total knee arthroplasty. 2. Entitlement to a disability rating in excess of 10 percent for right fifth metatarsal periostitis associated with status post right total knee arthroplasty. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at Law ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran had active service from November 1971 to October 1973. These matters came before the Board of Veterans' Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In October 2010, the Board reopened the Veteran's claims of entitlement to service connection for right and left hip disabilities and denied those claims on their merits. The Board also denied a claim of entitlement to service connection for diabetes mellitus and remanded the issues of increased ratings for status post right total knee arthroplasty and right fifth metatarsal periostitis, as well as for a total rating based on unemployability due to service-connected disability (TDIU). The Veteran appealed the Board's decision to the U.S. Court of Appeals for Veterans Claims. In June 2011 the Court granted a joint motion for partial vacatur and remand, wherein the parties requested that the Court vacate and remand the October 2010 Board decision to the extent that it denied the Veteran's claims of entitlement to service connection for right and left hip disabilities. They agreed that the Veteran expressly abandoned his claim of entitlement to service connection for diabetes mellitus; they also noted that to the extent that the Board remanded claims of entitlement to increased ratings for status post right total knee arthroplasty and right fifth metatarsal periostitis and for a TDIU, the Court had no jurisdiction. In November 2011, the Board remanded the issues of entitlement to service connection for right and left hip disabilities for further development. In a July 2012 Decision Review Officer decision, service connection was granted for right and left hip disabilities. Additionally, a TDIU was granted. As such, the appeal regarding those issues has been satisfied, and the only issues remaining before the Board are the issues of increased ratings for status post right total knee arthroplasty and right fifth metatarsal periostitis. FINDINGS OF FACT 1. Throughout the period of appeal, the Veteran's right knee condition has been manifested by no more than a limitation of flexion to 70 degrees and full extension, weakness, subjective accounts of stiffness and a limited ability to stand or walk, and no clinical findings of instability. 2. Throughout the entire period of appeal, the Veteran's right foot condition has been manifested by no more than moderate painful motion. CONCLUSIONS OF LAW 1. Throughout the period of appeal, the criteria for an evaluation in excess of 30 percent for a right knee condition have not been met. See 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5256, 5257, 5261, 5262 (2011). 2. Throughout the period of appeal, the criteria for an evaluation in excess of 10 percent for a right foot condition have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 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 representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); 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. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. In December 2007, VA advised the Veteran of the evidence necessary to support a claim for increased ratings. He was asked to submit or identify relevant evidence. The evidence of record was discussed and the Veteran was told how VA would assist him in obtaining additional pertinent evidence. This letter also advised the Veteran of the manner in which VA determines disability ratings and effective dates. The Board finds that the content of the notice fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his claim. With respect to VA's duty to assist, the Board notes that identified records have been associated with the claims file. He was afforded VA examinations during the period at issue in this decision. The Board finds that the examinations were adequate in that they were performed by a neutral skilled provider who reviewed the Veteran's pertinent history, interviewed the Veteran, and conducted a complete physical examination. Neither the Veteran nor his representative has identified any additional evidence or information which could be obtained to substantiate the claims. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that the RO has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the Veteran for the Board to proceed to a final decision in this appeal. Analysis I. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. See 38 C.F.R. Part 4 (2012). When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2012); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. See 38 C.F.R. § 4.14 (2011). In general, after the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the Board resolves the benefit of the doubt for each such issue in favor of the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). A. Right Knee In the instant case, the Veteran underwent a right knee total arthroscopy in August 2003. The present claim for an increased rating was filed in November 2005. Under diagnostic code 5055 (for knee replacement), a 100 percent disability rating applies during the one year following the implantation of a knee prosthesis. Accordingly, the Veteran received a 100 percent evaluation for each knee through July 31, 2011. Thereafter, the minimum disability rating following a knee replacement is 30 percent, and the Veteran received this minimum 30 percent rating from August 1, 2011. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain, or limitation of motion, adjudicators rate diagnostic code 5055 by analogy to diagnostic codes 5256 (knee ankylosis), 5261 (limitation of leg extension), or 5262 (impairment of the tibia and fibula). The rating schedule does not define the terms "intermediate" or "severe" as used in this diagnostic code. Instead, adjudicators must evaluate all of the evidence and render a decision that is "equitable and just." See 38 C.F.R. § 4.6 (2012). Clinicians' use of terminology such as "severe," although an element that the Board will consider, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. See 38 C.F.R. §§ 4.2, 4.6 (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. See 38 C.F.R. § 4.40 (2012). When making a rating determination, VA must consider whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2012); Johnson v. Brown, 9 Vet. App. 7, 10 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). VA's General Counsel has concluded that codes pertaining to limitation of motion and the code pertaining to instability of a knee may be rated separately; evaluation of knee dysfunction under those codes does not amount to pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97 (July 1, 1997); VAOPGCPREC 09-98 (August 14, 1998). Although diagnostic code 5055 covers a range of symptoms and manifestations of knee disability, it does not appear to contemplate subluxation or instability; thus consideration of a separate rating under diagnostic code 5257 does not violate the rule against pyramiding set forth in 38 C.F.R. § 4.14. With regard to knee instability, recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). Turning to the facts in the instant case, a VA treatment record form May 2006 contains the Veteran's complaints of joint pain, tenderness, and stiffness. The examiner indicated that the Veteran's range of motion was within normal limits. Another treatment record from April 2007 contains the Veteran's report of pain. In June 2007, the Veteran told a VA treatment provider that his right knee pain rated a 5 to 6 on a 0 (low) to 10 (high) pain scale. The Veteran was provided with a VA examination in July 2007. The examiner noted that the Veteran was able to get in and out of a chair without difficulty. The Veteran limped mainly on his right hip. The examiner observed crepitation with no swelling, heat, or tenderness. The range of motion of the right knee was from 0 degrees to 105 degrees. The examiner remarked that the knee was stable. An X-ray revealed a well-aligned total knee arthroplasty without signs of problems of loosening or malalignment. The examiner opined that the Veteran was more impaired from his back and his hip, and his right knee was well-functioning. No pain on motion, flare-ups, or instability was found. Lay statements from P.S., M.H., and O.D. received in February 2008 reflect that the Veteran complained of knee pain. On VA examination in May 2008, the Veteran mentioned that he took Darvocet and Advil for his knee pain. The examiner found that the Veteran was able to get out of a chair with difficulty. The examiner noted that the Veteran limped markedly on the right side mainly due to his right hip. There was knee swelling but no heat. The range of motion was from 0 to 102 degrees. Crepitation was observed. An X-ray revealed a total knee arthroplasty without sign of problems. No instability of the knee was found, and no flare-ups were described. Lay statements from D.R. and C.Y. received in December 2009 reflect that the Veteran experienced pain in his right knee and limped. A VA treatment record from July 2011 contains the Veteran's complains of right knee pain and stiffness. On VA examination in August 2011, the Veteran complained of right knee pain that he rated as an 8 on a 0 (low) to 10 (high) pain scale. He took Flexeril and Naproxen for his symptoms. He used a cane for ambulation. He reported that he could not mow his yard or climb a ladder. He could not squat, walk long distances, or run. He used a cane and favored his right leg. Repetitive use worsened his pain. He wore an elastic bandage but not a knee brace. The examiner noted that the right knee was slightly swollen and tender. No instability was found. Flexion was to 70 degrees with pain. Extension was to 0 degrees. With three repetitions, there was an increase in pain but no additional loss in range of motion. X-rays reportedly showed no loosening or other abnormality. Turning to the possibility of a rating in excess of 30 percent for the right knee, the Board has considered whether the Veteran is entitled to a 60 percent rating under diagnostic code 5055, which applies to chronic residuals consisting of severe painful motion or weakness in the affected extremity. In this regard, the Board has considered the argument of the Veteran's representative that the Veteran is shown by the record to experience severe weakness so as to support an award of 60 percent. Contrary to the representative's argument, however, the Board finds that the preponderance of the evidence is against such a finding. As noted above, this diagnostic code does not define the word "severe," but the Board's review of the entirety of the evidence does not support a finding of severe symptoms associated with the Veteran's right knee condition. According to the medical records, throughout the period of appeal the Veteran had flexion limited to at most 70 degrees. The Veteran had a full range of extension. Additionally, while the August 2011 VA examiner observed weakness in the Veteran's right knee, he did not describe that weakness as severe. In fact, the examiner explained that there was some weakness with repetitive use, but that this did not have any effect on range of motion. In addition, the examiner also noted that there was no additional loss of range of motion due to pain, fatigue, or incoordination following repetition, beyond the initial limitation of flexion to 70 degrees. While the Veteran has reported walking with a limp, the May 2008 VA examiner specifically noted that the limp was mainly due to his right hip disability. While the Board acknowledges the competence of the Veteran to report experiencing both weakness and flare-ups of pain, the Board places greater weight on the clinical findings of the examiners, which consistently weigh against finding of either severe painful motion or weakness. A 60 percent rating under diagnostic code 5055 is therefore unavailable. Diagnostic code 5055 also allows for a rating greater than 30 percent when the Veteran's symptoms consist of intermediate degrees of residual weakness, pain or limitation of motion. VA may then rate the disability by analogy under diagnostic code 5256 (ankylosis of the knee), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). With respect to diagnostic code 5256, ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran's disability is not analogous to ankylosis because he is able to move his right knee, albeit with a limitation of flexion to 70 degrees. With respect to diagnostic code 5261, applicable to limitation of extension, although the Veteran's knee has exhibited some limitation of flexion, the Veteran's right knee had full extension bilaterally throughout the period of appeal; the disability is not, therefore, ratable by analogy to the diagnostic code applicable to limitation of extension. With respect to diagnostic code 5262, applicable to impairment of the tibia and fibula, the Veteran's knee disability is not manifested by nonunion or malunion of the tibia and fibula. Indeed, while a higher rating of 40 percent is available under this diagnostic code based on nonunion of the tibia and fibula with loose motion requiring a brace, no such nonunion is of record. None of the examiners have observed any instability, loosening, or malalignment, and all of the VA examination reports indicate that the right knee arthroscopy is well-maintained and stable. The Board has considered lay statements of record reflecting that the Veteran wears a knee brace on occasion. However, the Board concludes that the greater weight of probative evidence is against granting a separate disability rating based on instability. As noted above, clinical stability tests of the knee have been repeatedly normal and showed no evidence of recurrent subluxation or lateral instability. The Board finds that the results of these objective examinations by competent health care providers are the most probative evidence as to whether his knee disability is manifested by instability, and greatly outweigh the Veteran's reports of wearing a knee brace. The Board has additionally considered functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. See 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. See 38 C.F.R. § 4.45 (2012). In this case, a higher rating based on functional loss is not warranted. The Veteran has complained of pain, decreased mobility, swelling, tenderness, and difficulty performing occupational and daily tasks. The Board notes, however, that the 30 percent rating already assigned under diagnostic code 5055 contemplates the potential problems associated with a total knee replacement, such as the degree of weakness and painful motion demonstrated here. Additionally, as discussed above, the Veteran has full extension and limitation of flexion to no less than 70 degrees, and the all of the VA examination reports revealed no additional limitation of motion on repetitive use that would meet the criteria for compensable ratings under diagnostic codes 5260 or 5261. The Board further finds that there have been no distinct periods during the relevant time period in which the Veteran's level of disability was more or less than the 30 percent rating discussed above. The Veteran is accordingly not entitled to receive a "staged" rating. B. Right Foot The present claim for an increased rating was filed in November 2005. Disabilities of the foot are generally evaluated under Diagnostic Codes 5276 through 5284. See 38 C.F.R. § 4.71a (2012). Diagnostic Code 5284, Foot Injuries, other, provides a 10 percent rating for moderate symptoms, a 20 percent rating for moderately severe, a 30 percent rating for severe, and a 40 percent rating for loss of use of the foot. On VA compensation and pension examination in July 2007, the examiner noted that the Veteran was able to walk heel-and-toe with some difficulty. The examiner found that the Veteran had planovalgus flat feet. Dorsiflexion was to 10 degrees, and plantar flexion was to 20 degrees. Inversion was to 15 degrees on the right, and eversion was 0 degrees. An X-ray revealed a spur on the heal which the examiner noted was an incidental finding. The diagnosis given was history of right foot pain, now asymptomatic. A November 2007 VA treatment record reflects that the Veteran had a one-month history of right foot pain. The Veteran denied experiencing swelling, erythema, or warmth. The examiner gave a diagnosis of a foot sprain. A VA treatment record from December 2007 reflects that the Veteran walked on his heel because the top of his right foot hurt. The Veteran rated his pain as a 7 on a 0 (low) to 10 (high) pain scale. He described his pain as a "throbbing, burning" type of pain. An X-ray revealed no acute fracture or dislocation. The examiner indicated that there was a pes planus deformity and a plantar calcaneal spur. A January 2008 VA treatment record indicates that the Veteran received diabetic foot care. He complained of pain on the top of his right foot that was aggravated with weight-bearing activities. A February 2008 statement from P.S. reflects that the Veteran experienced foot pain. A September 2009 letter from J.B., D.P.M., indicates that the Veteran had persistent bilateral heel pain consistent with plantar fasciitis. Letters from C.Y. and D.R. received in December 2009 reflect that the Veteran experienced right foot pain. Both individuals observed the Veteran taking off his shoes at work. On VA examination in August 2011, the Veteran complained of numbness on the bottom of his foot with burning on the top. He said that he had foot cramps at night. He was not able to walk long distances or run. The examiner found some tenderness of the ball of the foot and at the base of the fifth toe and along the fifth metatarsal. The medial arch had collapsed. The examiner found no pain on manipulation of the foot. The range of motion of the toes was deemed normal. The examiner found no weakness, instability, or evidence of abnormal weightbearing. The diagnosis given was right fifth metatarsal periostitis. The examiner related the pain and tenderness along the fifth metatarsal to the fifth metatarsal periositis. As reviewed above, the evidence of record reflects that the Veteran has received diagnoses of several different ailments of the right foot, to include pes planus and complications of diabetes. However, service connection is in effect only for fifth metatarsal periositis. As such, only the symptoms relatable to fifth metatarsal periositis should be considered in adjudicating the claim for a higher rating. In light of the above, the Board finds that the Veteran's service-connected fifth metatarsal periositis does not meet the criteria for a disability rating greater than 10 percent under Diagnostic Code 5284 because the Veteran's symptoms are not shown to be "moderately severe" so as to warrant the next higher, 20 percent rating criteria. As shown above, the July 2007 VA examiner noted that although the Veteran had difficulty walking heel-to-toe, the proper diagnosis of the Veteran's foot disorder was "history of right foot pain, now asymptomatic." Additionally, the August 2011 VA examiner found no weakness, instability, or evidence of abnormal weightbearing. The August 2011 VA examiner also observed normal ranges of motion. Likewise, it was noted that his x-rays were essentially normal, except for a finding of a heel spur that was deemed to be incidental. All of these factors indicate that the right foot strain is no more than "moderate" in severity, much less "moderately severe" or "severe." The Board acknowledges that in December 2007, the Veteran complained of throbbing and burning foot pain that rated a 7 on a 0 (low) to 10 (high) pain scale. However, the medical record reflects that at that time, the pain was relatable to pes planus and a heel spur-not the service-connected fifth metatarsal periositis. As such, this record does not support the claim for an increased rating. The Board has additionally considered the lay statements submitted which reflect that the Veteran has had to take off his shoes and rub his feet while at work. However, while these lay people are competent to observe the Veteran's complaints of pain, they have not been shown to have the expertise necessary to attribute the Veteran's foot pain to his service-connected fifth metatarsal periositis as opposed to his non-service connected complications of diabetes or pes planus. As such, these statements do not support the claim for an increased rating. With regard to Deluca considerations, while the Board acknowledges the Veteran's complaints of pain and loss of motion and function, the Board ultimately places more weight on the objective findings of the VA examiners that the Veteran experienced no functional limitations due to the service-connected fifth metatarsal periositis, his range of motion was normal, x-rays were normal, etc., based on their medical expertise. The Board has considered whether the Veteran may be entitled to a higher rating under any other diagnostic code. Diagnostic Codes 5276, 5277, 5278, 5279, 5280, 5281, 5282 and 5283 are not for application because the medical evidence does not indicate a service-connected flat foot deformity, atrophy of the musculature, disturbed circulation and weakness of the feet, claw foot, hallux rigidus, hammer toe, or malunion or nonunion of tarsal or metatarsal bones. Additionally, a higher rating is not warranted under Diagnostic Code 5003, as service-connected arthritis has not been established by X-ray findings. The Board adds that no limitation of motion is shown. In summary, the Board finds that the preponderance of the evidence is against granting a disability rating in excess of 10 percent for the Veteran's service-connected right fifth metatarsal periositis; the assignment of staged ratings is not for application. C. Extra-Schedular Considerations In addition, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In Thun v. Peake, the Court set forth a three-step inquiry to determine a veteran's entitlement to an extra-schedular rating. See 22 Vet. App. 111 (2008). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. In this case, it is not necessary to go any further than the first step of the Thun analysis. The rating criteria employed for evaluating both of the Veteran's disorders are not inadequate, and it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorders considered in this decision that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disabilities considered in this decision are adequate. Referral for extra-schedular consideration is not warranted. Further inquiry into extra-schedular consideration is moot. See Thun, supra. ORDER Entitlement to a disability rating in excess of 30 percent for status post right total knee arthroplasty is denied. Entitlement to a disability rating in excess of 10 percent for right fifth metatarsal periostitis associated with status post right total knee arthroplasty is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs