Citation Nr: 1315868 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 07-10 712 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right lower extremity disorder (claimed as a right leg disorder) as secondary to the service-connected lumbosacral degenerative disc disease. 2. Entitlement to an increased rating in excess of 20 percent for degenerative joint disease of the left knee. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to May 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which in pertinent part, determined that new and material evidence had not been submitted to reopen a claim for service connection for right leg pain and denied entitlement to an increased rating in excess of 20 percent for a left knee injury with degenerative joint disease. In a March 2011 decision, the Board remanded the claims on appeal for the RO to perform additional adjudicative action and the RO complied by completion of a March 2012 supplemental statement of the case (SSOC). The case was returned to the Board for further appellate review. In a September 2012 decision, the Board determined that new and material evidence was received to reopen the claim of entitlement to service connection for a right leg disorder and remanded the claims on appeal for additional development and adjudicative action. The case has been returned to the Board for further appellate review. In August 2007, the Veteran testified at a local hearing before a Decision Review Officer (DRO). In July 2010, the Veteran and his wife testified at a Board hearing held before the undersigned Acting Veterans Law Judge (VLJ) in Waco, Texas. A copy of each transcript is of record. Any deficiencies in development were addressed in the subsequent March 2011 and September 2012 Board remands, as discussed below. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding that the VLJ who conducts a hearing fulfill the duty to fully explain the issues and the duty to suggest the submission of evidence that may have been overlooked). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issue of entitlement to an increased rating in excess of 10 percent for lumbosacral degenerative disc disease has been raised by the Veteran in a November 2012 statement, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal has been obtained. 2. The current radiculopathy of the right lower extremity is causally related to the service-connected lumbosacral degenerative disc disease. 3. For the entire increased rating period, the service-connected degenerative joint disease of the left knee more closely approximates a manifestation of arthritis and cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a right lower extremity disorder manifested as radiculopathy as secondary to the service-connected lumbosacral degenerative disc disease have been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 2. The criteria for an increased disability rating in excess of 20 percent for degenerative joint disease of the left knee have not been met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5258 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and 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). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Given the fully favorable decision discussed below for the issue of entitlement to service connection for a right lower extremity disorder as secondary to the service-connected degenerative disc disease, the Board finds that any issue with regard to the timing or content of the VCAA notice provided to the Veteran is moot or represents harmless error. As to additional notice regarding the rating percentage and effective date to be assigned, the RO will address these matters in effectuating the award. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With regard to the issue of entitlement to an increased rating in excess of 20 percent for degenerative joint disease of the left knee, the Board finds that the VCAA notice requirements have been satisfied by a September 2006 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for an increased evaluation for his service-connected left knee disability, the evidence must show that such disability has gotten worse. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. 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. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the September 2006 letter included the type of evidence necessary to establish a disability rating and effective date. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the claims on appeal, the evidence of record includes the Veteran's service treatment records, VA outpatient treatment records, statements from the Veteran, VA examination reports dated October 2006, January 2012, and February 2013, and a February 2013 VA medical opinion. The VA examiners reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that the VA examination reports are probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Pursuant to the Board's September 2012 remand instructions, the RO sent the Veteran a November 2012 VCAA notice letter, to include information regarding what the evidence must show to establish that the claimed right leg disability was caused or aggravated by his service-connected lumbosacral spine or other service-connected disability. The letter also requested the Veteran to complete and return the enclosed VA Form 21-4142, Authorization and Consent to Release Information, for each private health care provider that has treated him for the left knee and right leg disorders so that VA can obtain treatment information. In a subsequent November 2012 statement, the Veteran reported that he has no other records than those of VA as VA has been his medical provider since 2006. Outstanding VA outpatient treatment records from January 2012 to February 2013 were also obtained and associated with the record The RO also arranged for a VA Disability Benefits Questionnaire (DBQ) examination in February 2013 and a February 2013 VA medical opinion. The examination report and medical opinion reflect that the examiner considered the evidence of record and the reported history of the Veteran, conducted a thorough examination of the Veteran, noting all findings necessary for proper adjudication of the matter, and explained the rationale for the opinion offered. Hence, the Board concludes that the February 2013 examination and February 2013 opinion are adequate and substantially complied with the September 2012 remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes); see also Dyment v. West, 13 Vet. App. 141 (1999) (a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there is substantial compliance with the Board's remand instructions). Thereafter, the RO readjudicated the claims on appeal in a March 2013 SSOC. Hence, the Board concludes that all of the September 2012 remand instructions were substantially complied and VA's duty to assist is met. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims on appeal. The evidence of record provides sufficient information to adequately evaluate the claims, all obtainable evidence identified by the Veteran relative to the claims has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims on appeal. Service Connection Laws and Regulations and Analysis for a Right Lower Extremity Disorder At the July 2010 Board hearing, the Veteran argued that his right leg disability is a result of his service-connected back disability. Under 38 C.F.R. § 3.303(a), service connection means that the facts, as shown by the evidence, establishes that a particular injury or disease was incurred coincident with service. It may be granting by affirmatively showing inception or aggravation during service. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a) (2012). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id.; see Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See 38 C.F.R. § 3.310(b) (2012); Allen v. Brown, 7 Vet. App. 439, 448 (1995); Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In making all determinations, the Board must consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed, Cir. 2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The evidence shows a current diagnosis of radiculopathy of the right lower extremity, as noted in the February 2013 VA DBQ examination report for the back. Specifically, the diagnosis was lumbar degenerative disc disease with secondary bilateral radiculopathy. The Board acknowledges it noted in the September 2012 decision that the Veteran's current diagnosis of a varus deformity of the right knee was documented in a January 2010 VA outpatient treatment record. Nevertheless, a February 2013 VA DBQ examination for the knee and lower leg documented a diagnosis of right knee degenerative joint disease and that varus deformity of the knees is "genu varus, or in lay terms, bow legged [and] is not a medical issue." As a result, the Board finds that pursuant to the Veteran's claim on appeal for a right leg disorder, not just limiting to the knee, the Board finds that the Veteran has a current disability of the right lower extremity, specifically radiculopathy. Service connection is in effect for lumbosacral degenerative disc disease, as the issue was granted in the September 2012 decision by the Board. In an October 2012 rating decision, the RO assigned a 10 percent disability rating for degenerative disc disease and degenerative joint disease of the lumbosacral spine (claimed as a low back injury). After reviewing all the evidence, the Board finds that the evidence demonstrates that the Veteran's radiculopathy of the right lower extremity is proximately due to the service-connected lumbosacral degenerative disc disease. On VA examination in February 2013, the Veteran demonstrated, in pertinent part, moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness of the right lower extremity. The examiner concluded that "[w]ith regard to the right 'leg condition' the Veteran has been complaining of bilateral pain and paresthesias of the posterior buttocks and thighs bilaterally, with paresthesias into the bilateral plantar feet. This 'leg' condition is radiculopathy from the Veteran's service-connected lumbar degenerative disease and is not a separate issue of the right knee, thigh, leg or hip." The Board finds this VA medical opinion is competent and probative medical evidence because it is factually accurate, as it appears the examining physician conducted a comprehensive in-person examination, recorded pertinent examination findings, and relied on the accurate facts. In addition, the examiner addressed the criteria required for establishing service connection on a secondary basis by providing an opinion regarding the link between the current right lower extremity disorder and the service-connected back disability. Moreover, during the pendency of this appeal, the Veteran asserted in a January 2007 notice of disagreement that he has pain in the right hip extending down the leg and tingling in the foot and that such pain the hips and legs are related to a bulging disc in his back. In a March 2006 private medical statement, Dr. P. M. reported treating the Veteran for a number of years for pain and numbness in the legs. The Board also notes that in the October 2012 rating decision, the RO granted service connection for radiculopathy of the left lower extremity as secondary to the lumbosacral degenerative disc disease assigned at 10 percent disabling. For the reasons and bases discussed above and after resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection is warranted for a right lower extremity disorder manifested by radiculopathy as secondary to the service-connected lumbosacral degenerative disc disease. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Disability Rating Legal Criteria and Analysis for Degenerative Joint Disease of the Left Knee In January 2007, the Veteran expressed disagreement with the 20 percent rating for his service-connected left knee disability. He reported having pain near the patella and when he steps on rough terrain or incline, attempts to turn and step at the same time, and squats or bends the knee. He also asserted a higher rating is warranted based on his loss of earnings from being a plumber and a school bus driver. Most recently, the Veteran noted at the July 2010 Board hearing that the left knee continues to deteriorate. Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155 (West 2002). Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2 (2012); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating, and rating disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45 (2012). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Pursuant to the rating criteria for the knee and leg, the service-connected degenerative joint disease of the left knee is rated at 20 percent disabling. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5258 (2012). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27 (2012). Arthritis, due to trauma and substantiated by x-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). Degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). When limitation of motion of the specific joint or joints involved is noncompensable, a rating of 10 percent is assigned for each major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. Diagnostic Code 5258 provides a 20 percent rating for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. In this case, the Board finds that the Veteran's service-connected degenerative joint disease of the left knee has been assigned the maximum schedular rating available under Diagnostic Codes 5010-5258. 38 C.F.R. § 4.71a. Therefore, the Board considers whether any other diagnostic codes pertaining to the knee are applicable in this case to warrant an increased rating in excess of 20 percent for the service-connected left knee disability. At the outset, the Board notes that, in a March 2013 rating decision, the RO granted service connection for left knee instability assigned at 10 percent disabling under Diagnostic Code 5257. See 38 C.F.R. § 4.71a. In an October 2012 rating decision, the RO also granted service connection for radiculopathy of the left lower extremity under Diagnostic Code 8520. See 38 C.F.R. § 4.124a. Limitation of motion for the knee is rated under Diagnostic Codes 5260 and 5261. See 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5260, flexion limited to 15 degrees warrants a 30 percent evaluation. Id. Under Diagnostic Code 5261, extension limited to 20 degrees warrants a 30 percent evaluation, extension limited to 30 degrees warrants a 40 percent evaluation, and extension limited to 45 degrees warrants a 50 percent evaluation. Id. Normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. See 38 C.F.R. § 4.71, Plate II (2012). On VA examination in February 2013, the DBQ report noted the Veteran exhibited limited left knee flexion to 130 degrees and full left knee extension to 0 degrees prior to and after repetitive use testing. On VA examination in October 2006, the Veteran exhibited limited left knee flexion to 120 degrees and full left knee extension to 0 degrees. Furthermore, review of the VA outpatient treatment records do not indicate the Veteran demonstrated limited left knee flexion to 15 degrees or less and/or limited left knee extension to 20 degrees or more. In addition, there are no objective findings of impairment of the left tibia and fibula (nonunion or malunion with marked knee or ankle disability) or ankylosis of the left knee as evidenced by the Veteran's documented movement of the left knee and review of the VA examination reports and VA outpatient treatment records. The limitation of motion of the left knee is noncompensable under Diagnostic C9de 5260. The manifestation of pain is contemplated in the 20 percent rating under Diagnostic Code 5258. As a result, a rating in excess of 20 percent under Diagnostic Codes 5260, 5261, 5262, or 5256 is not warranted. See 38 C.F.R. § 4.71a (2012). A separate rating under Diagnostic Codes 5260, 5261, 5262, or 5256 is not warranted since all compensable manifestations are contemplated by the 20 percent rating under Diagnostic Code 5258. See 38 C.F.R. § 4.71a (2012). With respect to the possibility of higher ratings under 38 C.F.R. §§ 4.40, 4.45, the Board has considered whether an evaluation in excess of 20 percent could be assigned on the basis of functional loss due to the Veteran's service-connected left knee disability. See DeLuca, 8 Vet. App. at 204-05; VAOPGCPREC 36-97, 63 Fed. Reg. 31, 262 (1998). The Board notes that the findings of record do not support an evaluation in excess of the currently assigned 20 percent due to functional loss. The Veteran's complaints of left knee pain are documented in VA outpatient treatment records. The October 2006 VA examiner reported the Veteran completed range of motion testing without pain, continued to have periodic pain and occasional swelling of the left knee, pain may occur once a month or once every week, and there is no additional limitation with flare-ups, incoordination, stability, fatigability, or lack of endurance. Most recently, the February 2013 VA examiner noted, with regard to functional impact, that the Veteran is unable to engage in prolonged standing, walking, or squatting and is able to engage in sedentary sitting employment. Residuals from the 1988 left knee joint replacement include intermediate degrees of residual weakness, pain or limitation of motion. There is tenderness or pain to palpation for joint line or soft tissues of the left knee. The Veteran does not have additional limitation in range of motion of the knee and lower leg following repetitive-use testing; however, there is functional loss and/or functional impairment on the left side to include less movement than normal, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The Veteran exhibited painful motion at 100 degrees of left knee flexion and at 0 degrees of left knee extension. The VA examiner also marked "no" for the Veteran reporting that flare-ups impact the function of the knee and/or lower leg. Furthermore, in an April 2007 substantive appeal, via a VA Form 9, the Veteran reported the following functional limitations with the left knee due to pain: repeated motion, walking for a long distance, inability to squat and stand back up, and sitting for a long period of time. At the August 2007 DRO hearing, the Veteran reiterated such limitations with the left knee and that he stopped plumbing work because of the left knee. At the July 2010 Board hearing, the Veteran testified that limitations of the left knee include pain from prolonged sitting, inability to ride bicycles or jog, and some difficulty with climbing stairs. After review of the entire disability picture of the service-connected degenerative joint disease of the left knee, the Board finds that the Veteran's degree of painful motion and functional loss due to the left knee disability is currently contemplated in the 20 percent rating and does not demonstrate that an evaluation in excess of 20 percent for the Veteran's left knee disability is warranted based on application of 38 C.F.R. §§ 4.40, 4.45, and DeLuca, 8 Vet. App. at 202. The Board has also considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, with respect to the claim as required by the Court. See Schafrath, 1 Vet. App. at 594. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign a rating higher than the currently assigned evaluation for the service-connected left knee disability on appeal for any period. The Board acknowledges that at the July 2010 Board hearing, the Veteran's wife testified that she has known the Veteran for 45 years and observed the service-connected left knee disability steadily get worse over the years and he gets up with a limp. The Board has considered the reported history of symptomatology regarding the service-connected left knee disability by the Veteran and his wife and acknowledges that they are competent to report such symptoms because this requires only personal knowledge as it comes through ones senses. Layno, 6 Vet. App. at 470. However, the Veteran and his wife are not competent to identify a specific level of the disability on appeal according to the appropriate diagnostic code. In this case, such competent evidence concerning the nature and extent of the service-connected left knee disability has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints and his wife's observations of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The issue of a total disability rating based on individual unemployability (TDIU) due to the service-connected degenerative joint disease of the left knee is currently not on appeal before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In the December 2006 rating decision, the RO denied the claim of entitlement to TDIU. The Veteran expressed disagreement in January 2007 and the RO continued the denial in a March 2007 SOC, and the Veteran withdrew from appellate status this issue in an August 2007 statement. Moreover, the Board notes that at the August 2007 DRO hearing, the Veteran testified that he was last employed as a plumber in 1995 and currently works part time as a school bus driver. Subsequently, the Veteran stated at the July 2010 Board hearing that when the bus driver job ended he started working in janitorial service, as well as, affirmed his withdrawal of this issue. An extra-schedular rating may be provided in exceptional cases. 38 C.F.R. § 3.321 (2012). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. In this case, the Board finds that the schedular rating criteria adequately contemplate and describe the symptoms and impairment caused by the service-connected left knee disability symptoms. A rating in excess of the 20 percent rating currently assigned is provided for certain manifestations of the service-connected disability at issue, but the lay and medical evidence, as discussed in detail above, reflect that those manifestations are not present in this case. Additionally, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, referral for extra-schedular consideration for the service-connected disability on appeal is not required. After a full review of the record and consideration of whether the assignment of separate ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against the Veteran's appeal for an increased rating in excess of 20 percent for degenerative joint disease of the left knee for any period. 38 C.F.R. §§ 4.3, 4.7. ORDER Service connection for a right lower extremity disorder, manifested as radiculopathy as secondary to the service-connected lumbosacral degenerative disc disease is granted. An increased rating in excess of 20 percent for degenerative joint disease of the left knee is denied. ____________________________________________ C. L. Krasinski Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs