Citation Nr: 1316006 Decision Date: 05/15/13 Archive Date: 05/29/13 DOCKET NO. 08-01 241 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an initial disability rating for right wrist carpal tunnel syndrome in excess of 10 percent prior to February 29, 2012. 2. Entitlement to an initial disability rating for right wrist carpal tunnel syndrome in excess of 30 percent as of February 29, 2012. 3. Entitlement to an initial disability rating for left sciatic neuropathy in excess of 10 percent prior to February 29, 2012. 4. Entitlement to an initial disability rating for left sciatic neuropathy in excess of 20 percent as of February 29, 2012. 5. Entitlement to an initial disability rating in excess of 20 percent for intervertebral disc syndrome with scar. 6. Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD) with scars, status post Nissen fundoplication. 7. Entitlement to an initial disability rating in excess of 10 percent for right knee osteoarthritis with scars. 8. Entitlement to an initial disability rating in excess of 10 percent for left knee osteoarthritis. 9. Entitlement to an initial disability rating in excess of 10 percent for left shoulder degenerative joint disease with scar. 10. Entitlement to an initial disability rating in excess of 10 percent for right sciatic neuropathy. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran served on active duty from August 1984 to December 1984, from June 1985 to November 1987, and from September 1989 to December 2006. He served in Kuwait from March 7, 2003 to October 16, 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, which granted the Veteran's claims of service connection for (1) right wrist carpal tunnel syndrome, and assigned a 10 percent rating; (2) lumbar spine degenerative disc disease status post L4-5 diskectomy and partial hemilaminectomy, later rated as intervertebral disc syndrome with scar, and assigned a 10 percent rating; (3) GERD status post Nissen fundoplication, and assigned a noncompensable rating; (4) right knee status post partial medial meniscectomy with patella femoral syndrome, later rated as right knee osteoarthritis with scars, and assigned a 10 percent rating; (5) left knee patella femoral syndrome, later rated as left knee osteoarthritis, and assigned a noncompensable rating; and (6) left shoulder degenerative joint disease, later rated as left shoulder degenerative joint disease with scars, and assigned a 10 percent rating. All claims for service connection granted in the June 2007 rating decision were assigned an effective date of January 1, 2007-the day after the Veteran's separation from active service. In a July 2009 rating decision, the RO (1) increased the Veteran's rating for GERD with scars, status post Nissen fundoplication, from noncompensable to 10 percent, effective January 1, 2007; (2) increased his rating for intervertebral disc syndrome with scar from 10 to 20 percent, effective January 1, 2007; (3) increased his rating for left knee osteoarthritis from noncompensable to 10 percent, effective January 1, 2007; (4) granted service connection for left sciatic neuropathy and assigned a 10 percent rating effective June 6, 2008; and (5) granted service connection for right sciatic neuropathy and assigned a 10 percent rating effective June 6, 2008. In a July 2012 rating decision, the RO (1) increased the Veteran's rating for right wrist carpal tunnel syndrome from 10 to 30 percent, effective February 29, 2012; (2) increased his rating for left sciatic neuropathy from 10 to 20 percent, effective February 29, 2012; and (3) continued his 10 percent rating for left shoulder degenerative joint disease with scar. The issues of entitlement to service connection for a right hip strain and entitlement to service connection for residuals of a right ankle fracture were granted by the RO in a July 2012 rating decision prior to adjudication by the Board. As such are complete grants of the benefits sought on appeal, those issues are no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The Veteran originally requested a Board hearing in his January 2008 substantive appeal; however, in a November 2012 statement, he withdrew this request. The request for a Board is thus deemed withdrawn. 38 C.F.R. § 20.704(e). In January 2013, the Veteran submitted additional evidence with a waiver of Agency of Original Jurisdiction (AOJ) consideration. 38 C.F.R. § 20.1304(c) (2012). Therefore, the Board may properly consider such newly received evidence. The issues of (1) entitlement to service connection for hypertensive kidney disease, to include as secondary to hypertension, and (2) entitlement to service connection for hypogonadism have been raised by the record-see Veteran's November 2012 statement-but have not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of entitlement to an initial disability rating in excess of 10 percent for left shoulder degenerative joint disease with scar is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the appellate period, the Veteran's right wrist carpal tunnel syndrome is characterized by pain, numbness, tingling, weakness, and no more than moderate incomplete paralysis of the right median nerve. 2. Prior to February 29, 2012, the Veteran's left sciatic neuropathy is characterized by numbness and by mild incomplete paralysis of the sciatic nerve. 3. As of February 29, 2012, the Veteran's left sciatic neuropathy is characterized by numbness and by moderate incomplete paralysis of the sciatic nerve. 4. The Veteran's right sciatic neuropathy is characterized by numbness and pain, and by mild incomplete paralysis of the sciatic nerve. 5. The Veteran's intervertebral disc syndrome with scar is characterized by forward flexion of the thoracolumbar spine as low as 50 degrees, with no ankylosis and no incapacitating episodes over the past 12 months. The Veteran's low back scar is not painful, unstable, or due to burns; is linear; and does not result in limitation of function or impact the Veteran's ability to work. 6. The Veteran's GERD with scars, status post Nissen fundoplication is characterized by slowness in the emptying of his stomach, dysphagia, regurgitation, nausea and vomiting. The Veteran's five abdominal scars range from 1.5 cm by 0.5 cm to 1 cm by 0.5 cm; include no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation or edema; and do not result in limitation of function or impact the Veteran's ability to work. 7. The Veteran's right knee osteoarthritis with scar has been productive of pain with extension to 0 degrees and flexion to no less than 110 degrees including on repetition, without clinical evidence of ankylosis; his right knee surgical scar is not tender and does not result in limitation of function or impact his ability to work. 8. The Veteran's left knee is not tender, and his osteoarthritis has been productive of pain with extension to 0 degrees and flexion to no less than 88 degrees including on repetition, without clinical evidence of ankylosis. CONCLUSIONS OF LAW 1. For the period from January 1, 2007, to February 28, 2012, the criteria for an initial 30 percent disability evaluation, and no higher, for right wrist carpal tunnel syndrome have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.124a Diagnostic Code (DC) 8515 (2012). 2. As of February 29, 2012, the criteria for an initial disability rating in excess of 30 percent for right wrist carpal tunnel syndrome have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.124a Diagnostic Code (DC) 8515 (2012). 3. For the period from June 6, 2008 to February 28, 2012, the criteria for an initial disability rating in excess of 10 percent for left sciatic neuropathy have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.124a Diagnostic Code (DC) 8520 (2012). 4. As of February 29, 2012, the criteria for an initial disability rating in excess of 20 percent for left sciatic neuropathy have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.124a Diagnostic Code (DC) 8520 (2012). 5. The criteria for an initial disability rating in excess of 10 percent for right sciatic neuropathy have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.124a Diagnostic Code (DC) 8520 (2012). 6. The criteria for an initial disability rating in excess of 20 percent for intervertebral disc syndrome with scar have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a Diagnostic Code (DC) 5243 (2012). 7. The criteria for an initial disability rating in excess of 10 percent for GERD with scars, status post Nissen fundoplication have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.114 Diagnostic Code (DC) 7346 (2012). 8. The criteria for an initial disability rating in excess of 10 percent for right knee osteoarthritis with scars have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a Diagnostic Code (DC) 5010-5260 (2012). 9. The criteria for an initial disability rating in excess of 10 percent for left knee osteoarthritis have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a Diagnostic Code (DC) 5010-5260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). These claims arise from a disagreement with the initial disability ratings that were assigned following the grants of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. The Veteran has been provided with adequate VA examinations in connection with his present claims, including most recently in February 2012. To the extent that the Veteran found flaws in prior examination reports, these have been cured by the February 2012 VA examination. He has not indicated that there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Analysis Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations. 38 U.S.C.A. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged ratings" is required. Fenderson v. West 12 Vet. App. 119, 126 (1999). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board notes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the veteran's relevant medical history, his current 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). As an initial matter, the Board notes that the Veteran reported at his February 2012 VA examination that his right hand is his dominant, or major, hand. Right Wrist Carpal Tunnel Syndrome The Veteran contends in his January 2008 substantive appeal that his right wrist carpal tunnel syndrome includes crepitus. The RO has evaluated the Veteran's right wrist carpal tunnel syndrome under 38 C.F.R. § 4.124a, Diagnostic Code 8515 at 10 percent from January 1, 2007-the day after his separation from service-and at 30 percent as of February 29, 2012-the date of his most recent VA examination. Under 38 C.F.R. § 4.124a, Diagnostic Code 8515, a 70 percent rating is warranted for complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand ("ape hand"); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. A 50 percent rating is warranted for severe incomplete paralysis of the median nerve. A 30 percent rating is warranted for moderate incomplete paralysis of the median nerve. A 10 percent rating is warranted for mild incomplete paralysis of the median nerve. At his March 2007 VA examination, the Veteran reported experiencing pain and numbness in his right wrist, and decreased physical activity; he also reported that there was no incapacitation. The VA examiner found signs of crepitus. Right wrist x-ray findings were within normal limits. The examiner diagnosed carpal tunnel syndrome, but did not directly address the severity of the incomplete paralysis of the median nerve. At his June 2008 VA examination, the Veteran reported experiencing tingling and numbness of the fingers at the fingertips in four digits daily, including when his hand is above his waist or heart, which can slow his work. The VA examiner found that the Veteran's right hand strength is within normal limits. Tinel's sign was present/positive. Phalen's test was negative. The examiner diagnosed carpal tunnel syndrome, but did not directly address the severity of the incomplete paralysis of the median nerve. At his August 2009 VA examination, the Veteran reported having constant tingling, numbness, and weakness of the fingers-including while grasping, leading to dropping things at times. The VA examiner found that Tinel's sign was present, and Phalen's test was positive. The examiner diagnosed carpal tunnel syndrome, but did not directly address the severity of the incomplete paralysis of the median nerve. At the February 2012 VA examination, the examiner found that the Veteran's constant right upper extremity pain was mild, his intermittent right upper extremity pain was mild, his right upper extremity paresthesias and/or dysthesias were moderate, and his right upper extremity numbness was moderate. His muscle strength testing in the right wrist was normal (5/5). There was no muscle atrophy. Sensory examination of the right hand and fingers was normal. Tinel's sign was positive. Phalen's sign was positive. The VA examiner diagnosed the Veteran with carpal tunnel syndrome and found that he has moderate incomplete paralysis of the right median nerve. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that a 30 percent rating for right wrist carpal tunnel syndrome under 38 C.F.R. § 4.124a, Diagnostic Code 8515, is warranted throughout the appellate period-i.e., since January 1, 2007. Significantly, the February 2012 VA examination report is the first one in which the examiner directly addressed the severity of the incomplete paralysis of the Veteran's right median nerve. Moreover, the Veteran's descriptions of his right wrist symptoms throughout the appeal are consistent with a finding of moderate incomplete paralysis. The Board further finds that a rating in excess of 30 percent is not warranted because the Veteran's symptoms more nearly approximate the criteria for a 30 percent rating. Specifically, no findings of severe incomplete paralysis or complete paralysis of the right median nerve are of record. Moreover, the Veteran's descriptions of his pain, numbness, tingling, and weakness, are not consistent with severe incomplete paralysis or complete paralysis of the right median nerve. Similarly, his descriptions of the impact on his life and work, including decreased physical activity, slowing down at work, and dropping things at times, are likewise inconsistent with severe incomplete paralysis or complete paralysis of the right median nerve. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's right wrist carpal tunnel syndrome, including moderate incomplete paralysis of the right median nerve. The rating criteria are therefore adequate to evaluate the right wrist carpal tunnel syndrome and referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's disabilities, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, although the Veteran reported some slowing of his work at his June 2008 VA examination, there is no indication that this rose to the level of marked interference; rather, the Veteran explained that if he puts his hand below the level of his waist for one minute, he could resume his work. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. Left and Right Sciatic Neuropathy The Veteran contends in his August 2007 notice of disagreement that he has sciatic pain on his right side. In his January 2008 substantive appeal, the Veteran reported that he has to bend to the left or right to have the nerve move in order to avoid additional numbness in his legs. The RO has evaluated the Veteran's left and right sciatic neuropathy under 38 C.F.R. § 4.124a, Diagnostic Code 8520. For the left sciatic neuropathy, the RO granted service connection and assigned a 10 percent disability rating from June 6, 2008-the date of a VA examination-and assigned a 20 percent disability rating as of February 29, 2012-the date of a subsequent VA examination. For the right sciatic neuropathy, the RO granted service connection and assigned a 10 percent disability rating from June 6, 2008. The Board notes that the Veteran's left and right sciatic neuropathy disabilities were not filed as a separate claim for service connection; rather, the RO granted service connection because the June 2008 VA examiner found that the Veteran's left and right sciatic neuropathy were complications of his service-connected intervertebral disc syndrome. Under 38 C.F.R. § 4.124a, Diagnostic Code 8520, an 80 percent rating is warranted for complete paralysis of the sciatic nerve, wherein the foot dangles and drops, no active movement of muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. A 60 percent rating is warranted for severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy. A 40 percent rating is warranted for moderately severe incomplete paralysis of the sciatic nerve. A 20 percent rating is warranted for moderate incomplete paralysis of the sciatic nerve. A 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve. Under 38 C.F.R. § 4.124, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. At his March 2007 VA examination, the Veteran reported that his spine condition did not cause any pain symptom. However, the VA examiner referenced subjective evidence of pain in his diagnosis of the Veteran's laminectomy/discectomy. The Veteran had positive straight leg raising tests bilaterally. The VA examiner found no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. The VA examiner did not diagnose sciatic neuropathy. At his June 2008 VA examination, the Veteran reported experiencing burning, aching, and sticking lumbar spine pain that travels to the right and left sides. He stated that the aches and pain slow his activity levels. The VA examiner found a sensory deficit of bilateral dorsal feet and bilateral lateral feet at L5, and a sensory deficit of bilateral back of the thighs, bilateral lateral legs and bilateral lateral feet at S1. The examiner found neuralgia of the sciatic nerves bilaterally, with sensory dysfunction demonstrated by decreased sensation in the lower legs and ankles, but no motor dysfunction. The examiner did not directly address the severity of the neuralgia of the sciatic nerve. At his August 2009 VA examination, the Veteran reported experiencing mild pain coming from his lumbar spine. The VA examiner found no evidence of radiating pain on movement of the thoracolumbar spine. Straight leg raising tests were negative bilaterally. The examiner found no sensory deficits from L1-L5, no sensory deficits of S1, and no signs of Lumbar Intervertebral Disc Syndrome with chronic and permanent nerve root involvement. The VA examiner did not diagnose sciatic neuropathy. At the February 2012 VA examination, the examiner found that the Veteran's constant bilateral lower extremity pain was mild, his intermittent bilateral lower extremity pain was mild, his bilateral lower extremity paresthesias and/or dysthesias were moderate, and his bilateral lower extremity numbness was moderate. The VA examiner found that the Veteran's left sciatic nerve has moderate incomplete paralysis, and that his right sciatic nerve is normal (i.e., has neither incomplete nor complete paralysis). After reviewing all of the clinical evidence and subjective complaints, the Board finds that the effective date of the grant of service connection-June 6, 2008-is consistent with the initial finding of objective evidence of a sciatic nerve disorder, in this case by the VA examiner. Although the Board acknowledges that the Veteran reported having sciatic pain on his right side in his August 2007 notice of disagreement and numbness in his legs in his January 2008 substantive appeal, the Veteran had also previously denied having signs of chronic and permanent nerve root involvement at his March 2007 VA examination. Therefore, the Veteran's report of sciatic pain on the right side prior to June 6, 2008 is not credible, and the June 6, 2008 effective date of service connection is warranted. As a finder of fact, when considering whether lay evidence is credible, the Board may properly consider the internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Board further finds that ratings in excess of 10 percent prior to February 29, 2012, and in excess of 20 percent as of that date, for left sciatic neuropathy are not warranted under 38 C.F.R. § 4.124a, Diagnostic Code 8520. A rating in excess of 10 percent prior to February 29, 2012 is not warranted because that date was the first on which moderate incomplete paralysis of the left sciatic nerve was found. Moreover, in the most recent prior examination, in August 2009, the VA examiner had found no sensory deficits from L1-L5, no sensory deficits of S1, and no signs of Lumbar Intervertebral Disc Syndrome with chronic and permanent nerve root involvement. Furthermore, the June 2008 VA examiner had characterized the Veteran's sciatic nerve disability as neuralgia, and had not stated the level of severity. The Board finds that the VA examiners' descriptions of the Veteran's disability, when considered with the Veteran's descriptions of pain and numbness, more nearly approximate mild incomplete paralysis of the left sciatic nerve for the appellate period prior to February 29, 2012. A rating in excess of 20 percent as of February 29, 2012 for left sciatic neuropathy is not warranted because the most probative evidence of record, the February 2012 VA examination report, includes the examiner's finding that the Veteran's left sciatic nerve has moderate incomplete paralysis. A rating in excess of 10 percent for right sciatic neuropathy is not warranted because the June 2008 VA examiner had characterized the Veteran's sciatic nerve disability as neuralgia, and had not stated the level of severity; the August 2009 VA examiner had found no sensory deficits from L1-L5, no sensory deficits of S1, and no signs of Lumbar Intervertebral Disc Syndrome with chronic and permanent nerve root involvement; and the February 2012 VA examiner found that the Veteran's right sciatic nerve is normal. The Board finds that the VA examiners' descriptions of the Veteran's disability, when considered with the Veteran's descriptions of pain and numbness, more nearly approximate mild incomplete paralysis of the right sciatic nerve. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321; Thun, supra. Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's left and right sciatic neuropathy, including incomplete paralysis of the sciatic nerve. The rating criteria are therefore adequate to evaluate the sciatic neuropathy and referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's disabilities, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, although the Veteran reported some pain and numbness radiating to his legs, there is no indication that this rose to the level of marked interference with employment. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. Intervertebral Disc Syndrome with Scar The Veteran contends in his January 2008 substantive appeal that his back has myopathy, swelling, tenderness, and cramping. He reported that he can no longer do squats or run without causing more damage. The RO has evaluated the Veteran's intervertebral disc syndrome with scar under 38 C.F.R. § 4.71a, Diagnostic Code 5243 at 20 percent. Under 38 C.F.R. § 4.71a, there are several diagnostic codes that may potentially be employed to evaluate impairment resulting from service-connected back disorders. Diagnostic Codes 5003 and 5010, for evaluation of degenerative and traumatic arthritic changes, are applicable to the back. 38 C.F.R. § 4.71a, DCs 5003, 5010. Diagnostic Code 5010 applies to traumatic arthritis and provides that such is evaluated under the criteria for 38 C.F.R. § 4.71a, DC 5003. Diagnostic Code 5003 provides that degenerative arthritis is to be rated on the basis of limitation of motion of the affected joint under the appropriate diagnostic code for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint group or minor joint group affected by limitation of motion. In the absence of limitation of motion, a 20 percent evaluation is provided where there is X-ray evidence of involvement of two or more major joints, or two of more minor joint groups with occasional incapacitating exacerbations. A 10 percent evaluation is provided where there is X-ray evidence of involvement of two or more major joints, or two of more minor joint groups without exacerbations. 38 C.F.R. § 4.71a, DCs 5003, 5010 (2012). A lumbar spine disability may be rated pursuant to the general rating formula for diseases and injuries of the spine set forth in DCs 5235-5242. Under the general rating formula, a 20 percent rating requires forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires that the condition be manifested by forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating requires unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a, Note 2. Intervertebral Disc Syndrome is rated under Diagnostic Code 5243, based upon the frequency of incapacitating episodes. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Intervertebral disc syndrome is evaluated either on the total duration of incapacitating episodes over the past twelve months, or by combining under 38 C.F.R. § 4.25 separate ratings of its chronic orthopedic and neurologic manifestations along with rating of all other disabilities, whichever method results in the higher rating. A 20 percent rating applies where there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating applies where there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating applies where there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. At his March 2007 VA examination, the Veteran reported experiencing constant stiffness and weakness in his spine. He reported that in the past year he had no incidents of incapacitation, although he had some incapacitation before the appellate period. The Veteran reported that his functional impairment is decreased physical activity. The VA examiner found lumbar spine range of motion (ROM) to include flexion to 75 degrees, with pain at 75 degrees; extension to 22 degrees, with pain at 22 degrees; right lateral flexion to 22 degrees, with pain at 22 degrees; left lateral flexion to 24 degrees, with pain at 24 degrees; right rotation to 26 degrees, with pain at 26 degrees; and left rotation to 26 degrees, with pain at 26 degrees. Other than pain, the examiner found no other factors which additionally limited motion, and that pain limited motion by 0 degrees. A lumbar spine x-ray showed degenerative arthritis. The VA examiner diagnosed the Veteran with laminectomy/discectomy, degenerative disc disease, osteoarthritis, and a scar. With respect to the low back scar, the examiner found that it measured about 2 cm by 1 cm, and included no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation or edema. At his June 2008 VA examination, the Veteran reported experiencing stiffness, weakness, numbness, and pain in his spine, as well as slowed activity levels due to aches and pain. The VA examiner found tenderness in the Veteran's low back. There was no ankylosis of the lumbar spine. The examiner found thoracolumbar spine ROM to include flexion to 50 degrees, with pain at 50 degrees; extension to 15 degrees, with pain at 15 degrees; right lateral flexion to 15 degrees, with pain at 15 degrees; left lateral flexion to 15 degrees, with pain at 15 degrees; right rotation to 15 degrees, with pain at 15 degrees; and left rotation to 15 degrees, with pain at 15 degrees. Other than pain, the examiner found no other factors which additionally limited motion, and that pain limited motion by 0 degrees. The VA examiner diagnosed the Veteran with status post hemilaminectomy and discectomy with residuals of scar, and intervertebral disc syndrome (IVDS). In an addendum, the examiner clarified that his diagnosis was a progression of the established diagnosis. With respect to the low back scar, the examiner found that it measured about 5.5 cm by 1 cm, and included no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation or edema. At his August 2009 VA examination, the Veteran reported experiencing stiffness, weakness, and pain. The Veteran denied any incapacitation. The examiner found thoracolumbar spine ROM to include flexion to 77 degrees, with pain at 77 degrees; extension to 22 degrees, with pain at 22 degrees; right lateral flexion to 30 degrees, with pain at 30 degrees; left lateral flexion to 30 degrees, with pain at 30 degrees; right rotation to 30 degrees, with pain at 30 degrees; and left rotation to 30 degrees, with pain at 30 degrees. There was no additional limitation by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The VA examiner diagnosed the Veteran with degenerative arthritis of the lumbar spine. At the February 2012 VA examination, the Veteran reported that he had not had any incapacitating episodes over the past 12 months due to IVDS. The examiner found that the Veteran's ROM included flexion to 80 degrees, with pain at 80 degrees; extension to 20 degrees, with pain at 20 degrees; right lateral flexion to 20 degrees, with pain at 20 degrees; left lateral flexion to 20 degrees, with pain at 20 degrees; right rotation to 20 degrees, with pain at 20 degrees; and left rotation to 20 degrees, with pain at 20 degrees, including after repetitive testing. The Veteran's functional loss or impairment included less movement than normal and pain on movement after repetitive use. The VA examiner diagnosed the Veteran with status post lumbar laminectomy with scar, multilevel degenerative disc and facet disease of the lumbar spine, and IVDS of the lumbosacral spine. The examiner found that the functional impact of the Veteran's back disability was that he does not stand for long periods of time. With respect to the low back scar, the examiner found that it was not painful, unstable, or due to burns; it measured at 4 cm, and was linear. The examiner found that the scar does not result in limitation of function or impact the Veteran's ability to work. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that the preponderance of the evidence shows that an initial disability evaluation in excess of 20 percent for the Veteran's lumbar spine disability with scar is not warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5243. A rating in excess of 20 percent is not warranted under the General Rating Formula for Diseases and Injuries of the Spine because the Veteran does not have forward flexion of the thoracolumbar spine to 30 degrees or less, or ankylosis of any kind. The Veteran's worst forward flexion of the thoracolumbar spine during the appellate period was to 50 degrees, and the June 2008 VA examiner expressly found that the Veteran has no ankylosis of the lumbar spine. A rating in excess of 20 percent is also not warranted under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes because the Veteran did not have incapacitating episodes having a total duration of 4 weeks or more during the past 12 months at any time during the appellate period. Specifically, at the February 2012 VA examination the Veteran reported that he had not had any incapacitating episodes over the past 12 months due to IVDS; at the August 2009 examination he denied any incapacitation; and at the March 2007 VA examination he reported that in the past year he had no incidents of incapacitation. With respect to the Veteran's low back scar, the Board finds that a separate compensable rating is not warranted because, as the February 2012 VA examiner ascertained, it is not painful, unstable, or due to burns; is linear; and does not result in limitation of function or impact the Veteran's ability to work. Additionally, the Veteran's scar was not found to be tender. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321; Thun, supra. Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's back disability, including limitation of motion. The rating criteria are therefore adequate to evaluate the IVDS and referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's disabilities, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, although the Veteran reported some myopathy, swelling, tenderness, and cramping, there is no indication that this rose to the level of marked interference with employment. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. GERD with Scars status post Nissen Fundoplication The Veteran contends in his August 2007 notice of disagreement that his GERD symptoms include elongated emptying time, dysphagia (difficulty swallowing), and regurgitation. In his January 2008 substantive appeal, the Veteran reported that he is status post Nissen fundoplication, but still has slowness in the emptying of his stomach, dysphagia, and regurgitation. The RO has evaluated the Veteran's GERD with scars status post Nissen fundoplication under 38 C.F.R. § 4.114, Diagnostic Code 7346, at 10 percent. Under 38 C.F.R. § 4.114, Diagnostic Code 7346, a 60 percent rating is warranted for a hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis (vomiting of blood) or melena (black, tarry feces associated with gastrointestinal hemorrhage) with moderate anemia (a decreased number of red blood cells); or other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted for a hiatal hernia with persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation, of less severity. At his March 2007 VA examination, the Veteran reported that his GERD with Nissen fundoplication does not affect his body weight. He reported having dysphagia intermittently, as often as 2 times a week with each occurrence lasting 4 hours, and 100 attacks in the past year. There was no functional impairment resulting from the Veteran's GERD. An upper gastrointestinal (GI) series showed esophageal motility disturbance with relative lack of primary and secondary stripping waves. The VA examiner diagnosed the Veteran with GERD, resolved status post Nissen fundoplication. The subjective factor was reflux. The examiner found that the hiatus hernia/GERD does not cause malnutrition or significant anemia. At his June 2008 VA examination, the Veteran reported that his GERD does not affect his body weight. He reported having dysphagia and slow emptying time, with meals taking longer to digest. The VA examiner diagnosed the Veteran as status post laparoscopic surgery of Nissen procedure with residual of scars, with no anemia and no findings of malnutrition. With respect to scars, the examiner found five abdominal scars, ranging from 1.5 cm by 0.5 cm, to 1 cm by 0.5 cm. The scars included no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation or edema. At his February 2012 VA examination, the examiner found that the Veteran had reflux, nausea, and vomiting; the Veteran did not have persistently recurring or infrequent episodes of gastric distress, dysphagia, pyrosis, regurgitation, substernal arm or shoulder pain, sleep disturbance caused by esophageal reflux, anemia, weight loss, hematemesis, or melena. The examiner found that the Veteran did not have esophageal stricture, spasm of the esophagus, or acquired diverticulum of the esophagus. The VA examiner diagnosed the Veteran with GERD, and found that it does not impact his ability to work. Another February 2012 VA examiner found that the Veteran had three scars located in his upper and mid abdomen from Nissen surgery for GERD, measuring 2 cm, 1 cm, and 1 cm; the examiner found that the scars do not result in limitation of function or impact the Veteran's ability to work. The Veteran's scars were not found to be tender. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that the preponderance of the evidence shows that an initial disability evaluation in excess of 10 percent for the Veteran's GERD with scars status post Nissen fundoplication is not warranted under 38 C.F.R. § 4.114, Diagnostic Code 7346. A 60 percent rating is not warranted because, as the February 2012 VA examiner expressly found, the Veteran does not have symptoms of material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Although the February 2012 VA examiner noted that the Veteran had vomiting associated with his GERD, the Board finds that the Veteran's overall symptoms do not more nearly approximate the 60 percent rating criteria, particularly in light of the February 2012 VA examiner's finding that the Veteran's GERD does not impact his ability to work, and the March 2007 VA examiner's finding that there is no functional impairment resulting from the Veteran's GERD. Similarly, a 30 percent rating is not warranted because, as the examiner expressly found, the Veteran does not have persistently recurring or infrequent episodes of gastric distress, pyrosis, or substernal or arm or shoulder pain, productive of considerable impairment of health. Although the Veteran has previously reported experiencing dysphagia and regurgitation, the Board finds that his reported symptoms more nearly approximate the criteria for a 10 percent disability rating because they represent two of the symptoms for the 30 percent evaluation. Furthermore, based on the February 2012 and March 2007 VA examiners' determinations that the Veteran's GERD does not impact his ability to work or cause functional impairment, the Board finds that these symptoms are of less severity, as contemplated by the criteria for a 10 percent rating. With respect to the Veteran's scars resulting from GERD, the Board finds that a separate compensable rating is not warranted because, as the February 2012 VA examiner ascertained, the scars do not result in limitation of function or impact the Veteran's ability to work. The Veteran has not reported a limitation of function or impact on his ability to work due to his abdominal scars. Additionally, the Veteran's scars were not found to be tender. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321; Thun, supra. Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's GERD status post Nissen fundoplication with scars, including dysphagia, vomiting, and regurgitation. The rating criteria are therefore adequate to evaluate the GERD and referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's disabilities, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, although the Veteran reported some slowness in the emptying of his stomach, there is no indication that this rose to the level of marked interference with employment. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. Right Knee Osteoarthritis with Scars and Left Knee Osteoarthritis The Veteran contends in his August 2007 notice of disagreement that his bilateral knee diagnosis includes patella femoral syndrome with crepitus. He reported experiencing pain when sitting cross-legged or bending for long periods, and aching when running. He explained that he uses the joint lubricant Synvisc, which is not a steroid. In his January 2008 substantive appeal, the Veteran reported that he has continual pain with soreness, daily fatigue, and very loud crepitus in his knees. The RO has evaluated the Veteran's right knee osteoarthritis with scars, and left knee osteoarthritis, under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260, and assigned separate 10 percent ratings for each knee. Under 38 C.F.R. § 4.71a, there are several diagnostic codes that may potentially be employed to evaluate impairment resulting from service-connected knee disorders. Diagnostic Codes (DCs) 5003 and 5010, for evaluation of degenerative and traumatic arthritic changes, are applicable to the knee. 38 C.F.R. § 4.71a, DCs 5003, 5010. Diagnostic Code (DC) 5010 applies to traumatic arthritis and provides that such is evaluated under the criteria for 38 C.F.R. § 4.71a, DC 5003. These diagnostic codes are discussed in greater detail above. Knee impairment with recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight; a 20 percent evaluation if it is moderate; or, a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, DC 5257. Limitation of flexion of a leg warrants a noncompensable evaluation when flexion is limited to 60 degrees. A 10 percent evaluation is appropriate if flexion is limited to 45 degrees and a 20 percent evaluation is assigned if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees is evaluated as 30 percent disabling. 38 C.F.R. § 4.71a, DC 5260. Limitation of extension of a leg is noncompensable when extension is limited to 5 degrees. A 10 percent evaluation is warranted with extension limited to 10 degrees and a 20 percent evaluation when it is limited to 15 degrees. 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. Additional rating criteria are found under DCs 5256 (ankylosis of the knee), DC 5258 (which provides for a 20 percent rating for dislocated, semilunar cartilage with frequent episodes of locking, pain and effusion into the joint), 5259 (which provides for a 10 percent rating for symptomatic removal of the semilunar cartilage), and 5262 (impairment of the tibia and fibula). VA's General Counsel has clarified that for a knee disability rated under DC 5257 or DC 5259 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable, but must at least meet the criteria for a zero-percent rating under those codes. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59 and DC 5003. VAOPGCPREC 9-98 (1998). VA's General Counsel has more recently held that separate ratings are also available for limitation of flexion and limitation of extension under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The knee is considered a major joint. 38 C.F.R. § 4.45(f) (2012). At his March 2007 VA examination, the Veteran reported experiencing weakness, stiffness, swelling, giving way, lack of endurance, and fatigability in his knees with activity. He also reported experiencing constant localized burning, aching, sharp, sticking, and cramping pain in his knees. The Veteran reported that his bilateral knee disorder is not incapacitating, but does cause difficulty running and decreased physical activity. The VA examiner found crepitus bilaterally, but no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, subluxation, or guarding of movement. The examiner found that both knees had flexion to 140 degrees and extension to 0 degrees, with no additional limitation from pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Testing of the stability of the anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, and the medial and lateral menisci bilaterally was within normal limits. Bilateral knee x-ray findings were within normal limits. The VA examiner diagnosed the Veteran with bilateral patella femoral syndrome, and with status post medial meniscectomy on the right knee. In January 2008, a private radiologist, F. Al-Refai, found that x-rays of the Veteran's right knee showed mild narrowing of the patellofemoral joint space. At his June 2008 VA examination, the Veteran reported experiencing weakness, stiffness, giving way, lack of endurance, and fatigability in his left knee. He also reported having pain, soreness, aches, stiffness, decrepitated noise and a popping sound in his left knee. He denied experiencing swelling, heat, redness, locking, or dislocation, and reported that he does not experience any functional impairment from this condition in his left knee. In his right knee, the Veteran reported experiencing weakness, stiffness, swelling, fatigability, decrepitation, and popping. He also reported having aching and sticking pain and soreness in his right knee. He denied experiencing heat, redness, giving way, lack of endurance, locking, or dislocation. The Veteran reported having decreased weight-bearing ability in his right knee. The VA examiner found tenderness bilaterally, and crepitus in the right knee but not the left. The VA examiner found no signs of edema, effusion, weakness, redness, heat, guarding of movement, or subluxation bilaterally. The VA examiner found no genu recurvatum or locking pain bilaterally. The Veteran had right knee flexion to 120 degrees, with pain at 120 degrees; left knee flexion to 135 degrees, with pain at 135 degrees; and extension to 0 degrees bilaterally. Pain additionally limited motion after repetitive use by 0 degrees bilaterally; there was no additional limitation of joint function by fatigue, weakness, lack of endurance or incoordination. Testing of the stability of the anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, and the medial and lateral menisci bilaterally was within normal limits. X-rays showed mild-to-moderate bilateral tricompartmental osteoarthritis with discrete posterior patellar spurring, squaring of the plateau, spiking of the tibial spine and medial compartment narrowing bilaterally. The VA examiner diagnosed the Veteran with bilateral patella femoral syndrome, and with and with status post partial medial meniscectomy on the right knee. The examiner found two scars on the Veteran's right knee, each measuring about 1 cm by 1 cm, with no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation, or edema. At his August 2009 VA examination, the Veteran reported experiencing weakness, stiffness, swelling, and lack of endurance in his left knee. He denied experiencing heat, redness, giving way, locking, fatigability, deformity, tenderness, drainage, effusion, subluxation, pain, or dislocation in his left knee. He reported having flare-ups as often as twice per week, lasting two hours each, with soreness upon bending in his left knee. The Veteran denied any incapacitation or hospitalization for his left knee. The Veteran reported experiencing swelling, giving way, lack of endurance, locking, and pain in his right knee. He denied experiencing weakness, stiffness, heat, redness, fatigability, deformity, tenderness, drainage, effusion, subluxation, or dislocation in his right knee. He reported having flare-ups of his right knee as often as once per week, lasting one hour each, with pain and an inability to stoop or stand. He denied any incapacitation of his right knee, and noted that he had surgery on it in 1995. The Veteran had right knee flexion to 132 degrees, with pain at 122 degrees; left knee flexion to 140 degrees, without pain; and extension to 0 degrees without pain bilaterally. In an addendum, the Veteran's left knee flexion was found to be to 138 degrees, with pain at 88 degrees and no additional degree of limitation after repetitive motion. There was no additional limitation of joint function by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The medial/lateral collateral ligaments stability test, anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus ligaments stability test were all within normal limits bilaterally. Left knee x-rays were within normal limits. The VA examiner diagnosed the Veteran with left knee patella femoral syndrome with some pain, and with right knee osteoarthritis with scar and pain. The VA examiner found a linear, superficial, and non-painful scar with no skin breakdown and no underlying tissue damage measuring 3 cm by 0.5 cm on the Veteran's right knee. The scar involved no inflammation, edema, keloid formation, disfigurement, limitation of motion, or limitation of function. At his February 2012 VA examination, the Veteran reported experiencing flare-ups every day. He had right knee flexion to 110 degrees, with pain at 110 degrees. He had left knee flexion to 120 degrees, with pain at 120 degrees. He had extension to 0 degrees with no objective evidence of painful motion bilaterally. Range of motion was unchanged after repetitive-use testing, although there was pain on movement and less movement than normal bilaterally. The VA examiner found tenderness or pain to palpation bilaterally. Muscle strength testing was 5/5 on flexion and extension bilaterally. Joint stability tests for anterior, posterior, and medial-lateral instability were all normal. There was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran had no shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran had no meniscal (semilunar cartilage) conditions or surgical procedures for a meniscal condition; his only surgery was arthroscopic surgery on his right knee-with residual weakness, pain, and limited range of motion. The Veteran does not use any assistive devices as a normal mode of locomotion. There was no x-ray evidence of patellar subluxation. The VA examiner diagnosed the Veteran with bilateral knee osteoarthritis, and with status post right knee arthroscopic surgery. The functional impact is that he cannot bend at his knees for a long time, and has audible crepitus and must pop his knees. With respect to the right knee arthroscopic surgery scar, the examiner found that it does not result in limitation of function or impact the Veteran's ability to work. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that the preponderance of the evidence shows that initial disability evaluations in excess of 10 percent for the Veteran's right knee osteoarthritis with scars and left knee osteoarthritis are not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260. Although the Board acknowledges the Veteran's reports that he had a sensation of his knees giving way, the objective evidence consistently shows that he has no recurrent subluxation or lateral instability-including the August 2012 VA examiner's x-ray and joint stability test findings-is entitled to greater probative weight as it is a medical finding that requires diagnostic testing by an examiner with the appropriate education and training. See 38 C.F.R. § 3.159(a) (2012); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (holding that "[l]ay evidence can be competent and sufficient to establish a diagnosis when ... a lay person is competent to identify the medical condition" and providing, as an example, that a layperson would be competent to identify a condition such as a broken leg, but would not be competent to identify a form of cancer); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In addition, objective testing has revealed no ankylosis, dislocation or removal of semilunar cartilage, compensable level of flexion or extension, impairment of tibia and fibula, or genu recurvatum. Furthermore, in response to the Veteran's repeated contentions that his earlier VA examination was abruptly conducted and included falsified findings, he has been provided three additional VA examinations, most recently in February 2012. With respect to the Veteran's scars resulting from his right knee arthroscopic surgery, the Board finds that a separate compensable rating is not warranted because there is no indication that they are tender and, as the February 2012 VA examiner ascertained, the scars do not result in limitation of function or impact the Veteran's ability to work. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321; Thun, supra. Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's right knee osteoarthritis with scars and left knee osteoarthritis, including degenerative arthritis due to trauma and substantiated by x-rays. The rating criteria are therefore adequate to evaluate the right knee osteoarthritis with scars and left knee osteoarthritis, and referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's disabilities, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, although the Veteran reported some soreness, crepitus, and related symptoms, there is no indication that this rose to the level of marked interference with employment. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. Total Disability Rating Based on Individual Unemployability (TDIU) Finally, the Court has held that a TDIU is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Although the Veteran's representative, without citing any specifics, in his January 2013 written argument stated that "a person may be too disabled to engage in employment although he or she is up and about and fairly comfortable at home or upon limited activity," the specific evidence of record in this case does not warrant a TDIU. The Veteran is gainfully employed, according to a June 2012 Madigan Army Medical Center (AMC) treatment record. Moreover, as discussed above, the Veteran reported at his June 2008 VA examination that if he puts his hand below the level of his waist for one minute, he is able to resume his work. His symptoms are not of such severity as to prevent him from being able to secure or follow a substantially gainful occupation. Thus, TDIU is not raised by the record. ORDER Effective January 1, 2007, an initial rating of 30 percent, but no higher, for right wrist carpal tunnel syndrome is granted, subject to the applicable criteria governing the payment of monetary benefits. An initial rating in excess of 30 percent for right wrist carpal tunnel syndrome is denied. An initial rating in excess of 10 percent for left sciatic neuropathy prior to February 29, 2012 is denied. An initial rating in excess of 20 percent for left sciatic neuropathy as of February 29, 2012 is denied. An initial rating in excess of 10 percent for right sciatic neuropathy is denied. An initial rating in excess of 20 percent for intervertebral disc syndrome with scar is denied. An initial rating in excess of 10 percent for GERD with scars, status post Nissen fundoplication is denied. An initial rating in excess of 10 percent for right knee osteoarthritis with scars is denied. An initial rating in excess of 10 percent for left knee osteoarthritis is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). As to the issue of entitlement to an initial rating in excess of 10 percent for left shoulder degenerative joint disease with scar, the Board finds that a new examination is required because the Veteran asserted at his February 2012 VA examination that he saw an impingement in his left shoulder nerve, and sometimes experiences a feeling of pins stabbing in his left shoulder. The Board finds that he is competent to report this condition as a layperson; moreover, his experience as a medical specialist in service makes him particularly competent to identify the left shoulder nerve as its source. The VA examiner should assume that the Veteran's reported feeling of pins stabbing in his left shoulder is both competent and credible. The Board's review of the February 2012 left shoulder examination and peripheral nerves examination reveals no examination or diagnosis of the nerves corresponding to the Veteran's left shoulder. Specifically, the February 2012 VA peripheral nerves examination included no findings as to the Veteran's left circumflex nerve, long thoracic nerve, or upper radicular nerve group. On remand, the Veteran should be provided with a new examination of his left shoulder, to include examination of the nerves associated with his left shoulder. While on remand, the Veteran should be given an opportunity to identify any healthcare provider who treated him for his service-connected left shoulder degenerative joint disease with scar since February 2012. Thereafter, any identified records, to include those from any VA healthcare provider dated from February 2012 to the present that are not already included in the claims file should be obtained for consideration in the Veteran's appeal. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge of the nature and severity of his left shoulder disability and the combined impact of his service-connected disabilities on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 2. Ensure that all available, pertinent, and non-duplicative VA and private treatment records, dated since February 2012, are physically or electronically associated with the claims folder. 3. After associating any pertinent, outstanding records, afford the Veteran an appropriate VA examination of his left shoulder degenerative joint disease with scar, to include examination of his left shoulder nerves. The claims file should be made available to and reviewed by the examiner. The examiner should perform an appropriate range of motion examination, and discuss the extent of any ankylosis of scapulohumeral articulation, impairment of the humerus, and impairment of the clavicle or scapula. The examiner should also state whether any associated neurologic abnormalities are present, and, if so, identify the nerve(s) involved and determine whether each such disability is best characterized as neuritis, neuralgia, or complete or incomplete paralysis. The severity of any neurologic abnormalities should also be reported. In offering any opinion, the examiner should take into consideration all the evidence of record, to include medical records as well as the Veteran's lay statements, accepted medical principles, and objective medical findings. All opinions expressed should be accompanied by a supporting rationale. 4. Then adjudicate the Veteran's claim of entitlement to an initial disability rating in excess of 10 percent for left shoulder degenerative joint disease with scar. Thereafter, readjudicate the appeal. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs