Citation Nr: 1316474 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 06-00 218 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for a low back disability, to include as secondary to service-connected bilateral knee disabilities. 2. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected bilateral knee disabilities. 3. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected bilateral knee disabilities. 4. Entitlement to service connection for a left hip disability, to include as secondary to service-connected bilateral knee disabilities. 5. Entitlement to service connection for a right hip disability, to include as secondary to service-connected bilateral knee disabilities. 6. Entitlement to a disability rating in excess of 10 percent for residuals of a medial meniscus tear of the left knee, with arthritis. 7. Entitlement to a disability rating in excess of 10 percent for residuals of a medial meniscus tear of the right knee with arthritis. 8. Entitlement to an initial disability rating in excess of 10 percent for instability of the right knee. 9. Entitlement to an initial disability rating in excess of 10 percent for instability of the left knee. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The appellant and F.R. ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The Veteran had active service from August 1978 to August 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in 2005, 2008, and 2009 from the VARO in Waco, Texas. In October 2009 the Veteran testified before a Decision Review Officer at a hearing held at the Waco RO. He and his sister, F.R., also testified before the undersigned Veterans Law Judge at a Travel Board hearing in the Waco RO in January 2011. Transcripts from both hearing proceedings are of record and have been reviewed. The case was previously before the Board in September 2011 at which time it was remanded for further development. One of the issues remanded by the Board at that time was the Veteran's entitlement to service connection for an acquired psychiatric disability, to include major depressive disorder, to include as secondary to his service-connected disabilities. Evidence was developed and by rating decision dated in December 2012, service connection for a major depressive disorder was granted. A 50 percent rating was assigned, effective October 7, 2008. When combined with the 10 percent ratings for the meniscus tear residuals of the left knee, the meniscus tear residuals of the right knee, the instability of the right knee, and the instability of the left knee, the disability rating was increased to 70 percent, from October 7, 2008. The Board notes that in a separate decision issued in September 2011, entitlement to dependency status for C.B. and E.B. was denied. However, of record is an October 2012 memorandum from the Appeals Management Center in Washington, D.C., referring to evidence regarding support needing to be submitted. It was indicated that development and/or notification to the Veteran was in order. The attention of the RO is called to this matter for appropriate consideration. FINDINGS OF FACT 1. A low back disability did not have its onset during service and is not related to disease, injury, or event of service origin or to a service-connected disability. 2. A left ankle disability did not have its onset during service and is not related to disease, injury, or event of service origin or to a service-connected disability. 3. A right ankle disability did not have its onset during service and is not related to disease, injury, or event of service origin or to a service-connected disability. 4. A left hip disability did not have its onset during service and is not related to disease, injury, or event of service origin or to a service-connected disability. 5. A right hip disability did not have its onset during service and is not related to disease, injury, or event of service origin or to a service-connected disability. 6. Left knee laxity is productive of slight recurrent subluxation or instability. 7. Right knee laxity is productive of no more than slight recurrent subluxation or instability. 8. Prior to October 11, 2011, range of motion involving the right knee was from 0 to 70 degrees. X-ray studies showed only mild arthritis. 9. Prior to October 11, 2011, range of motion of the left knee was from 0 to 60 degrees. 10. The Veteran is employed as a corrections officer. 11. From October 11, 2011, the Veteran most nearly approximates moderate motion restriction of the right knee. 12. From October 11, 2011, the Veteran most nearly approximates moderate motion restriction of the right knee. CONCLUSION OF LAW 1. The criteria for service connection for a low back disability are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for a left ankle disability are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 3. The criteria for service connection for a right ankle disability are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 4. The criteria for service connection for a left hip disability are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 5. The criteria for service connection for a right hip disability are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.313 (2013). 6. The criteria for an initial rating higher than 10 percent for left knee instability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.31, 4.71a, Diagnostic Code 5257 (2012). 7. The criteria for an initial rating higher than 10 percent for right knee instability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2012). 8. The criteria for an initial rating higher than 10 percent for residuals of left knee medial meniscus tear with arthritis are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5260 (2012). 9. The criteria for an initial rating prior to October 11, 2100, higher than 10 percent for residuals of a right knee medial meniscus tear, with arthritis, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5260 (2012). 10. The criteria for a disability rating of 20 percent, but not more, for motion restriction of the right knee from October 11, 2011, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2012). 11. The criteria for a disability rating of 20 percent, but not more, for motion restriction of the left knee from October 11, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)) defines VA's duties to notify and assist a Veteran in the development of claims for VA benefits. Regulations for the implementation of the VCAA are codified as amended at 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has held that 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 elements are: 1) Veteran status; 2) existence of a current disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability award. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). A review of the evidence discloses the Veteran has received all required notice, has had a meaningful opportunity to present evidence that would help him develop his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1,369 (Fed. Cir. 2004). He has been sent appropriate VCAA letters as recently as September 2011. The claim was most recently adjudicated in a September 2012 supplemental statement of the case. Regarding the duty to assist, VA has also satisfied its obligation in terms of obtaining all potentially relevant evidence concerning the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records, VA medical records, and identified private medical records have been obtained. The Veteran also has been provided VA compensation examinations, including the obtaining of medical nexus opinions, concerning the etiology of the disabilities for which service connection is sought. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The medical nexus opinions obtained are responsive to the determinative issue of causation, so additional examinations and opinions are not needed. 38 C.F.R. § 4.2. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to obtain an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one, or, at a minimum, notify the claimant why one will not or cannot be provided). See also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination once such an examination is indicated). The medical evidence of record is adequate to address all pertinent concerns, as the claims file has been reviewed for all relevant medical and other history, the Veteran has been examined, the findings have been reported in sufficient detail, and there has been discussion of the underlying medical rationale, which is where most of the probative value of an opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The examination reports of record are thorough and supported by the record. The Veteran had the opportunity to provide testimony in his own behalf with regard to the disabilities at issue before the undersigned Veterans Law Judge conducting a travel board hearing in Waco in January 2011. A transcript of the hearing proceedings is in the claims file. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103 (c )(2) requires that the judge who conducts a hearing fulfill two duties to comply with this regulation. Those are: 1) fully explaining the issue and 2) suggesting the submission of evidence that may have been overlooked. Here, the judge addressed the issues for consideration and discussed the pertinent evidence. Neither the veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103 (c )(2), nor has either referred to any prejudice in the conducting of the hearing. The hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate the claims for benefits. Accordingly, the Board finds that the presiding judge complied with the duties set forth in 38 C.F.R. § 3.103 (c ) (2). In view of the foregoing, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board finds it difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claims. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001). Indeed, in a communication dated in September 2012, the Veteran stated that he had no other information or evidence to submit. He wanted his case decided by the Board as soon as possible. Law and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires competent evidence of three things: 1) A current disability; 2) inservice incurrence or aggravation of a disease or injury; and 3) a causal relationship, that is, a nexus, between the claimed inservice disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a) (2012). In addition, arthritis, if present, will be presumed to have been incurred in service if manifest to a degree of 10 percent or more within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131; 38 C.F.R. §§ 3.307, 3.309 (2012). Pursuant to 38 C.F.R. § 3.310(a), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. See Evans v. West, 12 Vet. App. 22, 29 (1998) (noting requirements for establishing service connection on a secondary basis). In order to establish a secondary service connection claim, the claimant must show: 1) The existence of a current secondary disability; 2) the existence of a service-connected disability; and 3) evidence that the service-connected disability proximately caused the secondary disability. 38 C.F.R. § 3.310. A claimant may also establish secondary service connection by demonstrating that his current secondary disability was aggravated or worsened by the already service-connected disorder. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (when aggravation of a Veteran's nonservice-connected [secondary] condition is proximately due to or the result of a service-connected condition, such Veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability as shown prior to the aggravation); Libertine v. Brown, 9 Vet. App. 521, 522 (1996) (additional disability resulting from aggravation of a nonservice-connected [secondary] condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a)). If the claimant succeeds in establishing service connection for a secondary condition, "the secondary condition shall be considered a part of the original condition." 38 C.F.R. § 3.310(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Factual Background and Analysis With Regard to Service Connection The Board has thoroughly reviewed all the evidence in the claims folders. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail each and every piece of evidence submitted by the Veteran or in his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence, and on what this evidence shows, or fails to show, on the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board discuss its reasons for rejecting evidence favorable to the Veteran). A review of the service treatment records reflects the Veteran was evaluated for low back symptoms during service. He was also evaluated for left ankle problems three times during service and for bilateral ankle pain on one occasion. There was no evidence of complaints, treatment, or findings regarding a bilateral hip disorder during service. Of record is a service department form dated in August 1981 in which the Veteran acknowledged that he understood he was not required to undergo a medical examination for separation from active service. He acknowledged that if he elected not to undergo a separation examination, he understood that his medical records would be reviewed by a physician at the appropriate medical treatment facility, and if the reviewer indicated that an examination should be accomplished, he would be scheduled for one based on the results of review. The Veteran signed a statement that he did not desire a separation medical examination. A medical officer reviewed the Veteran's medical records and opined that a medical examination for separation was not required. The post service medical evidence dates from the late 1990's. At the time of a private medical examination in June 1998 for evaluation of hematuria, diabetes, and asymptomatic gallstones, the only reference to a pertinent disability was a complaint of pain in the right knee. On examination the right knee was described as stable, with no effusion and no localized tenderness. The assessments following examination pertained to other disabilities with no mention of the back, the hips, or the ankles. Similarly, at the time of a November 1999 private evaluation, it was noted the Veteran returned after a long absence and this was for a diabetes check. Past medical history reflected there had been no previous surgeries. No mention was made to the disabilities at issue except for a report of some low back pain on occasion, but no history of injuries involving the back. The Veteran stated he was feeling well at the present time. Examination revealed no pertinent abnormality and no pertinent assessment was made. It was not until a private office visit in October 2004 that the Veteran was seen for complaint of pain involving the left knee for the past couple weeks. He was not aware of any injury. He remembered injuring the right knee "some several years ago" and had had problems with it intermittently. X-ray studies of the left knee several days later showed arthritis. The evidence includes a report of a VA joints examination of the Veteran in August 2005. The claims file was reviewed by the examiner. The focus of the examination was on the Veteran's knees for which service connection is now in effect. No reference was made to involvement or problems with the back, the hips, and/or the ankles. Of record is a November 2005 communication from a private physician who stated that he saw the Veteran in August of that year for a complaint of back pain. X-ray studies at that time showed some spurring of the thoracic spine. The physician stated this "is a little unusual for a man of his young age and I think it is conceivable that this is related to a fall impact injury that he [the Veteran] had many years ago which has produced some premature osteoarthritic change." The Veteran was accorded an examination of the joints by VA in June 2008. For some reason, the claims file was not available for review. Following examination, diagnoses were made of: Bilateral knee degenerative joint disease; arthralgia of both hips; congenital tilt of the talotibial joints with arthralgias of both ankles. The examiner opined that the bilateral hip and ankle arthralgias "are not a result of the bilateral knee" degenerative joint disease. The examiner stated a review of the orthopedic literature revealed no peer reviewed studies that supported the contention that post-traumatic degenerative changes of one joint may induce changes in another joint, either of the affected or contralateral extremity. The examiner stated, "It is more than likely his hip and ankle conditions are related to the result of aging and obesity." The Veteran was accorded an examination of the spine by VA in November 2009. The claims file was reviewed by the examiner. The Veteran reported that he injured his spine around 1978 during basic training when he fell down some stairs. He indicated he was placed on light duty and then improved in 3 to 4 weeks' time. He did not seek further care. He acknowledged the back was fine until the late 1990's when he experienced an episode of low back pain at home. He went to his physician, received X-ray studies, and was given medication. He did not seek any further care, although he currently complained of continued low back pain since the late 1990's. Following examination he was given a pertinent assessment of lumbosacral strain with mild disc space narrowing at the L5/S1 level. The examiner noted that following thorough review of the service treatment records, the back difficulties the Veteran had in service appeared to be acute in nature. He noted there was no interim data following separation from service until the late 1990's. The examiner stated that "based on the evidence available, it is less likely than not that the Veteran's current lumbar spine condition is related to his two separate episodes of back pain while on active duty." The claims file was reviewed by a VA health-care provider in September 2011. The review was for the purpose of opining as to secondary service connection with regard to the back and the Veteran's service-connected bilateral knee disability. The health-care professional stated there was no change to his opinion regarding direct service connection for the lumbar spine stated in November 2009. He indicated there "is nothing in the currently accepted, peer reviewed, credible, orthopedic/medical literature that demonstrates that intrinsic conditions of the knee(s) with or without altered gait will cause intrinsic conditions of the spine. It is this examiner's opinion that the Veteran's spine condition is not related to, proximately due to, or the result of the service-connected bilateral knee conditions. There is nothing in the record indicating that the bilateral knee conditions have aggravated (defined as permanent progression beyond that which is considered normal for the condition) the spine condition. There is nothing in the currently accepted, credible, peer reviewed orthopedic/medical literature that demonstrates that intrinsic knee conditions will aggravate (as defined) spine conditions. It is this examiner's opinion that the Veteran's spine condition was/is not aggravated (as defined) by the service-connected knee condition(s)." The health-care professional also stated that he reviewed the claims file as well as the report of the joints examination in June 2008 with regard to an opinion as to whether any current bilateral hip and ankle arthralgias were related to or aggravated by the service-connected knee disability. He stated that "a review of the credible literature reveals no peer reviewed studies that support his contention that degenerative arthritis of the knees would aggravate or cause any condition of the other joints in the ipsilateral or contralateral extremities. It is more likely that his arthralgias are related to his morbid obesity, the attrition of aging and a genetic predilection for developing joint problems. In regards to his current ankle arthralgias, they are not related to the minor strains that he had while on active duty. The ankle arthralgias are more likely than not due to his morbid obesity and the attrition of aging. There was no chronicity regarding his ankles established while he was on active duty." Based on the foregoing, the Board finds there is no competent and credible evidence of record showing that any current disability involving the ankles, hips, and/or the back is related to the Veteran's active service or to any service-connected disabilities. VA health-care professionals have examined the Veteran and reviewed the claims file in 2008 and 2009 and expressed opinions in 2011. The examining health-care professionals have opined that any current disabilities involving those joints were not caused by or aggravated by the service-connected knee disabilities. The examiners have referred to a review of pertinent literature and have stated that there are no peer reviewed studies supporting the Veteran's contention that arthritis of the knees would aggravate or cause any condition of the other joints in the ipsilateral or contralateral extremities. They believe it is more likely that the arthralgias involving the hips and ankles are related to the Veteran's morbid obesity, the attrition of aging, and a genetic predilection for developing joint problems. The examiners acknowledged the Veteran had minor strains while on active service, but they opined that these likely resolved without residual disability. As noted in the reporting of the evidence above, near the time of service discharge, the Veteran did not undergo a separation examination. He waived this, but a physician talked to him and the physician opined that an examination was not necessary. The Veteran was seen by private health-care providers in the mid-1990's for unrelated complaints and no hip, knee, or ankle disability was identified. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as to any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). In this case, the Board finds that the opinions of the VA health-care professionals in 2008, 2009, and 2011 are of great probative weight. The health-care professional who reviewed the claims file in 2011 reiterated that current bilateral hip and ankle arthralgias are not related to, or aggravated by the service-connected knee disorders. He also expressed a similar opinion with regard to a low back disability. The examiner gave reasons for his opinion that there was no causal relationship to service or to any service-connected disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (probative value of medical opinion comes from its reasoning). There is no medical opinion of record to the contrary. The Board acknowledges the Veteran's assertions that his current problems are related to service and/or a service-connected knee disability. However, while laypersons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, etiology of back, hip, and ankle disabilities and causal relationships between one disability and the development of another, this falls outside the realm of common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (laypersons are not competent to diagnose cancer). Such matters require medical knowledge. The Veteran does not assert any such medical knowledge. As the opinions of record are competent and conclusively stated, and consistent with the record, the Board assigns those opinions great probative weight regarding etiology. As a result, the Board finds that the persuasive evidence regarding nexus weighs against a relationship between the back, the ankles, and the hips on the one hand and the Veteran's active service and his service-connected knee disabilities on the other hand. As such, service connection for bilateral ankle disability, bilateral hip disability, and/or a back disability under any theory is not warranted. The Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Pertinent Law and Regulations With Regard to Increased Ratings Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in that disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, as explained below, the uniform 10 percent ratings for right and left knee laxity are proper. The ratings for right and left knee motion restriction with be discussed below. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, knee impairment with recurrent subluxation or lateral instability, warrants a 10 percent rating if it is slight, a 20 percent rating if it is moderate, or a 30 percent rating if it is severe. Under Code 5260, a 10 percent rating is assigned for limitation of flexion of the leg to 45 degrees. The next higher rating of 20 percent is assigned when flexion is limited to 30 degrees. A 30 percent rating is assigned when flexion is limited to 15 degrees. Under Code 5261, a 10 percent rating is authorized when there is limitation of extension of a leg to 10 degrees. A 20 percent rating is assigned when extension is limited to 15 degrees. A 30 percent rating is provided when extension is limited to 20 degrees, while a 40 percent rating is for assignment when extension is limited to 30 degrees, and the maximum 50 percent rating is assigned when extension is limited to 45 degrees. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the Veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Normal range of knee extension and flexion is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II. The medical evidence of record includes the report of a joints examination accorded the Veteran by VA in August 2005. The claims file was reviewed by the examiner. At that time left knee flexion was 110 of 140 degrees. There was increased pain at 80 degrees of flexion and this is where the flexion stopped on repeated efforts. Extension was 0 of 0 degrees. As for the right knee, flexion was 120 of 140 degrees. There was increased pain at 90 degrees of flexion, which is where the flexion stopped on repeated efforts. Extension was 0 of 0 degrees. The examiner stated there was no fatigue, weakness, lack of endurance or incoordination. The diagnoses were medial meniscus tear of the right knee with osteoarthritis and medial meniscus tear of the left knee, status post arthroscopic surgery, with arthritis. Although there was pain on use, the examiner again indicated there was no fatigue, weakness, lack of endurance, or incoordination noted. The Veteran was accorded another joints examination by VA in June 2008. He reported having had no surgery involving the right knee. He was status post arthroscopic procedure on the left knee with medial meniscus tear that was partially excised. He complained of pain in both knees when standing or walking. He added the knees would swell and become sore and stiff. He did not utilize any braces or assistive devices at the time of current examination. He estimated he had missed four weeks of work in the past 12 months due to his joints. He was currently employed by the Texas Department of Corrections as a guard. Activities of daily living were affected in that he found it difficult to mow the grass or bend his joints secondary to pain. He added that kneeling or trying to change the oil in his car was difficult. On examination he exhibited a shuffling, mildly antalgic gait bilaterally. The right knee showed a slight varus deformity. Motion was from 0 to 90 degrees with pain and crepitus throughout. There was tenderness in the medial joint line. There was small effusion and mild medial instability with valgus stress. Lachman's testing was negative. The findings with regard to the left knee were exactly the same. The examiner stated there were no additional limitations following repetitive use other than increased pain with no further loss of motion. There were no flare-ups. There was no effective incoordination, fatigue, weakness, or lack of endurance or joint function. The examination diagnoses included bilateral knee degenerative joint disease. The record also includes a May 2009 communication from a private physician who stated that the Veteran was being seen for a general reevaluation of his joints. Complaints included worsening symptoms of the knees, with right knee being worse. The examiner stated that X-ray studies were reviewed and showed bone on bone end-stage arthritis of the right knee with the left knee not far behind. He stated this was tricompartmental arthritis, although he noted it was not as bad in the lateral compartment or retropatellar as it was medially. The impression was advancing degenerative arthritis of multiple joints, right knee, tricompartmental and severe. He believed there might be benefit from an angle-changing osteotomy and a cleanout arthroscopy, but noted the degree of arthritis and the tricompartmental nature would also mitigate for the possibility of just waiting and having the knee replaced. The examiner noted that both knees eventually would need replacement. Additional pertinent evidence includes the report of VA orthopedic examination accorded the Veteran in October 2011. Right knee flexion was 70 degrees with pain beginning in the same area. Right knee extension was to 0 degrees. Left knee flexion was to 60 degrees and painful motion began at 60 degrees. Left knee extension was also to 0 degrees. The examiner stated there was no additional limitation of motion following repetitive use testing. He also indicated there was no functional loss or functional damage involving the knee and lower leg. Tenderness and pain to palpation were noted in both knees. Muscle strength was normal in each knee. Testing did not show instability involving either knee. There was no evidence of history of recurrent patellar subluxation or dislocation. As for impact on work, the examiner stated standing and walking as a prison guard increased pain in the knees. The examination diagnosis was degenerative joint disease of both knees. In this case, the Veteran has been shown to have flexion better than 60 degrees and extension better than 5 degrees. As noted above, a 10 percent evaluation requires flexion limited to 45 degrees and a 20 percent evaluation requires flexion limited to 30 degrees. 38 C.F.R. § 4.71a, Code 5260. Similarly, for extension, a 10 percent evaluation requires extension limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Here, there is no limitation of extension shown. The Veteran's range of motion was not significantly limited at the time of the examinations between 2005 and 2011. However, at the time of the October 2011 examination right knee flexion was limited to 70 degrees while left knee flexion was limited to 60 degrees. Given the significantly restricted range of motion in both knees at the time of the 2011 examination, the Board finds that a 20 percent evaluation for motion restriction involving each knee is warranted from that date, that being October 11, 2011. However, prior to that time the motion restriction is shown to be adequately compensated by the 10 percent rating that was in effect. As for instability, separate ratings of 10 percent for each knee have been in effect since 2008. However, at the time of the most recent examination accorded the Veteran in October 2011, no instability was noted involving either knee. Accordingly, a higher rating than the 10 percent rating currently in effect is not warranted. Because the Veteran does not have nonunion of the tibia and fibula requiring a brace, or malunion of the tibia and fibula with either marked or moderate knee disability, a higher disability evaluation based on impairment of the tibia and fibula is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Genu recurvatum is not shown. Thus, a rating under this code is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5253. The Board has considered the Veteran's reports of functional impairment due to pain involving the knees. However, the examinations of record have not shown any additional loss of motion with repetitive use, weakness in the affected extremity, or incoordination. The Board believes that the assigned 10 percent disability rating for each knee prior to October 2011 contemplates the functional impairment caused by the complaints of pain and instability. Importantly, as just noted, instability involving either knee was not even shown at the time of the October 2011 examination. The Veteran is competent to report that his disabilities involving the knees are worse than presently evaluated. However, whether a disability has worsened sufficiently to meet the schedular criteria for the assignment of a higher (or separate) evaluation is a factual determination by the Board based on the Veteran's complaints coupled with the medical evidence. Here, although the Veteran believes he meets the criteria for a higher disability rating, his complaints and the medical findings do not meet the schedular requirements for higher ratings up to October 2011 and no more than a 20 percent rating for each knee based on motion restriction with arthritis since that date. The Board finds the specific findings of the trained health-care professionals are of greater probative weight than the Veteran's more general lay assertions with regard to pain and discomfort. Extraschedular Consideration As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd. sub nom Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran'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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's motion restriction and laxity are fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms of limitation of motion that are addressed in the separate ratings that the Veteran is receiving under Codes 5257, 5260, and 5261. The Board has been able to compare the various symptoms to the criteria and arrive at the appropriate ratings. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. In any event, the Board notes the Veteran has not been frequently hospitalized for his knee disabilities. He is continuing to be employed, although the knees do cause him some concern in his position as a guard. However, the Board notes that there are currently separate ratings in effect for the instability and motion restriction that the Veteran is receiving for his bilateral knee disabilities. Therefore, referral for consideration of an extraschedular rating for the knee disabilities is not warranted. 38 C.F.R. § 3.321(b)(1). The Board has also considered the requirements of Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (claim for an increased rating includes consideration of whether a total disability rating by reason of individual unemployability is warranted under the provisions of 38 C.F.R. § 4.16). However, as noted above, the Veteran is still working. ORDER Service connection for a low back disability, to include as secondary to service-connected bilateral knee disabilities, is denied. Service connection for a left ankle disability, to include as secondary to service-connected left knee disability, is denied. Service connection for right ankle disability, to include as secondary to service-connected right knee disability, is denied. Service connection for a left hip disability, to include as secondary to service-connected knee disabilities, is denied. Service connection for a right hip disability, to include as due to service-connected knee disabilities, is denied. An initial disability rating in excess of 10 percent for instability of the right knee is denied. An initial disability rating in excess of 10 percent for left knee instability is denied. A disability rating in excess of 10 percent for left knee medial meniscus tear, status post arthroscopic surgery, with arthritis, prior to October 11, 2011, is denied. A disability rating in excess of 10 percent for right knee motion restriction with arthritis prior to October 11, 2011, is denied. A 20 percent rating, but not more, for left knee disability, from October 11, 2011, is granted. A 20 percent rating, but not more, for right knee motion restriction with arthritis is granted from October 11, 2011. ____________________________________________ KRISTI L. GUNN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs