Citation Nr: 1317868 Decision Date: 05/31/13 Archive Date: 06/06/13 DOCKET NO. 09-26 402 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome of the right knee. 2. Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome of the left knee. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from March 1985 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The case was remanded by the Board in November 2012 and, as will be discussed herein, is now ready for appellate review. The Veteran provided testimony at a personal hearing before the undersigned Veterans Law Judge sitting at the RO in July 2012. A transcript of this hearing has been associated with the Veteran's VA claims folder. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal with the exception of VA treatment records dated through October 2012, which, as will be discussed herein, were considered by the agency of original jurisdiction (AOJ) in the April 2013 supplemental statement of the case (SSOC). FINDINGS OF FACT 1. For the entire appeal period, patellofemoral pain syndrome of the right knee is manifested by subjective complaints of pain, stiffness, locking, swelling, popping, and flare-ups, and objective evidence of tenderness, effusion, and crepitus, resulting in painful motion with functional loss equal to flexion to no worse than 50 degrees and extension to no worse than zero degrees, without X-ray evidence of arthritis, instability or subluxation, ankylosis, cartilage dislocation or removal, impairment of the tibia or fibula, or genu recurvatum. 2. For the entire appeal period, patellofemoral pain syndrome of the left knee is manifested by subjective complaints of pain, stiffness, locking, swelling, popping, and flare-ups, and objective evidence of tenderness, effusion, and crepitus, resulting in painful motion with functional loss equal to flexion to no worse than 80 degrees and extension to no worse than zero degrees, without X-ray evidence of arthritis, instability or subluxation, ankylosis, cartilage dislocation or removal, impairment of the tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for rating in excess of 10 percent for patellofemoral pain syndrome of the right knee are not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5014 (2012). 2. The criteria for rating in excess of 10 percent for patellofemoral pain syndrome of the left knee are not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5099-5024 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) 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 five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Regarding claims for increased ratings such as in the instant case, the VCAA requirement with such claims is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Board finds that VA has satisfied its duty to notify under the VCAA with respect to the increased rating claims on appeal. Specifically, a July 2008 letter, sent prior to the initial unfavorable September 2008 rating decision, advised the Veteran of the evidence and information necessary to substantiate his increased rating claims as well as his and VA's respective responsibilities in obtaining such evidence and information. This letter also provided the Veteran with relevant rating criteria and informed him of the evidence and information necessary to establish an effective date in accordance with Dingess/Hartman, supra. Additionally, a May 2009 letter, which referenced Vazquez-Flores, provided more specific information concerning the evidence and information necessary to substantiate the Veteran's claims for increased ratings for his bilateral knee disabilities, to include the rating criteria under which such disabilities are rated. While the May 2009 letter was issued after the initial September 2008 rating decision, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case (SOC) could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the May 2009 letter was issued, the Veteran's claims were readjudicated in a July 2009 SOC and July 2011 and April 2013 SSOCs. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Next, VA has a duty to assist the Veteran in the development of the claims. 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 necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records and post-service VA treatment records, to include the additional VA treatment records requested in the November 2012 Board remand. Stegall v. West, 11 Vet. App. 268 (1998) (standing for the proposition that the Board is required to insure compliance with the instructions of it remands.) Moreover, the Veteran's statements in support of his claims, to include his testimony at the July 2012 Board hearing, are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. The Veteran was afforded VA examinations in August 2008, April 2011, and March 2013 to evaluate the severity of his service-connected bilateral knee disabilities. Neither the Veteran nor his representative has alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected bilateral knee disabilities as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claims and no further examination is necessary. The March 2013 VA examination was also conducted in compliance with the directives of the November 2012 remand. Stegall, supra. Additionally, in July 2012, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the July 2012 hearing, the undersigned noted the issues on appeal. Additionally, testimony regarding the nature and severity of the Veteran's service-connected knee disabilities was solicited, to include the type and frequency of the symptoms he experiences as a result of such disabilities, as well as the impact such have on his daily life and employment. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, aside from the Veteran's reference to continuing VA treatment, the records from which have been obtained in accordance with the Board's November 2012 remand as set forth above, the hearing discussion did not reveal any evidence that might be available that had not been submitted. In this regard, the Veteran testified that only VA medical providers, and no private healthcare providers, have rendered treatment for his knees. (See July 2012 hearing transcript, page 15). Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Furthermore, as discussed previously, in November 2012, the Board remanded the case for additional development. As discussed in the preceding paragraphs, VA treatment records dated through October 2012 have been obtained and the Veteran was afforded a VA examination in March 2013 so as to determine the current severity of his bilateral knee disabilities in accordance with the January 2011 remand directives. Moreover, the April 2013 SSOC specifically considered whether the Veteran is entitled to extra-schedular ratings for his bilateral knee disabilities as directed in the November 2012 remand. Therefore, the Board finds that the AOJ has substantially complied with the November 2012 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall, supra, where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Analysis Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. In this regard, the Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and the Virtual VA file (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. The Virtual VA file reveals VA outpatient treatment reports dated through October 16, 2012 and the April 2013 SSOC documents review of such reports. In this regard, while the list of evidence contained in this SSOC reflects VA outpatient treatment reports dated through October 16, 2010, this is a clearly a typographically error as the discussion in the Reasons and Bases portion of the SSOC includes reference to VA outpatient treatment reports contained in the Virtual VA file dated after October 2010; namely, September 2012. As such, a remand for consideration of any documents contained in the Virtual File that are not physically of record in another SSOC pursuant to 38 C.F.R. § 20.1304(c) is not necessary. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. 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). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca, supra. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. DC 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X- ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Osteomalacia (DC 5014) and tenosynovitis (DC 5024) are rated as degenerative arthritis. Under DC 5260, a 10 percent rating is warranted for knee flexion limited to 45 degrees. A 20 percent rating under DC 5260 requires flexion to be limited to 30 degrees, and a 30 percent evaluation is warranted when flexion is limited to 15 degrees. Under DC 5261, a 10 percent rating is warranted for limitation of extension to 10 degrees. A 20 percent rating requires extension to be limited to 15 degrees, and a 30 percent evaluation is warranted when extension is limited to 20 degrees. The normal range of motion of the knee is from 140 degrees flexion to 0 degrees extension. 38 C.F.R. § 4.71, Plate II. In the event of a disability manifesting both limitation of flexion and limitation of extension, VA is to provide two separate ratings under DCs 5260 and 5261. See VAOPGCPREC 9-04, 69 Fed. Reg. 59990 (2004). Slight recurrent subluxation or lateral instability of a knee warrants a 10 percent rating under DC 5257. A 20 percent rating requires moderate recurrent subluxation or lateral instability, and a 30 percent evaluation is warranted for severe recurrent subluxation or lateral instability. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003/5010 and 5257, respectively. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604(1997). In VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998), the VA General Counsel further explained that, to warrant a separate rating, the limitation of motion need not be compensable under DC 5260 or 5261; rather, such limited motion must at least meet the criteria for a zero (0) percent rating. The service treatment records reflect treatment for left knee pain, and a January 2005 VA examination resulted in the conclusion by the examiner that the patellofemoral pain syndrome diagnosed in the left knee at that time was more likely than not related to service. No limitation of motion in the left knee was shown at this examination. Thereafter, a January 2005 rating decision granted service connection for patellofemoral pain syndrome in the left knee and assigned a noncompensable rating, effective May 16, 2001, under DC 5024 by analogy to tenosynovitis. In rating a disability that is not listed in the Ratings Schedule, it is permissible to rate that disability under a closely related disease or injury in which not only the functions affected, but the anatomical location and symptomatology are closely analogous. 38 C.F.R. § 4.20. This rating was increased to 10 percent, also effective from May 16, 2001, by a May 2005 rating decision after April 2005 VA outpatient treatment reports reflected complaints from the Veteran about tenderness and crepitus with a full range of motion in the left knee. The 10 percent rating for the left knee has been continued until the present time. An April 2006 VA examination resulted in a diagnosis of patellofemoral pain syndrome in the right knee. There was full motion in the right knee at this examination with complaints of pain at the end of the flexion. The examiner concluded that it was at least as likely as not that patellofemoral pain syndrome in the right knee was due to an altered gait pattern resulting from his left knee disability, and, therefore, was caused by or a result of the service-connected patellofemoral pain syndrome in the left knee. Thereafter, a May 2006 rating decision granted service connection for patellofemoral pain syndrome in the right knee as secondary to the service-connected left knee disability. A 10 percent rating was assigned for such disability by analogy to osteomalacia under DC 5014, effective February 21, 2006. This rating has been continued until the present time. The Veteran did not enter a notice of disagreement with respect to the initially assigned ratings for his bilateral knee disabilities. Moreover, no additional evidence demonstrating a worsening of the Veteran's left or right knee disability was associated with the claims file within one year of the issuance of the May 2005 and May 2006 rating decisions. In this regard, the Board notes that additional VA treatment records and an April 2006 VA examination report were associated with the claims file within one year of the May 2005 rating decision; however, while such demonstrate complaints of left knee pain, they do not demonstrate a worsening of such disability that would warrant an increased rating and, therefore, are not material to such issue. 38 C.F.R. § 3.156(b) (when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period); Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). Thereafter, VA received the Veteran's current claims for an increased ratings for his bilateral knee disabilities on February 26, 2008. Following the submission of his claims for increased ratings for his service-connected bilateral knee disabilities in February 2008, the medical history recorded at an August 2008 VA examination conducted in conjunction with these claims reflected no complaints of giving way or instability in either knee. The Veteran did complain about pain and stiffness in each knee, but reported having no weakness, episodes of dislocation or subluxation, locking, effusion, or flareups of joint disease. Upon physical examination in August 2008, the Veteran walked with an antalgic gait. Motion in the right knee was to 115 degrees of flexion with complaints of pain at 90 degrees and full extension with no complaints of pain. Motion in the left knee was to 118 degrees of flexion with complaints of pain at 90 degrees and full extension with no complaints of pain. There was no ankylosis and, in the portion of the examination devoted to a summary of general joint conditions, there was said to be tenderness in each knee but no bumps consistent with Osgood-Schlatter's disease, crepitation, masses, clicks, snaps, grinding, instability, or meniscus, tendon, or bursa abnormalities in either knee. X-rays showed joint effusion in each knee. The examiner stated that the service-connected bilateral knee disabilities resulted in no significant occupational effects and mild effects on the ability to exercise and engage in sports but no other effects on daily activities. At an April 2011 VA examination, the Veteran reported that his knee pain had steadily increased over the prior three to four years. He also described stiffness and locking when he sits in the same position for greater than 15 or 20 minutes. The Veteran also described occasional swelling, usually after kneeling or any pressure to the knee caps. He reported no subluxation, dislocation, or giving way. With respect to whether there were any flareups of joint disease, the Veteran reported that his knees are about the same most days and indicated his "bad days" occurred approximately 80 percent of the time. He reported that he wore braces on both knees approximately three days per week but did not utilize a cane or crutches. No hospitalizations, surgery, or injuries were described at the April 2011 VA examination, nor were any symptoms of inflammatory arthritis. The examiner stated that the Veteran's knee problems did not limit his ability to work and that he had not missed any days of work due to such problems. He was said to be able to complete an hour of yard work at a time but that he no longer played sports such as softball due to his knee disability. It was noted that the Veteran could stand for approximately one hour and walk for up to three miles although he is very sore the next day. Upon physical examination in April 2011, it was noted that there was guarding with patellar pressure and extremes range of motion with no swelling or erythema. There was tenderness with patellar pressure. No ankylosis or instability was described. Repetitive motion of both knees was completed without any increase in pain or decrease in motion. Motion in the right knee was from full extension to 108 degrees of flexion and motion in the left knee was from full extension to 127 degrees of flexion. There was no ligamentous laxity on collateral ligament stress testing and the drawer sign was negative in each knee. There was pain, but no locking, with McMurray's testing. At the March 2013 VA examination, which was provided as directed by the November 2012 remand, the Veteran reported chronic bilateral knee pain, greater on the right. He reported that the pain was worse with prolonged standing and sitting and that this also caused locking. The Veteran reported pain and popping with bending in the knees and flareups that occur with prolonged walking. He also described occasional swelling. The Veteran reported flare-ups of pain that prevent him from working, and estimated that he missed two to three weeks of work in 2012 due to knee pain. He stated that he used braces for his knees about three days a week and that he took meloxicam and tramadol daily. The Veteran reported that his medications did not help much and that used a cane with prolonged walking. He denied limitations with walking but stated that prolonged walking triggers a flare-up the next day. It was noted that the Veteran cannot run or play sports and that his ability to bend his knees was limited to the point that he could no longer ride his motorcycle. Standing and sitting were said to be limited to about 30 to 40 minutes. No surgery for the knees was described but the Veteran reported that he goes to a physical therapist that recommended exercises and advised him not to use his braces too much. Upon physical examination in March 2013, range of motion in the right knee was to 50 degrees of flexion with objective evidence of pain at 5 degrees and to full extension with no pain. Motion in the left knee was to 80 degrees of flexion with objective evidence of pain at 5 degrees and to full extension with no pain. The Veteran was able to perform repetitive (three times) motion with no additional loss of motion but some additional pain and hesitancy to bend his knees due to pain. Strength with motion in each knee was normal and there was no instability, subluxation, or dislocation. The Veteran was observed to walk with a stiff gait, avoiding bending his knees. It was noted that there was no degenerative or traumatic arthritis documented on X-ray. The examiner noted that the described symptoms seemed to be greater than what one would expect given his diagnosis and x-rays. It was noted that the Veteran used his knee braces regularly and a cane occasionally. The examiner indicated that knee disability did impact work to the extent that the Veteran missed two to three weeks of work in 2012 due to flare ups of knee pain that limited prolonged walking, standing, and sitting. With respect to the specific requests for the examiner in the November 2012 remand, the examiner noted that the claims file had been reviewed and that repetitive motion was accompanied by pain but no incoordination, weakness, or excess fatigue. She also noted that flareups resulted in pain that limited functioning but that there was no recurrent subluxation or instability in either knee. Review of the VA outpatient treatment records, to include those contain in the Virtual VA file, reveal references to knee complaints. These reports do not reflect that the Veteran's bilateral knee disabilities, for rating purposes, are more severe than that described at the VA examinations set forth above. In this regard, the records primarily reflect complaints of bilateral knee pain. In March 2010, it was noted that the Veteran had early arthritis in the knees. In fact, the limitation of flexion shown at the most recent VA examination was not shown on VA outpatient treatment records contained in the Virtual VA file dated September 21, 2010, January 28, 2011, February 2, 2012, and September 28, 2012, which reflect a full range of motion in each knee. Specifically, such records reflect that the Veteran complained of bilateral knee pain. On examination in September 2010 and January 2011, there was tenderness; however, in February 2012 and September 2012, there was no tenderness. At all four evaluations, he had normal full range of motion with pain with extension, but there was crepitus on the right. Applying the penitent legal criteria to the facts set forth above, the Board finds that a rating in excess of 10 percent is not warranted for either knee disability. As indicated, any disability due to osteomalacia under DC 5014 or tenosynovitis under DC 5024, the diagnostic codes under which, respectively, the service-connected right and left knee disabilities are listed, is to be rated on the basis of limitation of motion. In this regard, the current 10 percent ratings are assigned for symptoms of the bilateral knees that result in the functional loss of limitation of flexion to a noncompensable degree. Specifically, flexion was shown by the VA examination reports to be, at worst, limited to 50 degrees in the right knee and 80 degrees in the left knee. The Board notes that the March 2013 VA examiner noted that the Veteran experienced pain on flexion of both knees at five degrees. In this regard, while pain began at five degrees of flexion, such does not warrant a higher rating unless it actually results in additional functional loss. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. In the instant case, despite pain beginning at five degrees of flexion, the Veteran was still able to flex his right knee to 50 degrees and his left knee to 80 degrees. Moreover, other range of motion studies conducted during the appeal period, to include those conducted after repetitive motion, fail to demonstrate even such a limitation. Specifically, the Veteran had flexion to 115, with pain beginning at 90 degrees, and 108 degrees on the right and flexion to 118 degrees, with pain beginning at 90 degrees, and 127 degrees on the left at his August 2008 and April 2011 VA examinations, respectively. Moreover, VA treatment records, to include those dated most recently in September 2012, reflect normal full range of motion. Therefore, while the Veteran does experience pain on motion beginning at five degrees, such does not result in a functional loss that more nearly approximates flexion limited to a compensable degree, i.e., 45 degrees. Furthermore, at no time during the appeal period, has the Veteran's extension of either knee been limited, even in consideration of pain and other factors. In this regard, upon all three VA examinations and as noted in the VA treatment records, the Veteran has consistently had full extension without pain. In reaching this conclusion, the Board has considered the Veteran's subjective complaints of pain, stiffness, locking, swelling, popping, and flare-ups, and objective evidence of tenderness, effusion, and crepitus; however, such do not result in functional loss beyond painful, limited flexion. Therefore, the Board finds that the Veteran is not entitled to higher or separate ratings under DC 5260 or 5261. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 and the holdings in DeLuca and Mitchell, supra, the reports from the examinations and VA treatment records document consideration of these principles, and there is no indication that increased compensation would be warranted under these principles as such factors do not result in functional loss that more nearly approximates flexion or extension limited to a compensable degree. Thus, while the Veteran does not meet the criteria for even a zero percent rating based on limitation of flexion or extension, since there has been at least some limited and painful flexion, a 10 percent rating is warranted for each knee per 38 C.F.R. § 4.59, which has already been assigned. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that the painful motion provisions of 38 C.F.R. § 4.59 are not limited solely to claims involving arthritis of a joint). The Board has also considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5257; however, the Board finds no objective evidence of subluxation or instability in the right or left knee. Specifically, upon examination in August 2008, April 2011, and March 2013, there was no instability bilaterally. Furthermore, in April 2011, it was noted that there was no ligamentous laxity and drawer signs were negative bilaterally. Likewise, there was no subluxation bilaterally at the time of the March 2013 VA examination. The Board acknowledges that, at the April 2011 and March 2013 VA examinations, the Veteran reported locking; however, upon objective examination in April 2011, there was no locking with McMurray's testing. Likewise, at both examinations, there was no instability, laxity, or subluxation. Furthermore, as a layperson, the Veteran is not competent to diagnose internal instability or subluxation. In this regard, while he is competent to report that his knees lock, there is no indication that she possesses the requisite knowledge to administer or interpret specialized testing that would reveal instability or subluxation. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The VA examiners, medical professionals, found that there was no laxity, instability, or subluxation in either knee. Based on the foregoing, the objective medical evidence shows that the Veteran's bilateral knees are stable without instability or subluxation. Accordingly, a separate rating for instability or subluxation of the either knee under Diagnostic Code 5257 is not warranted in this case. The Board also observes that a March 2010 VA treatment record noted that the Veteran had early arthritis in the knees; however, such was stated without the benefit of X-rays and, in March 2013, there was no degenerative or traumatic arthritis documented on X-ray in March 2013. Therefore, DC 5003 is inapplicable. The Board has also considered whether the Veteran is entitled to a separate or rating for ankylosis, cartilage dislocation or removal, impairment of the tibia or fibula, and/or genu recurvatum. However, because the evidence of record fails to demonstrate such symptomatology, the Veteran is not entitled to an increased or separate rating under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263, respectively. In this regard, the Board notes that VA examinations and VA treatment records reveal that the Veteran is capable of range of bilateral knee motion, albeit limited. Furthermore, such evidence fails to reveal any abnormality of the meniscus. Likewise, there is no evidence of impairment of the tibia or fibula, or genu recurvatum. Therefore, the rating criteria for ratings in excess of 10 percent for patellofemoral pain syndrome of the right and left knees are not met, to include on the basis of a staged rating. 38 C.F.R. § 4.71a, DCs 5014, 5024. See Hart, supra. In making its determinations in this case, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony, to include that presented orally at the July 2012 hearing before the undersigned, is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. The Board has also contemplated whether the case should be referred for extra-schedular consideration for either disability at issue. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In this regard, at his July 2012 Board hearing, the Veteran and his representative argued that extra-schedular ratings were warranted for his bilateral knee disabilities. In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected disabilities at issue with the established criteria found in the rating schedule. The Board finds that the disabilities at issue are fully addressed by the rating criteria under which his knee disabilities are rated. In this regard, the specific diagnostic criteria adequately address the whole of the Veteran's symptoms referable to his service-connected knee disabilities. There are no additional symptoms of the service-connected disabilities at issue. In this regard, a wide range of signs and symptoms are contemplated in the applicable rating criteria for the Veteran's knee disabilities. These service-connected disorders require application of the holding in Deluca, supra, and Mitchell, supra, which, in turn, requires consideration of 38 C.F.R. §§ 4.40 and 4.45. Furthermore, Burton, supra, requires consideration of 38 C.F.R. § 4.59. 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation as well as any painful arthritic motion. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected disabilities addressed above. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating for either of the service-connected disabilities addressed above is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). "Because the VA disability rating schedule is designed to consider the disabling effect of disabilities separately, no single DC provision will adequately assess the variety of symptoms involved with multiple service-connected disabilities." Johnson v. Shinseki, No. 10-1785, slip op. at 10 (Vet. App. Mar. 27, 2013) (en banc). Thus, as to the question of "whether [38 C.F.R.] § 3.321(b)(1) requires VA to consider multiple service-connected disabilities on a collective basis" the Court held that it did not. Johnson v. Shinseki, No. 10-1785, slip op. at 4 (Vet. App. Mar. 27, 2013) (en banc) (noting that a concurring opinion in Brambley v. Principi, 17 Vet. App. 20, 27 (2003) that there should have been a determination of "whether the appellant's service-connected disabilities as a whole [sic] entitled [a Veteran] to [an extra-schedular rating] under § 3.321(b)(1)" had never been adopted by the Court and concurring opinions are not binding on the Court" (citing Maryland v. Wilson, 519 U.S. 408, 412-13). Stated in other terms, an extraschedular rating may not be assigned for the cumulative impact of the service-connected disabilities herein at issue. Finally, the Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), that a total rating based on individual unemployability due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, however, the record does not suggest, and the Veteran does not allege, that his service-connected bilateral knee disabilities have rendered him unemployable. Rather, the evidence shows that the Veteran has maintained full-time employment during the appeal period. Furthermore, the interference of such service-connected disabilities upon his employment, to include missing work and cutting back on overtime, is addressed by the schedular rating criteria. 38 U.S.C.A. § 1155 ; 38 C.F.R. § 4.1. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. In sum, Board finds that the preponderance of the evidence is against entitlement to ratings in excess of 10 percent for patellofemoral pain syndrome of the right and left knees; as such, the benefit of the doubt doctrine is not applicable and the claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER A rating in excess of 10 percent for patellofemoral pain syndrome of the right knee is denied. A rating in excess of 10 percent for patellofemoral pain syndrome of the left knee is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs