Citation Nr: 1318905 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 09-22 036 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUE Entitlement to an increased disability rating for left knee petellofemoral syndrome with medial meniscus tear and limited motion, rated at 20 percent prior to January 5, 2010 and 30 percent since January 5, 2010. REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from May 1953 to April 1955. This appeal comes before the Board of Veterans' Appeals (Board) from a January 2009 rating decision of the RO in Roanoke, Virginia. In March 2009, the Veteran presented testimony at a hearing before RO personnel. A transcript of that hearing is associated with the claims file. In October 2012, the Veteran presented testimony at a Board hearing chaired by the undersigned Veterans Law Judge, who was seated in Washington, D.C. A transcript of that hearing is also associated with the claims file. Although the Veteran initiated appeals regarding the issues of entitlement to service connection for a left shoulder disability and a lumbar spine disability, which were denied in the January 2009 rating decision, he specified on the VA Form 9 that he did not intend to perfect an appeal as to those issues. Where a claimant expressly indicates an intent that adjudication of certain specific claims not proceed at a certain point in time, neither the RO nor the Board has authority to adjudicate those specific claims. See Hamilton v. Brown, 4 Vet. App. 528 (1993). In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. For the entire period of this appeal, the Veteran's service-connected left knee petellofemoral syndrome with medial meniscus tear and limited motion has been manifested by arthritis, weakened motion and painful motion resulting in decreased extension and flexion; however, flexion is not limited to 45 degrees and extension is not limited to 30 degrees. CONCLUSIONS OF LAW 1. Prior to January 5, 2010, the criteria for a 30 percent disability rating for left knee petellofemoral syndrome with medial meniscus tear and limited motion are met for the entire period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256, 5258-63 (2012). 2. The criteria for a disability rating in excess of 30 percent for left knee petellofemoral syndrome with medial meniscus tear and limited motion are not met for any portion of the period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256, 5258-63 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the Veteran submitted his claim for an increased disability rating in August 2008. The RO sent him a letter in October 2008 advising him of the information and evidence necessary to substantiate the claim and how disability ratings and effective dates are generally assigned. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Since the October 2008 letter was sent to the Veteran prior to the initial adjudication of the claim in January 2009, there exists no error in the timing of this notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). There is also no error in the content of the notice provided. The RO also provided additional information regarding disability ratings and the criteria applicable to the Veteran's increased rating claim in compliance with a decision of the CAVC that was subsequently vacated by the Federal Circuit. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In short, VA has complied with its duty to notify the Veteran in this case. The Board is cognizant that, when conducting a hearing, a VA hearing officer, to include a Veterans Law Judge, must suggest that a claimant submit evidence on any issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103 (2012). The hearing officer also must suggest the submission of evidence when testimony during the hearing indicates that it exists (or could be reduced to writing) but is not of record. Here, during the October 2012 Board hearing, the Veterans Law Judge verified which treatment providers had treated the left knee, elicited testimony as to the extent of range of motion, the severity of pain, the specific limitations regarding activities of daily life, and the effectiveness of various methods of symptom relief. Such actions put the Veteran on notice as to the evidence necessary in his case, supplementing the VCAA, and complying with 38 C.F.R. § 3.103. VA has made reasonable efforts to obtain relevant records and evidence in this case. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, private treatment records identified and submitted by the Veteran, a letter submitted by the Veteran's wife, and the Veteran's written assertions and personal hearing testimony. The Board acknowledges that the Veteran has asserted in written correspondence that certain records pertaining to post-service treatment were destroyed in the 1973 fire at the National Personnel Records Center (NPRC) in St. Louis. There is no indication other than the Veteran's assertion that any records pertaining to the Veteran were destroyed in the 1973 fire. The National Archives website indicates that the records affected were "Official Military Personnel Files," not VA treatment records as the Veteran asserts. The Veteran's service treatment records were obtained from the NPRC and associated with the claims file in 1955, well prior to the 1973 fire. Since 1955, these records have been located in the Veteran's VA claims file. While there is no indication that the asserted post-service VA records were destroyed in the 1973 fire, there is also no indication that the post-service treatment records noted by the Veteran would have any bearing on his symptomatology during the period of his current claim and appeal. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of his left knee disability. These examinations were adequate because each was performed by a medical professional based on solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The examination reports include findings pertinent to the rating criteria and are otherwise consistent with the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). Disability Ratings - Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Although the claimant's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In Hart v. Mansfield, 21 Vet. App. 505, 511 (2007), the CAVC extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved 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 rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Analysis The Veteran is seeking an increased disability rating for left knee petellofemoral syndrome with medial meniscus tear and limited motion. He generally contends that the disability is worse than is reflected by the current ratings. The history of the RO's attempts to categorize and rate this disability is complex. Service connection was granted for a left knee disability - originally characterized as tibial tuberosity/patellar tendonitis - in a January 2005 rating decision. A 10 percent rating was assigned under Diagnostic Code 5024-5260, effective December 9, 2003. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5024 is the code for tenosynovitis, and instructs the rating specialist to apply the codes for limitation of motion. Diagnostic Code 5260 rates on the basis of limitation of flexion of the knee. In a June 2008 rating decision, effective March 31, 2008, the disability rating was increased to 20 percent and the disability was recharacterized as patellofemoral syndrome, severe, with medial meniscus tear. The Diagnostic Code was changed to 5010-5257. Diagnostic Code 5010 applies to arthritis due to trauma and, as with Diagnostic Code 5024, it simply directs the rating specialist to apply the codes for limitation of motion. Oddly, the RO chose to apply Diagnostic Code 5257, which does not address limitation of motion, but addresses lateral instability and recurrent subluxation, even though, in the March 2008 decision, the RO noted a finding of no instability. In a June 2012 rating decision, the RO increased the rating for the left knee disability, but once again changed the diagnostic code and characterization of the disability. The RO characterized the disability that had previously been rated at 20 percent as patellofemoral syndrome, severe, with medial meniscus tear and limited range of motion. The rating was increased to 30 percent, effective January 5, 2010. The diagnostic code assigned by the RO was Diagnostic Code 5261 (limitation of extension). The RO did not acknowledge that this aspect of the disability had previously been rated under different diagnostic codes; rather, the rating sheet now reflects that Diagnostic Code 5261 has always been assigned (dating back to December 9, 2003). In the June 2012 decision, the RO also granted service connection for degenerative joint disease with instability of the left knee, and assigned a separate 10 percent rating under Diagnostic Code 5010-5257, effective April 18, 2010. Although notified of his right to appeal this decision, the Veteran has not appealed any aspect of the grant of service connection for degenerative joint disease with instability of the left knee. Therefore, the issue before the Board is limited to the rating assigned for left knee petellofemoral syndrome with medial meniscus tear and limited motion. The diagnostic codes governing limited motion of the knee include 5256 (ankylosis), 5260 (limitation of flexion), 5261 (limitation of extension). Under Diagnostic Code 5256, ankylosis of the knee is rated as follows: 60 percent - extremely unfavorable, in flexion at an angle of 45 degrees or more; 50 percent - in flexion between 20 degrees and 45 degrees; 40 percent - in flexion between 10 degrees and 20 degrees; 30 percent - favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. Under Diagnostic Code 5260, limitation of flexion is rated as follows: 30 percent - flexion limited to 15 degrees; 20 percent - flexion limited to 30 degrees; 10 percent - flexion limited to 45 degrees; 0 percent - flexion limited to 60 degrees. Under Diagnostic Code 5261, limitation of extension is rated as follows: 50 percent - extension limited to 45 degrees; 40 percent - extension limited to 30 degrees; 30 percent - extension limited to 20 degrees; 20 percent - extension limited to 15 degrees; 10 percent - extension limited to 10 degrees; 0 percent - extension limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5260, 5261. The report of VA examination in May 2008 reveals that active motion of the left knee against gravity was measured from 0 to 100 degrees. Pain began at 90 degrees and ended at 0 degrees. Passive range of motion was the same as active. An April 2008 report from Orthopedic Specialty Clinic reflects range of motion from 0 to 135 degrees. Later the same month, range of motion was measured from 0 to 105 degrees. In May 2008, range of motion was within functional limits. In July 2008, good range of motion of both knees was recorded. In January 2009, the knee examination showed good motion with full flexion. In August 2009, the left knee had an extension lag of about 5 degrees and flexion to 110 degrees. In May 2009, the left knee had motion from 3 to 125 degrees. In April 2009, the left knee had 0 to 115 degrees of motion, limited by pain on the medial joint line. In June 2011, the left knee had flexion to at least 130 degrees. In September 2011, the left knee had 0 to 130 degrees of motion. In September 2012, the left knee had flexion to at least 130 degrees. An April 30, 2009 report from Orthopedic and Sports Physical Therapy Associates reveals left knee range of motion was from 0 to 130 degrees of flexion passively and 0 to 120 degrees actively. On April 8, 2009, left knee range of motion was from 0 to 126 degrees of knee flexion passively and only 0 to 115 degrees actively. The January 2010 VA examiner recorded range of motion from 20 degrees to 110 degrees. There was no objective evidence of pain associated with motion. There was no additional limitation with repetition. The April 2012 VA examiner recorded range of motion from 20 degrees to 110 degrees, with onset of pain at 100 degrees. There was no decrease following repetition. The examiner noted pain, weakness, and fatigue. Muscle strength was 4 out of 5 on flexion and extension. After a review of all of the evidence, the Board finds that the evidence in favor of the assignment of a 30 percent rating prior to January 5, 2010 is in approximate balance with the evidence against a higher rating. All reasonable doubt is therefore resolved in the Veteran's favor. However, the weight of the evidence demonstrates that a disability rating in excess of 30 percent is not warranted during any portion of the period on appeal. Turning first to the period prior to January 5, 2010, the Board's finding that a 30 percent rating is warranted during this period is based largely on the Veteran's written assertions and hearing testimony. The RO assigned the effective date of January 5, 2010 based on the date of the VA examination. However, the Board finds that the January 2010 examination simply provided confirmation of the Veteran's assertion in his claim that his symptoms had worsened. The Board acknowledges that, prior to January 5, 2010, the findings for range of motion did not demonstrate a limitation to 20 degrees on extension. However, it is the Veteran's contention that these findings did not reflect his true abilities. The Veteran testified that, while the examiners were performing range of motion, he was gritting his teeth, and that, he could never reproduce on his own the range of motion these examiners reported. The Veteran is competent to report his observation of the range of motion he can produce in everyday activities. The Veteran's assertion is also bolstered by some discrepancies in the clinical findings for extension. While the findings have generally showed full extension, a January 2009 examination from the Orthopedic Specialty Clinic, after reporting good range of motion, noted that the Veteran lacks a few degrees from full extension. In August 2009, the examiner noted an extension lag of about 5 degrees, and that he lacks about 5 degrees from full extension. Records from the Orthopedic and Sports Physical Therapy Associates also reflect a finding that the Veteran lacks terminal knee extension - although the degree was not specified. While the Board acknowledges that the reports prior to January 5, 2010 examination do not specify the degree of limited extension supportive of a 30 percent rating, i.e., 20 degrees, the Board interprets these findings in light of the Veteran's testimony that his knee was generally put through a range of motion that he could never reproduce on his own. It may be that the Veteran simply gritted his teeth, as he testified, and cooperated with the examiners despite pain. The Board finds that the Veteran's testimony is credible and appears to be corroborated in part by clinical findings noted above. The Board has also considered the functional impairment associated with the disability, including pain and demonstrable decrease in strength resulting in difficulties with standing, walking, and also climbing and descending stairs. This will be addressed in greater detail below; however, this evidence supports the Board's finding that, notwithstanding the failure to meet the schedular criteria, the evidence for and against entitlement to a 30 percent rating prior to January 5, 2010 is in approximate balance. Perhaps as an aside, the Board also notes that the official RO characterization of the Veteran's patellofemoral syndrome with medial meniscus tear and limited range of motion since March 2008 has included the descriptor "severe." While the current rating sheet no longer acknowledges the prior use of Diagnostic Code 5257 to rate this disability, in fact, from March 31, 2008 to January 5, 2010, Diagnostic Code 5257 was applied to this disability. Unlike the codes for range of motion, Diagnostic Code 5257 uses categorizations of slight, moderate, and severe impairment to rate knee disabilities. Severe impairment under Diagnostic Code 5257 warrants a 30 percent rating. It would appear to be inconsistent with logic to designate the disability as "severe" in the rating sheet, and then find that severe impairment was not shown. In sum, the Board finds that, prior to January 5, 2010, the evidence demonstrating a limitation of left knee extension to the degree warranted for a 30 percent rating is in approximate balance with the evidence against the claim. With resolution of all reasonable doubt in favor of the Veteran, a 30 percent rating is warranted for the entire period on appeal. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that a disability rating in excess of 30 percent is not warranted during any portion of the period on appeal. Regarding limited extension, while higher ratings of 40 percent and 50 percent are available, they require extension that is limited to 30 degrees and 45 degrees, respectively. The maximum recorded limitation of extension is 20 degrees, as recorded by the January 2010 and April 2012 VA examiners. All other measurements have shown limitation to a lesser degree. The Board also notes that it has considered functional impairment and extended the benefit of the doubt simply to find that a 30 percent rating was warranted prior to the January 2010 examination. The evidence regarding any higher rating weighs against the claim. Regarding limited flexion, the Board notes that a separate rating is available in addition to the rating for limited extension, but only if symptomatology is demonstrated to a compensable degree. In this case, the evidence must show flexion that is limited at least to 45 degrees. Such symptomatology is not demonstrated or approximated at any time pertinent to the appeal. In each instance, flexion of the left knee has exceeded 45 degrees and a separate compensable rating is not warranted for limited flexion. The Board also notes that the Veteran has never been found to have ankylosis, and the May 2008 examiner specifically found no ankylosis. The demonstrated motion of the knee is definitive evidence that there is no ankylosis, which is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Augustine v. Principi, 18 Vet. App. 505, 506 (2004), citing Dorland's Illustrated Medical Dictionary 86 (28th ed.1994). Therefore, a rating under Diagnostic Code 5256 is not warranted. As noted above, the Board has considered the functional impairment caused by the knee disability to determine whether, notwithstanding the measured ranges of motion, the criteria for a higher rating are more nearly approximated than the current 30 percent rating. At the Board hearing, the Veteran's testimony was focused on pain and weakness on motion. He testified that he had a lot of steps at his home and "[s]tairs kill me." He testified that he avoids stairs when possible, but he has trouble negotiating the stairs. He also testified that he is scared to go up a ladder. He had to stop working with his son due to his inability to go up a ladder. He also testified that he is now to the point where he cannot get down on his knees any longer or get back up. He testified that he had previously planted many shrubs at his home, but he could not do that now. The May 2008 VA examination report reveals a limitation on standing of 15 to 30 minutes and walking of up to 1/4 mile. The Veteran reported giving way, pain, stiffness, and weakness. He reported severe flare ups on a weekly basis, during which the Veteran limits strenuous activity, but continues activities of daily life. These last for hours. The Veteran's gait was noted as antalgic with poor propulsion. The gait impairment was underscored by increased wear on the outside edge of the heel of the left shoe. There was bony enlargement, crepitus, edema, tenderness, painful movement, and guarding. There were clicks and snaps and subpatellar tenderness. The effect of the disability on activities of daily life was described as follows: sports are prevented; there is severe impairment of exercise; there is moderate impairment of chores, shopping, recreation, and traveling; there is mild impairment of bathing; there is no impairment of feeding, dressing, toileting, and grooming. An April 2008 report from Orthopedic Specialty Clinic reflects complaints of left knee medial pain and popping which is exquisite. It comes and goes. There is tenderness on the medial joint line. Later that month, it was noted that the Veteran has a gait dysfunction and increased pain with prolonged standing. There was still occasional locking and giving-out. In July 2008, it was noted that the Veteran had a normal gait pattern. An April 2009 report shows ongoing pain and dysfunction of the left knee; he was unable to perform several activities of daily living, including going up and down steps, as well with an occasional sense of giving out, though he had not specifically fallen due to the left knee. In August 2009, the Veteran reported pain and crepitus, but no locking, giving out, or swelling. In September 2012, the Veteran reported persistent left knee pain concentrating predominantly on the medial joint line. He had significant difficulty with ambulation and also climbing and descending stairs. An April 30, 2009 report from Orthopedic and Sports Physical Therapy Associates reveals complaints of left knee pain. The Veteran reported difficulty with stair ambulation and transitioning from sitting to standing. On evaluation, strength and flexibility deficits were present. The Veteran reported 70 to 80 percent improvement in left knee complaints. He felt the combination of physical therapy and a heel lift had helped to decrease left knee complaints. Manual muscle testing showed strength of 4 out of 5 on quadriceps and hamstrings. On April 8, 2009, strength deficits were noted throughout the bilateral lower extremities. Squatting greater than 45 degrees produced left knee complaints. Resistive testing of the lower extremity revealed generalized weakness. Manual muscle test scores of quadriceps strength were 4 out of 5. The January 2010 VA examiner noted that the Veteran could stand for 15 to 30 minutes and walk 1/4 mile. He walked with an antalgic gait. There was evidence of abnormal shoe wear and callous formation. The Veteran reported that he could not do yard work or climb ladders. The effects of the disability on usual daily activities were summarized in the report. There was a severe impact on chores and a mild impact on exercise. There was no impact on shopping, sports, recreation, traveling, feeding, bathing, dressing, toileting, grooming, or driving. The April 2012 VA examiner noted that the left knee hurts constantly, and this is a sharp ache. There is popping, especially with descending stairs. Pain is worse with prolonged sitting. Thus, during the entire period on appeal, the Veteran's left knee petellofemoral syndrome with medial meniscus tear and limited motion has resulted in pain and demonstrable decrease in strength resulting in difficulties with prolonged sitting, kneeling, standing, walking, navigating stairs, and using ladders. The Board finds that the type and degree of functional impairment demonstrated in this case are reflected in the decreased range of motion found to be present, and are consistent with the 30 percent rating assigned. It is clear from the record that the Veteran has joint pathology. In addition, there is limited motion, weakened motion, and painful motion. The provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to at least the minimum compensable evaluation for limitation of motion due to pain. See also Burton v. Shinseki, 25 Vet. App. 1 (2011). However, evaluations in excess of the minimum compensable rating must be based on demonstrated functional deficit. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. The examination results in this case exclude the possibility that the range of extension was ever limited-either by functional loss due to pain or structural limitation-to 30 degrees, or that range of flexion was ever limited to 45 degrees. The issue is not whether pain additionally limits motion, but whether that additional limitation would decrease the flexion or extension to the degrees specified for higher ratings. On this record, the Board finds that there was no such limitation of motion. Diagnostic Code 5258 provides a 20 percent rating for a dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of the semilunar cartilage. As these maximum ratings are less than the current rating, these codes are of no advantage to the Veteran. Moreover, separate compensable ratings under these codes are not appropriate. The meniscal symptomatology identified by the April 2012 VA examiner consisted of frequent episodes of joint pain, with no locking or effusion. The January 2010 examiner also noted no episodes of locking or effusion. At the RO hearing in March 2009, the Veteran reported that his left knee does not lock. Joint pain is already considered in the 30 percent rating under the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca. Accordingly, a separate rating under Diagnostic Codes 5258 or 5259 is not appropriate. Diagnostic Code 5263 (genu recurvatum) provides a maximum 10 percent rating; however, there is no finding of this condition. Diagnostic Code 5262 governs nonunion or malunion of the tibia and fibula. While this code provides a maximum 40 percent rating, this requires nonunion of the tibia and fibula with loose motion. Such symptomatology is neither shown objectively nor asserted by the Veteran. The Board also acknowledges that the Veteran has been found to have a 1/2-inch discrepancy in leg length, the left leg being shorter than the right. While it is unclear whether this is attributable to his left knee disability, the Board simply notes that the criteria for a compensable rating for shortening of an extremity require a discrepancy of at least 1-1/4 inches. Finally, the Board acknowledges the Veteran's report that a left knee replacement has been recommended by his physician. Ratings in excess of 30 percent are available on the basis of prosthetic knee replacement, and the Veteran currently has a prosthetic right knee, which is rated at 60 percent. However, the basic rating for a prosthetic knee replacement is 30 percent. Higher ratings require residual impairment. It would be pure speculation for the Board to assign a rating based on residual impairment from a procedure that has not been performed. For the reasons discussed, the Board finds that, while the evidence in favor of the assignment of a 30 percent rating prior to January 5, 2010 is in approximate balance with the evidence against a higher rating, the weight of the evidence demonstrates that a disability rating in excess of 30 percent is not warranted during any portion of the period on appeal. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath, 1 Vet. App. at 593. The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation 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 as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. 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. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected left knee symptomatology. The Veteran's symptoms include pain and weakness resulting in difficulties with kneeling, prolonged sitting, standing, walking, climbing and descending stairs, as well as using ladders. The criteria specifically provide for ratings based on the presence of limitation of flexion and limitation of extension, and they include higher ratings where appropriate limitation is shown. Moreover, the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca expand the scope of the schedular criteria to encompass orthopedic factors such as pain, weakness, fatigue, and incoordination, and the limitations these factors impose on the Veteran's ability to function in everyday activities and employment. Such factors are therefore explicitly part of the schedular rating criteria. Moreover, a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER Prior to January 5, 2010, a 30 percent rating, but not higher, for left knee petellofemoral syndrome with medial meniscus tear and limited motion is granted. For the entire period, a disability rating in excess of 30 percent for left knee petellofemoral syndrome with medial meniscus tear and limited motion is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs