Citation Nr: 1319024 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 12-08 871 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for service-connected osteoporosis of the cervical spine. 2. Entitlement to an initial evaluation in excess of 10 percent for service-connected osteoporosis of the lumbar spine. 3. Entitlement to an initial evaluation in excess of 10 percent for service-connected osteoporosis of the left knee. 4. Entitlement to an initial evaluation in excess of 10 percent for service-connected osteoporosis of the right knee. [Entitlement to service connection for arthritis of multiple joints to include as due to Agent Orange exposure and as secondary to service connected skin disorder; entitlement to benefits under the provisions of 38 U.S.C.A. § 1151 for arthritis of multiple joints as due to VA treatment for a skin disorder; entitlement to benefits under the provisions of 38 U.S.C.A. § 1151 for a vision disorder as due to VA treatment for a skin disorder; and entitlement to benefits under the provisions of 38 U.S.C.A. § 1151 for a kidney disorder, including hematuria, as due to VA treatment for a skin disorder, are the subject of a separate decision.] REPRESENTATION Veteran represented by: Daniel G. Krasnegor, Attorney ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from June 1966 to April 1970. This matter comes before the Board of Veterans Appeals (Board) from rating decisions of the RO. The case has a complex history: By an October 2009 decision, the Board granted service connection for osteoporosis. Consequently, in a November 2009 rating decision, the RO granted service connection for osteoporosis of the back, neck and knees, as these are the joints the Veteran identified in his original claim as being affected by osteoporosis, filed in December 1993. In November 2009, the Veteran filed a notice of disagreement with respect to the initial disability ratings assigned. He also expressed disagreement with regard to the fact that service connection was not granted for other joints apparently afflicted with osteoporosis. In a February 2013 rating decision, the RO granted service connection for osteoporosis of the ankles bilaterally and for osteoarthritis of the hips bilaterally and assigned a noncompensable initial evaluation for each disability. The Veteran has not expressed any disagreement with the initial ratings assigned. In October 2012, the Board remanded the issues enumerated above to the RO for additional development of the evidence. In addition, the Board remanded an issue identified as entitlement to a compensable rating for osteoporosis of joints other than the cervical spine, lumbar spine, right knee, and left knee. That issue was mischaracterized as one of an increased rating, as the issue of service connection for osteoporosis of additional joints was the one appealed by the Veteran. It was therefore premature to address an increased rating question for a disability for which service connection had not yet been granted. In a February 2013 rating decision, the RO granted service connection for the additional joints found to have been afflicted with osteoporosis. If the Veteran wishes to appeal either the initial ratings or effective dates assigned to the now service-connected osteoporosis of the ankles and hips, he must file a notice of disagreement and pursue the appeal process outlined in the pertinent regulations. See 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.302 (2012) (outlining the procedures and time limitations for appealing adverse RO determination to the Board). Regarding the Board's October 2012 remand, the Board finds that its directive were accomplished satisfactorily, and the Board concludes that it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Of course, the Veteran is reminded that he has a combined schedular rating of 100 percent and has also been awarded total disability based on individual unemployability (TDIU). Pending at the RO is the matter of whether an earlier effective date for TDIU is warranted. It is not before the Board at this time. In this regard, the Veteran (and his attorney) should be aware that filing additional claims for increase, when already receiving a total combined schedular rating, only delays the adjudication of his TDIU earlier effective date claim. As noted above, the Board has issued a separate decision addressing service connection for arthritis of multiple joints, and for benefits under the provisions of 38 U.S.C.A. § 1151 for arthritis, a vision disorder, and a kidney disorder, including hematuria. FINDINGS OF FACT 1. The Veteran's cervical spine osteoporosis is manifested by no more than moderate limitation of motion. 2. The Veteran's thoracolumbar spine osteoporosis is manifested by no more than slight limitation of motion. 3. The Veteran's service-connected left knee osteoporosis is manifested by no more than complete range of motion and some subjective symptomatology. 4. The Veteran's service-connected right knee osteoporosis is manifested by no more than complete range of motion and some subjective symptomatology CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability evaluation of 20 percent, but no higher, for the Veteran's service-connected cervical spine osteoporosis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5013 and 5235 to 5243 (2012) and 38 C.F.R. § 4.71a, Diagnostic Code 5290 (effective prior to September 23, 2003). 2. The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected low back osteoporosis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5013 and 5235 to 5243 (2012) and 38 C.F.R. § 4.71a, Diagnostic Code 5291, 5292 (effective prior to September 23, 2003). 3. The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected left knee osteoporosis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5013 and 5235 to 5243 (2012). 4. The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected right knee osteoporosis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.71a, Diagnostic Codes 5003-5013 and 5235 to 5243 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3 (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 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 the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of a veteran's disability. Schafrath, 1 Vet. App. at 594. Because the appeals are from the initial rating assigned with the grant of service connection, the possibility of "staged" ratings for separate periods during the appeal period, based on the facts found, must also be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). Osteoporosis of the cervical spine Osteoporosis of the cervical spine has been rated 10 percent disabling by the RO under Diagnostic Code 5013. 38 C.F.R. § 4.71a. Diagnostic Code 5013 pertains to osteoporosis. The diseases listed under Diagnostic Codes 5013-5024, that is, osteoporosis, osteomalacia, benign new growths of bones, osteitis deformans, gout, intermittent hydrarthrosis, bursitis, synovitis, myositis, periostitis, myositis ossificans, and tenosynovitis, are rated on limitation of motion of the affected parts, as degenerative arthritis, under Diagnostic Code 5003, except for gout which is rated under Code 5002. 38 C.F.R. § 4.71a, Diagnostic Codes 5021-5024. During the pendency of the Veteran's claim and appeal, the rating criteria for evaluating intervertebral disc syndrome were amended. See 38 C.F.R. § 4.71a, Diagnostic Code 5293, effective September 23, 2002. See 67 Fed. Reg. 54,345-49 (Aug. 22, 2002). In 2003, further amendments were made for evaluating disabilities of the spine. See 68 Fed. Reg. 51,454-58 (Aug. 27, 2003) (codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2012)). An omission was then corrected by reinserting two missing notes. See 69 Fed. Reg. 32,449 (June 10, 2004). The latter amendment and subsequent correction were made effective from September 26, 2003. Where a law or regulation (particularly those pertaining to the Rating Schedule) changes after a claim has been filed, but before the administrative and/or appeal process has been concluded, both the old and new versions must be considered. See VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 3-2000 (Apr. 10, 2000). The effective date rule established by 38 U.S.C.A. § 5110(g) (West 2002), however, prohibits the application of any liberalizing rule to a claim prior to the effective date of such law or regulation. Prior to September 23, 2002, under the old regulations, under Diagnostic Code 5293, when disability from intervertebral disc syndrome was mild, a 10 percent rating was assigned. When disability was moderate, with recurring attacks, a 20 percent evaluation was warranted. A 40 percent rating was in order when disability was severe, characterized by recurring attacks with intermittent relief. A maximum schedular rating of 60 percent was awarded when disability from intervertebral disc syndrome was pronounced, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2002), effective prior to September 23, 2002. Under the revised regulations for Diagnostic Code 5293, effective September 23, 2002, intervertebral disc syndrome (preoperatively or postoperatively) was evaluated either on the total duration of incapacitating episodes over the past 12 months or by combining under Sec. 4.25 separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5293, effective September 23, 2002. A 10 percent evaluation was warranted with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. Id. A 20 percent evaluation was assigned with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. Id. With incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 evaluation was warranted. Id. A 60 percent evaluation was assigned with incapacitating episodes having a total duration of at least six weeks during the past 12 months. Id. Note (1): For purposes of evaluations under 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." Chronic orthopedic and neurologic manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Note (2): When evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Evaluate neurologic disabilities separately using evaluation criteria for the most appropriate neurologic diagnostic code or codes. Note (3): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. Under Diagnostic Code 5290, effective prior to September 26, 2003, a rating of 10 percent was warranted for slight limitation of motion of the cervical spine; a 20 percent was assigned for moderate limitation of motion of the cervical spine; and a 30 percent rating was assigned for severe limitation of motion of the cervical spine. 38 C.F.R. 4.71a , DC 5290 (2003), effective prior to September 26, 2003. Under Diagnostic Code 5291, effective prior to September 26, 2003, a rating of zero percent was warranted for slight limitation of motion of the dorsal spine; a 10 percent was assigned for moderate limitation of motion of the dorsal spine; and a 10 percent rating was assigned for severe limitation of motion of the dorsal spine. 38 C.F.R. 4.71a, Diagnostic Code 5291 (2003), effective prior to September 26, 2003. Under Diagnostic Code 5292, effective prior to September 26, 2003, a rating of 10 percent was warranted for slight limitation of motion of the lumbar spine; a 20 percent was assigned for moderate limitation of motion of the lumbar spine; and a 40 percent rating was assigned for severe limitation of motion of the lumbar spine. 38 C.F.R. 4.71a, Diagnostic Code 5292 (2003), effective prior to September 26, 2003. The Board observes that the words "slight", "moderate", and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. § 4.6 (2012). It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104(a) (West 2002); 38 C.F.R. §§ 4.2, 4.6 (2012). Prior to September 26, 2003, under Diagnostic Code 5295, a 10 percent evaluation was warranted for lumbosacral strain if it was manifested by characteristic pain on motion. A 20 percent evaluation was assigned when lumbosacral strain was manifested by muscle spasm on extreme forward bending and loss of lateral spine motion, unilateral, in the standing position. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2002), effective prior to September 26, 2003. A 40 percent evaluation was assigned for lumbosacral strain when it was manifested by severe symptomatology that included listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of motion on forward bending in standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. Id. Effective prior to September 26, 2003, Diagnostic Code 5285 pertained to residuals of vertebral fractures. 38 C.F.R. 4.71a, Diagnostic Code 5285 (2003), effective prior to September 26, 2003. Diagnostic Code 5286 pertained to spinal ankylosis. 38 C.F.R. 4.71a, Diagnostic Code 5286 (2003), effective prior to September 26, 2003. Diagnostic Coded 5287, 5288, and 5289 pertained to ankylosis of the cervical spine, dorsal spine, and lumbar spine respectively. 38 C.F.R. 4.71a, Diagnostic Codes 5287, 5288, 5289 (2003), effective prior to September 26, 2003. Diagnostic Code 5294 pertained to sacroiliac injury and weakness and was rated under the criteria for lumbosacral strain under Diagnostic Code 5295. Diagnostic Code 5286 pertained to spinal ankylosis. 38 C.F.R. 4.71a, Diagnostic Code 5294 (2003), effective prior to September 26, 2003. Under the current regulations for evaluating intervertebral disc syndrome, effective September 26, 2003, revisions to Diagnostic Code 5293 include the renumbering of the diagnostic code to 5243. Under Diagnostic Code 5243 (that now evaluates intervertebral disc syndrome), Note 6 directs that intervertebral disc syndrome is to be evaluated under the General Rating Formula for Disease and Injuries of the Spine or under the formula for rating based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. With the possible exception of intervertebral disc syndrome, disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula for Diseases and Injuries of the Spine provide as follows: 100% Unfavorable ankylosis of the entire spine; 50% Unfavorable ankylosis of the entire thoracolumbar spine; 40% Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; 30% Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine; 20% Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; 10% Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2012) (unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Normal range of motion of the cervical spine includes flexion and extension to 45 degrees, lateral flexion to 45 degrees to each side, and lateral flexion to 80 degrees to each side. 38 C.F.R. § 4.71a (Plate V). Normal range of motion of the thoracolumbar spine encompasses flexion to 90 degrees and extension, bilateral lateral flexion, and bilateral rotation to 30 degrees. Id. On January 1994 VA examination, the examiner diagnosed osteoarthritis of the neck. He provided no other details as to cervical spine range of motion. On March 1998 VA orthopedic examination, the Veteran reported "excruciating pain," tightness, and stiffness of the neck. Cervical spine extension was to 50 degrees. Forward flexion was to 60 degrees. Bilateral rotation was to 55 degrees. Inclination to the left was to five or 10 degrees. Inclination to the right was to 20 degrees. The examiner diagnosed degenerative arthritis of the cervical spine as well as generalized osteoporosis. On VA examination in January 1999, the examiner stated that cervical spine range of motion was within normal limits. Based on X-ray evidence, the examiner diagnosed cervical spine degenerative arthritis. Forward flexion was to 60 or 65 degrees. Extension was to 45 or 50 degrees. Side bending was to 30 degrees bilaterally. Bilateral rotation was to 55 or 60 degrees. On January 2013 VA examination of the cervical spine, forward flexion of the cervical spine was to "45 degrees or greater" without objective evidence of painful motion. Extension was to "45 degrees or greater" without objective evidence of painful motion. Right and left lateral flexion was to "45 degrees or greater" without objective evidence of painful motion. Right and left lateral rotation was to "80 degrees or greater" with evidence of painful motion at 70 degrees. The Veteran was able to perform repetitive use testing. After three cervical spine range of motion repetitions, cervical spine range of motion was unchanged. There was some painful motion. There was no tenderness to palpation, guarding, or muscle spasm associated with the cervical spine. There was no cervical spine intervertebral disc syndrome. X-ray studies confirmed cervical spine arthritis. The examiner indicated that the service-connected cervical spine disability had no impact upon the Veteran's ability to work, providing evidence against this claim. The diagnosis was of cervical spine osteoporosis. On cervical spine examination in February 2013, the diagnosis given was of degenerative disc disease of the cervical spine. The Veteran reported cervical spine flare-ups that occurred when the neck tightened up. During flare-ups, the Veteran indicated that he could neither turn his head nor drive. Forward flexion of the cervical spine was to "45 degrees or greater" without objective evidence of painful motion. Extension was to "45 degrees or greater" with pain at the extremes of motion. Right lateral flexion was to 40 degrees with evidence of pain at the extremes of motion. Left lateral flexion was to 30 degrees with evidence of painful motion at 30 degrees. Right lateral rotation was to 60 degrees with evidence of painful motion at the extremes of motion. Left lateral rotation was to 45 with evidence of pain at the extremes of motion. The Veteran was able to perform repetitive use testing. Range of motion of the cervical spine was virtually unchanged after three range of motion exercises. Cervical spine functional loss was manifested by less movement than possible, weakened movement, excess fatigability, pain on movement, and interference with sitting, standing, and/or weight bearing. There was pain to palpation of the cervical spine. However, there was no guarding or muscle spasm. There was no cervical spine intervertebral disc syndrome. Imaging studies of the cervical spine revealed arthritis. At the outset, the Board notes that intervertebral disc syndrome of the cervical spine has not been demonstrated at any time during the appeal period. As such, the Board need not consider any of the provisions pertaining to intervertebral disc syndrome effective at any time during the appeal period. The Veteran suffers from both arthritis and osteoporosis of the cervical spine. Because it is unclear from the record which symptoms are attributable to which disability, the Board will consider all of the symptomatology contained in the evidence. See Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of a service-connected disability and a nonservice-connected disability, reasonable doubt must be resolved in the appellant's favor and the symptoms in question attributed to the service-connected disability). The Board must first consider whether an evaluation in excess of 10 percent for the service-connected cervical spine osteoporosis is warranted at any time during the appeal period under the regulations effective prior to September 23, 2003. The Board is of the opinion that a 20 percent evaluation for moderate limitation of motion of the cervical spine is warranted under Diagnostic Code 5290, as cervical spine limitation of motion has been shown in four of the six directions measured, in giving the Veteran the benefit of the doubt, in light of the fact that the Veteran is already at a 100 percent rating, and in an attempt to avoid further development and additional litigation on this appeal. Simply stated, there is significant evidence against this claim, however, to avoid any additional development/delays, the Board wishes to resolve all issues and fully adjudicate the Veteran's case without delay. In this regard, it is important for the Veteran to understand that a total review of the case, including its many claims files, that not all evidence in this case supports the 10 percent evaluation, let alone the finding of 20 percent. However, with consideration of the Veteran's pain and other factors the Board believes it can make this determination. The Board has concluded that cervical spine limitation of motion has never been severe, as forward flexion and extension have always been complete, and limitation of motion has only been shown with respect to rotation and lateral flexion. In addition, limitation of cervical spine motion is not severe because the Veteran has reported actual functional impairment (in the form of neck tightening and an inability to turn the head or drive) only during flare-ups of his cervical spine disability, and the record does not indicate frequent flare-ups. The Board is of the opinion that a 20 percent evaluation under Diagnostic Code 5290 is warranted for the entire appeal period because although markedly improved cervical spine range of motion and other symptoms was apparent on January 2013 VA examination, symptoms similar to those seen earlier were apparent just one month later. As the Board is required to view the evidence in the light most favorable to the Veteran, the Board finds that the more severe symptomatology is the more accurate depiction of the Veteran's cervical spine disability, particularly because it is in keeping with findings made years earlier. In any event, because cervical spine range of motion in February 2013 was not limited regarding forward flexion and extension and because the Veteran had most of his motion in the other relevant directions, the Board does not find that range of motion has been severe at any time during the appeal period. However, cervical spine limitation of motion has been moderate throughout because range of motion in four of the six relevant directions has been somewhat limited. Thus, the 20 percent evaluation under Diagnostic Code 5290 applied throughout the appeal period. 38 C.F.R. § 4.71a, Diagnostic Code 2920 (effective before September 23, 2003); Fenderson, supra. The other provisions potentially applicable to the cervical spine effective prior to September 23, 2003 are Diagnostic Code 5285 (residuals of vertebral fractures) and Diagnostic Code 5287 (ankylosis of the cervical spine). These need not be considered by the Board, as there is no evidence of cervical spine fracture and no sign of cervical spine ankylosis, either favorable or unfavorable. The provisions effective September 23, 2003 would not yield an evaluation in excess of 30 percent at any time beginning that date. An evaluation in excess of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine requires that cervical spine forward flexion be to 15 degrees or less or ankylosis of the entire cervical spine. Such cervical spine limitation of motion has not been shown at any time from September 23, 2003. As such, an evaluation in excess of 20 percent under the currently applicable provisions must be denied. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 (2012) 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 (2012) provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The Board has taken the foregoing manifestations, to the extent that they are present, into consideration in assigning the increased 20 percent evaluation herein. As apparent from the foregoing discussion, there is no means by which the Board can assign an evaluation in excess of 20 percent for the service-connected cervical spine osteoporosis. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant an even more favorable decision, beyond the one provided. Osteoporosis of the thoracolumbar spine Osteoporosis of the thoracolumbar spine has been rated 10 percent disabling by the RO under Diagnostic Code 5013. 38 C.F.R. § 4.71a. The law and regulations related to disabilities of the spine were outlined in detail above and are incorporated herein by reference. On January 1994 VA examination, the examiner diagnosed osteoarthritis of the back. Forward flexion of the thoracolumbar spine was to 95 degrees. Extension was to 30 degrees. Lateral flexion was to 40 degrees bilaterally, and lateral rotation was to 35 degrees bilaterally. On March 1998 VA orthopedic examination, the Veteran stated that at times he could not get out of bed without assistance due to back symptomatology, and he required various gaits and postures in order to feel comfortable. Objectively, in a standing position, the shoulders and pelvis were level. Forward flexion was to 70 degrees, which brought the Veteran's fingertips to within six inches from the floor. Lateral flexion was to 40 degrees bilaterally. The Veteran was not capable of extension. Pursuant to a physical examination and obtaining radiologic studies, the examiner diagnosed arthrosis of the right sacroiliac joint and generalized osteoporosis. On VA examination in January 1999, the examiner estimated that lumbosacral range of motion was within normal limits, and X-ray evidence revealed no pathological processes. Forward flexion was to 75 or 80 degrees. Side bending was to 35 degrees bilaterally. Extension was to 20 degrees. The Veteran did not complain of pain on range of motion. The examiner diagnosed right sacroiliac joint arthrosis by history. On January 2013 VA examination of the spine, the examiner diagnosed osteoporosis of the thoracolumbar spine. The Veteran denied that flare-ups had an impact upon the function of the thoracolumbar spine. Forward flexion of the thoracolumbar spine was to "90 degrees or greater" with no objective evidence of painful motion. Extension was to "30 degrees or greater" with no objective evidence of painful motion. Lateral flexion was to "30 degrees or greater" with no objective evidence of painful motion. Lateral rotation was to "30 degrees or greater" bilaterally with no objective evidence of painful motion. There was no additional thoracolumbar spine limitation of motion after three consecutive range of motion exercises. There was no functional loss or functional impairment of the thoracolumbar spine. There was no tenderness to palpation of the thoracolumbar spine, and there was no guarding or muscle spasm. There was no thoracolumbar spine intervertebral disc syndrome. The Veteran used no assistive devices in connection with the service-connected low back osteoporosis. According to the VA examiner, the Veteran's thoracolumbar spine disability did not have an impact upon his ability to work. On VA examination in February 2013, the examiner diagnosed mild degenerative arthritis of the thoracic spine. There was no lumbar arthritis. The Veteran reported occasional flare-ups that were sometimes "so bad" that he had to sleep on the floor. Forward flexion of the thoracolumbar spine was to "90 degrees or greater" with pain at 90 degrees. Extension was to 15 degrees with evidence of painful motion at 15 degrees. Lateral flexion was to 30 degrees bilaterally with evidence of painful motion at 30 degrees bilaterally. Right lateral rotation was to 30 degrees with evidence of painful motion at 30 degrees. Left lateral rotation was to 20 degrees with evidence of painful motion at 30 degrees. Regarding left lateral rotation, the Board notes the apparent discrepancy. The Board finds that the examiner intended to state that left lateral rotation was to 30 degrees because painful motion began at that point, and it cannot begin at a degree greater than the maximum range of motion. As well, after three repetitions, left lateral rotation was to 30 degrees. Is stands to reason that range of motion should be at least as good on the first range of motion exercise as on the last. Range of motion of the thoracolumbar spine was the same after three range of motion repetitions. Importantly, there was functional loss/impairment of the thoracolumbar spine consisting of less movement than normal, weakened movement, pain on movement, disturbance of locomotion, interference with sitting, standing, and/or weight bearing. There was no localized thoracolumbar spine tenderness. There was no thoracolumbar spine guarding or muscle spasm. There was no thoracolumbar spine inetrvertebral disc syndrome. There was documented arthritis but no evidence of vertebral fractures. According to the VA examiner, the Veteran's thoracolumbar spine disability had no impact upon his ability to work, providing highly probative evidence against this claim. The Veteran suffers from osteoporosis of the thoracolumbar spine and from arthritis of the thoracic spine. Because it is unclear from the record which symptoms are attributable to which disability, the Board will consider all of the symptomatology contained in the evidence in its evaluation of the severity of the Veteran's service-connected thoracolumbar spine disability. Mittleider, supra. The Board need not consider an increased rating under the provisions related to interveretebral disc syndrome in any iteration because intervertebral disc syndrome has not been present at any time during the appeal period. Under the criteria effective before September 23, 2003, an evaluation in excess of 10 percent is not warranted at any time during the appeal period. Fenderson, supra. The Board notes that the maximum rating for dorsal (thoracic) spine limitation of motion is 10 percent, and the Veteran is already in receipt of a 10 percent evaluation herein. 38 C.F.R. § 4.71a, Diagnostic Code 5291 (effective before September 23, 2003). To qualify for an increased rating under Diagnostic Code 5292 (limitation of motion of the lumbar spine), moderate limitation of motion would have to be shown. Here, extension has been limited at times. However, range of motion has been complete in all other relevant directions consistently over a period of many years. Thus, the Board finds that complete or almost complete range of motion of the low back does not reflect anything more than slight limitation of motion of the thoracolumbar spine. As such, an evaluation in excess of 10 percent cannot be granted under Diagnostic Code 5292. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (effective before September 23, 2003). Residuals of vertebral fractures, ankylosis, and sacroiliac injury or weakness have not been shown, and Diagnostic Codes 5285 (residuals of vertebral fractures), 5286 (ankylosis), 5288 (ankylosis dorsal spine), 5289 (ankylosis lumbar spine), and 5294 (sacroiliac injury or weakness) need not be considered. 38 C.F.R. § 4.71a, Diagnostic Codes 5285, 5286, 5288, 5289, and 5294 (effective before September 23, 2003); see also Schafrath, supra. Diagnostic Code 5295 concerns lumbosacral strain. An evaluation of 20 percent under this provision is not warranted because muscle spasm on extreme forward bending and loss of lateral spine motion, unilateral, in the standing position has not been shown. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (effective before September 23, 2003). In sum, an evaluation in excess of 10 percent for the service-connected thoracolumbar spine osteoporosis cannot be granted at any time during the appeal period under the criteria applicable before September 23, 2003. Fenderson, supra. The Board notes that a 20 percent evaluation cannot be assigned under the General Rating Formula for Diseases and Injuries of the Spine, which became effective September 23, 2003, for a variety of reasons. First, forward flexion of the thoracolumbar spine is greater than 60 degrees, the combined range of motion of the thoracolumbar spine greater than 120 degrees (even with consideration of pain), and muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis is not present. Thus, there is no means by which to assign a 20 percent evaluation for the service-connected low back disability at any time from the effective date of the currently effective regulations. Fenderson, supra. 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, supra. Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The Board has taken the foregoing manifestations, to the extent that they are present, into consideration. As apparent from the foregoing discussion, however, there is no means by which the Board can assign an evaluation in excess of 10 percent for the service-connected thoracolumbar spine osteoporosis at any time during the appeal period. Finally, in making the present determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. Osteoporosis of the left knee Osteoporosis of the left knee has been rated 10 percent disabling by the RO under Diagnostic Code 5013. 38 C.F.R. § 4.71a. Diagnostic Code 5013 pertains to osteoporosis. The diseases listed under Diagnostic Codes 5013-5024, that is, osteoporosis, osteomalacia, benign new growths of bones, osteitis deformans, gout, intermittent hydrarthrosis, bursitis, synovitis, myositis, periostitis, myositis ossificans, and tenosynovitis, are rated on limitation of motion of the affected parts, as degenerative arthritis, under Diagnostic Code 5003, except for gout which is rated under Code 5002. 38 C.F.R. § 4.71a, Diagnostic Codes 5021-5024. Standard motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2012). Limitation of leg motion is governed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 concerns limitation of leg flexion. A 10 percent evaluation is for application where flexion is limited to 45 degrees. A 20 percent evaluation is for application where flexion is limited to 30 degrees, and a 30 percent rating applies where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261 pertains to limitation of leg extension. Under that Code section, a 10 percent evaluation is for application where extension is limited to 10 degrees. A 20 percent evaluation is for application where extension is limited to 15 degrees. A 30 percent rating applies where extension is limited to 20 degrees. 38 C.F.R. § 4.71a. As for Diagnostic Code 5257, which pertains to other impairment of the knee, a 10 percent rating contemplates slight knee impairment due to recurrent subluxation or lateral instability. A 20 percent rating contemplates moderate impairment due to recurrent subluxation or lateral instability, and a maximum 30 percent rating is warranted for severe impairment of the knee. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent evaluation, the highest and only rating available under that schedular provision, may be assigned where there is evidence of dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the knee joint. 38 C.F.R. § 4.71a. VAOPGCPREC 9-2004 interprets that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. Further, regarding the question of entitlement to separate evaluations, VAOPGCPREC 23-97 interprets that a claimant who has arthritis and instability of the knee may, in some circumstances, be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 9-98. On January 1994 VA examination, the examiner diagnosed osteoarthritis of the knees. On March 1998 VA orthopedic examination, left knee range of motion was from zero to 140 degrees. There was some retropatellar grating on flexion and extension. The ligaments were intact. The examiner diagnosed generalized osteoporosis. On VA examination in January 1999, left knee range of motion was from zero to 135 degrees. There was retropatellar grating. There was slight laxity of the retropatellar structures in slight flexion that disappeared when the knee was brought into a locked position. The examiner diagnosed early grade chondromalacia. On January 2013 VA examination, the examiner diagnosed osteoporosis of the knees. The Veteran denied that flare-ups had a deleterious impact on knee function. Left knee range of motion was from zero to "140 degrees or greater" with no objective evidence of painful motion. There was no hyperextention. The Veteran was able to perform repetitive-use testing, and range of motion was from zero to "140 degrees or greater" after repetitive-use testing. There was no tenderness or pain to palpation of the left knee. There was no history of recurrent patellar subluxation or dislocation. The Veteran used no assistive devices. There was no degenerative arthritis, but osteoporosis was present. The left knee disability did not impede the Veteran's ability to work. On February 2013 VA examination, the examiner diagnosed chondromalacia of the left knee. A current X-ray study was normal with no evidence of arthritis. The Veteran indicated that with flare-ups, the left knee was swollen with pain and tenderness. Left knee range of motion was from zero to "140 degrees or greater" with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing. After three range of motion repetitions, left knee range of motion was from zero to "140 degrees or greater" with no evidence of hyperextension. There was no additional limitation of motion after repetitive-use testing. There was functional loss/impairment in the form of weakened movement, excess fatigability, swelling, disturbance of locomotion, and interference with sitting, standing, and/or weight bearing. There was tenderness to palpation of the left knee joint. There was no history of recurrent patellar subluxation/dislocation. The Veteran used no assistive devices for the left knee. X-ray studies revealed no degenerative or traumatic arthritis. The Veteran's left knee had no impact upon his ability to work. The Veteran suffers from osteoporosis of the left knee and from possible arthritic manifestations. Because it is unclear from the record which symptoms are attributable to which disability, the Board will consider all of the symptomatology contained in the evidence in its evaluation of the severity of the Veteran's service-connected left knee disability. Mittleider, supra. An evaluation in excess of 10 percent for the service-connected left knee osteoporosis cannot be assigned under Diagnostic Code 5260 (limitation of leg flexion) or under Diagnostic Code 5261 (limitation of leg extension) because the Veteran has been capable of complete left knee range of motion throughout the appeal period. 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261; see also Fenderson, supra. An evaluation in excess of 10 percent under Diagnostic Code 5257 (other impairment of the knee) need not be considered, as recurrent subluxation or lateral instability have been absent throughout the appeal period. Other provisions related to the knee need not be considered because they are not applicable. Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5258 (dislocation of the semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of the semilunar cartilage), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum) pertain to types of knee disabilities from which the Veteran does not suffer. Therefore, the Board need not consider them. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263; see also Schafrath, supra. 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, supra. Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The Board has taken the foregoing manifestations, to the extent that they are present, into consideration. As apparent from the foregoing discussion, however, there is no means by which the Board can assign an evaluation in excess of 10 percent for the service-connected left knee osteoporosis at any time during the appeal period. Indeed, although such symptoms as excess fatigability have been recently noted, the Veteran's left knee disability is manifested by no loss of motion or other objective manifestations. Multiple examination have provided highly probative evidence against this claim, consistently noting that the next higher evaluation have not been met. Finally, in making the present determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. Osteoporosis of the right knee Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Osteoporosis of the right knee has been rated 10 percent disabling by the RO under Diagnostic Code 5003-5013. 38 C.F.R. §§ 4.20, 4.71a. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, 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 Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The rest of the provisions related to disabilities of the knee are outlined in the section immediately above, and are incorporated herein by reference. On January 1994 VA examination, the examiner diagnosed osteoarthritis of the knees. On March 1998 VA orthopedic examination, right knee range of motion was from zero to 140 degrees. There was some retropatellar grating on flexion and extension. The ligaments were intact. An X-ray study of the right knee showed sharpening of the tibial spines with irregularity at the medial patellar facet head. The examiner diagnosed grade I right knee chondromalacia as well as generalized osteoporosis. On VA examination in January 1999, right knee range of motion was from zero to 135 degrees. There was pain on flexion and extension. There was retropatellar grating. There was slight laxity of the retropatellar structures in slight flexion that disappeared when the knee was brought into a locked position. The examiner diagnosed early grade chondromalacia. On January 2013 VA examination, the examiner diagnosed osteoporosis of the knees. The Veteran denied that flare-ups had a deleterious impact on knee function. Right knee range of motion was from zero to "140 degrees or greater" with no objective evidence of painful motion. There was no hyperextention. The Veteran was able to perform repetitive-use testing, and range of motion was from zero to "140 degrees or greater" after repetitive-use testing. There was no tenderness or pain to palpation of the right knee. There was no history of recurrent patellar subluxation or dislocation. The Veteran used no assistive devices. There was no degenerative arthritis, but osteoporosis was present. The right knee disability did not impede the Veteran's ability to work. On February 2013 VA examination, the examiner diagnosed chondromalacia of the right knee. A current X-ray study was normal with no evidence of arthritis. The Veteran indicated that with flare-ups, the right knee was swollen with pain and tenderness. Right knee range of motion was from zero to "140 degrees or greater" with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing. After three range of motion repetitions, right knee range of motion was from zero to "140 degrees or greater" with no evidence of hyperextension. There was no additional limitation of motion after repetitive-use testing. There was functional loss/impairment in the form of weakened movement, excess fatigability, swelling, disturbance of locomotion, and interference with sitting, standing, and/or weight bearing. There was tenderness to palpation of the right knee joint. There was no history of recurrent patellar subluxation/dislocation. The Veteran used no assistive devices for the right knee. X-ray studies revealed no degenerative or traumatic arthritis. The Veteran's right knee had no impact upon his ability to work. The Veteran suffers from osteoporosis of the right knee and from possible arthritic manifestations. Because it is unclear from the record which symptoms are attributable to which disability, the Board will consider all of the symptomatology contained in the evidence in its evaluation of the severity of the Veteran's service-connected right knee disability. Mittleider, supra. The Veteran is in receipt of the highest evaluation available to him under Diagnostic Code 5003. An evaluation in excess of 10 percent for the service-connected right knee osteoporosis cannot be assigned under Diagnostic Code 5260 (limitation of leg flexion) or under Diagnostic Code 5261 (limitation of leg extension) because the Veteran has been capable of complete right knee range of motion throughout the appeal period. 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261; Fenderson, supra. An evaluation in excess of 10 percent under Diagnostic Code 5257 (other impairment of the knee) need not be considered, as recurrent subluxation or lateral instability have been absent throughout the appeal period. Other provisions related to the knee need not be considered because they are not applicable. Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5258 (dislocation of the semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of the semilunar cartilage), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum) pertain to types of knee disabilities from which the Veteran does not suffer. Therefore, the Board need not consider them. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263; see also Schafrath, supra. 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, supra. Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The Board has taken the foregoing manifestations, to the extent that they are present, into consideration. As apparent from the foregoing discussion, however, there is no means by which the Board can assign an evaluation in excess of 10 percent for the service-connected right knee osteoporosis at any time during the appeal period. Indeed, although such symptoms as excess fatigability have been recently noted, the Veteran's right knee disability is manifested by no loss of motion and other or other objective manifestations. Finally, in making the present determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. Extraschedular Consideration In reviewing all of the increased rating claims, 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. The Board has considered Mittleider, supra. In Mittleider, the Court held that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. Here, the Board has considered all symptomatology potentially related to a service-connected disabilities. 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 (2008). Concerning the issue of a higher initial rating for osteoporosis of the cervical spine, low back, left knee, and right knee, the Board finds that the schedular rating criteria contemplate the limitations and impairment caused by the Veteran's service-connected cervical spine, low back, left knee, and right knee osteoporosis. The service-connected cervical spine, low back, left knee, and right knee disability rating criteria specifically provide for ratings based on the presence of painful arthritis and limitation of motion (to the extent present) of the cervical spine, low back, left knee, and right knee (including due to pain and other orthopedic factors; see 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); see also DeLuca). Because the schedular rating criteria are adequate to rate the Veteran's service-connected cervical spine, low back, left knee, and right knee disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards to each of the disabilities at issue herein. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met with respect to any of the disabilities discussed above. 38 C.F.R. § 3.321(b)(1). Veterans Claims Assistance Act of 2000 (VCAA) As provided for by VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Concerning the appeals herein, which are for initial higher ratings, because it is an appeal that arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for cervical spine, low back, left knee, and right knee disabilities, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007). The Board finds that all necessary development has been accomplished; therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claims. 38 U.S.C.A. § 5103A. VA has obtained service records, post-service VA and private treatment records, Social Security Administration (SSA) records, and other records identified by the Veteran. The Veteran has been afforded adequate examinations on the issue of higher initial ratings for cervical spine, low back, left knee, and right knee disabilities. VA provided the Veteran with multiple examinations regarding each disability discussed herein. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that, in the aggregate, the VA findings obtained in this case are adequate, as they are predicated on a full reading of the private and VA medical records in the Veteran's claims file. The VA examiners considered all of the pertinent evidence of record, to include service treatment records, VA and private treatment records, comprehensive physical examinations, and the statements of the Veteran. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER An evaluation of 20 percent for the service-connected cervical spine osteoporosis is granted subject to the law and regulations governing the payment of veterans' benefits. An evaluation in excess of 10 percent for the service-connected low back osteoporosis is denied. An evaluation in excess of 10 percent for left knee osteoporosis is denied. An evaluation in excess of 10 percent for right knee osteoporosis is denied. ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs