Citation Nr: 1319548 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-39 870 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an initial rating higher than 10 percent for right patellofemoral syndrome prior to January 5, 2009, and on or after March 1, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Mac, Counsel INTRODUCTION The Veteran served on active duty from April 1999 to October 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In January 2009, the Veteran underwent a right knee arthroscopy with partial medial meniscectomy for a right knee medial meniscus tear. A Decision Review Officer Decision in September 2009 granted the Veteran a temporary 100 percent evaluation effective from January 5, 2009, to February 28, 2009, based on surgical treatment necessitating convalescence. The 10 percent rating was continued from March 1, 2009. A review of the Virtual VA paperless claims processing system reveals documents that are either duplicative of the evidence of record or are not pertinent to the present appeal. FINDINGS OF FACT 1. Prior to January 5, 2009, the Veteran's right patellofemoral syndrome was not productive of ankylosis, flexion limited to 45 degrees, extension to 5 degrees, recurrent subluxation or lateral instability, or the symptomatic removal of the semilunar cartilage. 2. Prior to January 5, 2009, the Veteran's right knee had dislocated cartilage with frequent episodes of locking, pain, and effusion into the joint. 3. As of March 1, 2009, there is painful range of motion of the right knee more nearly approximating limitation of flexion to 30 degrees. 4. As of March 1, 2009, the Veteran has been shown to have the symptomatic removal of semilunar cartilage. 5. On or after March 1, 2009, the Veteran's right patellofemoral syndrome has not been productive of ankylosis, extension to 5 degrees, recurrent subluxation or lateral instability, or dislocated cartilage with frequent episodes of locking, pain, and effusion into the joint. CONCLUSIONS OF LAW 1. Prior to January 5, 2009, the criteria for an initial evaluation in excess of 10 percent for right patellofemoral have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5256, 5257, 5259, 5260, 5261 (2012). 2. Prior to January 5, 2009, the criteria for a separate 20 percent rating for a right knee meniscus disorder have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Code 5258 (2012). 3. Since March 1, 2009, the criteria for an initial rating of 20 percent, but not higher, for right patellofemoral syndrome have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5256, 5257, 5258, 5260, 5261 (2012). 4. Since March 1, 2009, the criteria for a separate 10 percent rating for the symptomatic removal of semilunar cartilage have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Code 5259 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A (West 2002); 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Nevertheless, the Veteran in this case is challenging the initial evaluation assigned following the grant of service connection for right knee patellofemoral syndrome. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied with respect to the issue of entitlement to a higher initial evaluation for his right knee disability. In this case, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. In his April 2007 claim, the Veteran did indicate that he was treated by doctors at the Anderson Family Practice from 2002 to 2007. In a June 2007 VA notice letter, the RO asked the Veteran to submit written authorization for VA to obtain these records; however, the Veteran did not reply. Thus, no further efforts are necessary. Moreover, there are other identified and available records pertinent to the claim being decided herein. Additionally, the Veteran was afforded VA examinations in October 2007 and in December 2009. In October 2008 and in October 2009, the Veteran claimed that the October 2007 VA examiner did not document all of the symptoms that he reported, to include instability, fatigue, and weakness. However, he was subsequently afforded a VA examination in December 2009, and the examiner reported his subjective complaints and objective findings. That examination was also predicated on a review of the claims file and all pertinent evidence of record as well as on an examination, and fully addressed the rating criteria that are relevant to rating the disability in this case. Moreover, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11- 95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. The Court has held, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 (July 1, 1997). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also held that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). In this case, the RO granted service connection for right patellofemoral syndrome and assigned a 10 percent evaluation effective from April 15, 2007, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260. During the pendency of the appeal, the RO granted a temporary 100 percent evaluation for the period from January 5, 2009, to March 1, 2009, due to surgery requiring convalescence. Thereafter, the Veteran's 10 percent evaluation was continued. Under Diagnostic Code 5260, a noncompensable evaluation is contemplated for flexion limited to 60 degrees. A 10 percent disability evaluation is assigned when flexion is limited to 45 degrees, and a 20 percent disability evaluation is warranted when flexion is limited to 30 degrees. A 30 percent disability evaluation is assigned when flexion is limited to 15 degrees, which is the maximum evaluation available under Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees, and a 10 percent disability evaluation is contemplated for extension limited to 10 degrees. When there is limitation of extension to 15 degrees, a 20 percent disability evaluation is warranted. A 30 percent rating will be assigned for extension limited to 20 degrees, and a 40 percent rating is contemplated for limitation of extension to 30 degrees. A 50 percent disability evaluation is warranted for extension limited to 45 degrees. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is contemplated when such impairment is moderate, and a maximum rating of 30 percent is assigned for severe impairment. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is assigned for the symptomatic removal of semilunar cartilage. The normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Factual Background The pertinent evidence of record consists of lay statements, VA medical records, and VA examination reports dated in October 2007 and in December 2009. During the October 2007 VA examination, the Veteran complained of right knee pain. He denied having instability, but reported having grinding, popping, and difficulty with stairs. He also indicated that he had periods of flare-ups of pain with any activity, including walking two blocks. The functional impairment caused the Veteran to stop and rest. He did not have episodes of dislocation or recurrent subluxation. The examiner noted that there was no inflammatory arthritis. A physical examination revealed flexion from 0 to 90 degrees and extension from 90 to 0 degrees. The Veteran had painful motion, and following repetitive motion, there was pain at 90 degrees. However, there was no fatigue, weakness, lack of endurance, or incoordination following repetitive motion. He had some pain at the extremes of motion, as well as tenderness and guarding of movement, but there was no objective evidence of edema, effusion, swelling, instability, weakness, or abnormal movement. Stability testing of the medial and lateral collateral ligaments was negative, as demonstrated by valgus stress test, varus stress test, and McMurray's test. There was no ankylosis. Accompanying x-rays show questionable minimal medial compartment joint space narrowing of the right knee. MRIs obtained in April 2008 and July 2008 showed a tear in the medial meniscus. There was diffuse thinning and irregularity of the cartilage in the medial compartment and mild degenerative joint disease most prominent at the medial compartment. An x-ray obtained in April 2008 revealed mild narrowing of the medial compartment in the right knee. VA records dated in August 2008 indicate that the Veteran complained of the knee locking, catching, giving way, and swelling. A physical examination revealed slight effusion. The range of motion was 0 to 130 degrees, and the right knee was stable to varus/valgus testing. The Lachman's test was negative, and the McMurray's test was positive. VA records dated in December 2008 documented the Veteran's range of motion of the right knee as being 20 to 105 degrees. The medial joint line test and McMurray's test was positive. In an October 2008 statement, the Veteran asserted that he told the VA examiner that he had knee instability and extreme pain upon driving more than 15 to 20 minutes, but that his complaints were not documented. In January 2009, the Veteran underwent right knee arthroscopy with a partial medial meniscectomy for a right knee medial meniscus tear. The findings show moderate degenerative joint disease of the patellofemoral and medial joint space and post horn medial meniscus tear. In an October 2009 statement, the Veteran's spouse claimed that the Veteran told the VA examiner that his knee gave out when he walked on unstable ground. She also asserted that the Veteran had problems walking up and down stairs. In an October 2009 statement, the Veteran reported that he wore a knee brace due to lateral instability in his knee both before and after the surgery. He also asserted he had fatigue and lack of endurance even though the VA examiner indicated otherwise. He further noted that, contrary to the examiner's findings, he had instability, weakness, and abnormal function. The Veteran claimed that he had significant limitation of motion in his daily life, as he was unable to squat because he could not rise without assistance. He also stated he has difficulty climbing up and down stairs. During a December 2009 hearing at the RO, the Veteran testified that he had instability and that his knee gave out. He claimed that the examiner underreported his symptoms during his October 2007 VA examination. He also reported that, prior to his January 2009 surgery, he experienced locking. The Veteran indicated that the surgery had since helped prevent such locking. In addition, his spouse testified he had constant pain. During a December 2009 VA examination, the Veteran complained of pain, weakness, and swelling in his right knee. He did not complain of any instability, giving way, locking, fatigability, or lack of endurance. He reported having flare-ups of pain, which occurred approximately once every couple of weeks and could last about 24 hours. He indicated that the flare-ups occurred with excessive activity. The Veteran also reported that he wore a brace for support. He denied having any episodes of dislocation or recurrent subluxation. The examiner noted that there was no inflammatory arthritis. The Veteran had trouble with occupational duties and recreational activities if there was significant stress on the knee, and it was noted that the Veteran could not drive for long periods due to pain. A physical examination revealed flexion from 0 to 99 degrees and extension from 0 degrees. There was painful motion, and the Veteran complained of pain and popping with flexion. Following repetitive motion, there was pain at 30 degrees of flexion, but there was no fatigue, weakness, lack of endurance, or incoordination. The objective findings revealed painful motion, tenderness, and abnormal movements, but did not show edema, effusion, swelling, instability, weakness, or guarding of movement. Stability testing of the medial and lateral collateral ligaments were negative, and there was no ankylosis. Accompanying x-rays show mild right medial compartment narrowing. The examiner provided a diagnosis of early degenerative joint disease involving primarily the medial joint compartment. I. Prior to January 5, 2009 In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a higher initial evaluation for his right patellofemoral syndrome prior to January 5, 2009. Initially, the Board finds that the Veteran is not entitled to such an increase under Diagnostic Code 5260. In this regard, the evidence shows that the Veteran's flexion was limited, at worst, to 90 degrees during this time period. In fact, VA records dates in August 2008 documented him as having flexion to 130 degrees, and VA records dated in December 2008 noted flexion to 105 degrees. The October 2007 VA examiner noted that there was no fatigue, weakness, lack of endurance, or incoordination following repetitive motion. The Veteran has since claimed that he did have fatigue, weakness, and lack of endurance during that examination. However, even if it is assumed that the Veteran experienced these symptoms during the October 2007 VA examination, there is no indication that those symptoms would have limited his flexion to 30 degrees or more closely approximated that level of impairment. In fact, during the repetitive motion testing, pain began at 90 degrees. Thus, as the criteria for the next higher rating of 20 percent is flexion limited to 30 degrees, the Veteran has not been shown to warrant an increased evaluation under Diagnostic Code 5260. Notably, the Court has held that pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011); 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board has also considered whether the Veteran is entitled to a higher or separate rating for limitation of extension. Prior to January 5, 2009, the evidence shows that the Veteran's extension was limited to 0 degrees with pain in October 2007, 0 degrees in August 2008, and 20 degrees in December 2008. There is only one instance when extension was limited to 20 degrees, and the other findings show 0 degrees even with pain. Thus, the preponderance of evidence shows that the Veteran did not have a compensable limitation of extension to 10 degrees, to include consideration of any additional functional loss due to pain, pain on movement, swelling, atrophy, fatigue, weakness, incoordination, to include during flare-ups and with repeated use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus, the Veteran is not entitled to a higher or separate evaluation under Diagnostic Code 5261. The Board also notes that the April 2008 and July 2008 MRIs findings in April 2008 and in July 2008 indicated that the Veteran had degenerative joint disease in his right knee. However, as the Veteran is already in receipt of a rating for painful limited motion under Diagnostic Code 5260, assigning a separate 10 percent rating for limitation of motion under Diagnostic Code 5003 for degenerative arthritis would constitute pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). Moreover, as discussed above, the preponderance of the evidence reveals normal extension. In addition, the Board has considered whether the Veteran is entitled to a separate or higher initial evaluation under Diagnostic Code 5257. The Veteran complained of his right knee giving way in August 2008, and in October 2008 and October 2009, the Veteran and his spouse stated that he had instability at the time of the October 2007 VA examination. Nevertheless, the Board finds that the weight of the evidence does no show that the criteria for a separate rating under Diagnostic 5257 is warranted, as the objective findings do not confirm recurrent subluxation or lateral instability. In this regard, the October 2007 VA examiner indicated that the medial and lateral collateral ligaments were stable, as demonstrated by a valgus stress test and a varus stress test. Similarly, in August 2008, the right knee was also stable to varus and valgus testing. Thus, the Board finds that the preponderance of the evidence shows that the criteria for a separate rating for recurrent subluxation or lateral instability under Diagnostic Code 5257 have not been met. The Board notes that the Veteran has complained of locking episodes; however, the October 2007 VA examiner determined that he did not have ankylosis of the right knee. Moreover, the aforementioned range of motion findings clearly show that the Veteran's right knee is not fixed or immobile. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint," citing Stedman's Medical Dictionary 87 (25th ed. 1990)). As there is no evidence of ankylosis or the symptomatic removal semilunar cartilage prior to January 5, 2009, Diagnostic Codes 5256 and 5259 are not applicable. Nevertheless, the Board has also considered whether the Veteran is entitled to a separate evaluation under Diagnostic Code 5258 for dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint. "Semilunar cartilage" is one of the menisci of the knee joint. Stedman's Medical Dictionary, 296 (27th ed., 2000). While x-rays in October 2007 and April 2008 do not provide an impression of a meniscal tear, MRI findings in April 2008 and in July 2008 do show a tear in the medial meniscus of the right knee. Moreover, the Veteran complained of grinding and popping in October 2007, and in August 2008, he complained of the knee locking and swelling. Thus, resolving all reasonable doubt in favor of the Veteran, the Board finds that a separate 20 percent disability evaluation is warranted under Diagnostic Code 5258. In reaching this determination, the Board has considered the lay statements made by the Veteran and his spouse describing his right knee pain and symptoms, to include instability, fatigue, weakness, lack of endurance, and locking. They are certainly competent to describe their observations; however, the Board finds the objective medical findings by skilled professionals are more persuasive. In summary, the Board finds that, prior to January 5, 2009, the Veteran is not entitled to a higher or separate evaluation under Diagnostic Codes 5256, 5257, 5259, 5260, and 5261. However, in addition to the currently assigned evaluation under Diagnostic Code 5260, the Veteran was also entitled to a separate 20 percent rating under Diagnostic Code 5258 during this time period. II. On or After March 1, 2009 In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a higher initial evaluation for his right patellofemoral syndrome as of March 1, 2009. During the December 2009 VA examination, the Veteran was found to have flexion to 99 degrees. However, there was painful motion, and following repetitive motion testing, the Veteran had pain at 30 degrees of flexion. Taking into account the provisions of 38 C.F.R. §§ 4.40 , 4.45, 4.59 and the holdings of DeLuca, supra, the Board finds that the Veteran's range of motion of his right knee more nearly approximates limitation to 30 degrees. Accordingly, resolving all reasonable doubt in favor of the Veteran, the Board concludes that a 20 percent evaluation is warranted under Diagnostic Code 5260 during this time period. The Board has also considered whether the Veteran is entitled to a higher or separate rating for limitation of extension. However, even with pain, the Veteran has had extension to 0 degrees since March 1, 2009. Thus, the Veteran does not have not have compensable limitation of extension to 10 degrees, to include consideration of any additional functional loss due to pain, pain on movement, swelling, atrophy, fatigue, weakness, incoordination, to include during flare-ups and with repeated use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, the Veteran is not entitled to a higher or separate evaluation under Diagnostic Code 5261. The Board again notes that there is evidence of degenerative joint disease in the Veteran's right knee. However, as the Veteran is already in receipt of a 20 percent rating for painful limited motion under Diagnostic Code 5260, assigning a separate 10 percent rating for limitation of motion under Diagnostic Code 5003 for degenerative arthritis would constitute pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). Moreover, as discussed above, the evidence reveals normal extension. In addition, the Board has considered whether the Veteran is entitled to a separate or higher initial evaluation under Diagnostic Code 5257. The Veteran stated that he had right knee instability in October 2009 and December 2009. However, during the December 2009 VA examination, he denied having any episodes of dislocation or subluxation. Moreover, the examination itself revealed stability of the medial and lateral ligaments. Thus, the preponderance of the evidence shows that the criteria for a separate rating for recurrent subluxation or lateral instability under Diagnostic Code 5257 have not been met. The Board also notes that the Veteran indicated in December 2009 that his partial medial meniscectomy in January 2009 had helped prevent locking. The aforementioned range of motion findings further suggest that his right knee is not fixed or immobile. Moreover, the December 2009 VA examiner stated that the Veteran did not have ankylosis of the right knee. As there is no evidence of ankylosis, Diagnostic Code 5256 is not applicable in this case. With regard to Diagnostic Code 5258, the evidence does not show the Veteran has had locking in his right knee since March 1, 2009. As noted above, the Veteran testified in December 2009 that his right knee surgery had helped prevent locking. While he complained of swelling during the December 2009 VA examination, the objective findings during that examination also do not show edema or effusion. Moreover, the Veteran's pain is already contemplated under Diagnostic Code 5260. For these reasons the weight of the evidence shows that the criteria for a separate rating for dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint under Diagnostic Code 5258 is not warranted during this period. Nevertheless, the Board does find that the Veteran is entitled to a separate 10 percent rating for the symptomatic removal of semilunar cartilage. As discussed above, the Veteran underwent arthroscopic surgery with a partial meniscectomy for a tear in his right knee medial meniscus in January 2009 During the December 2009 VA examination, he complained of popping, and objective findings show tenderness and abnormal movements. Therefore, the maximum rating of 10 percent is warranted under Diagnostic Code 5259. In reaching this determination, the Board has considered the lay statements made by the Veteran and his spouse describing his right knee pain and symptoms, to include pain and swelling. They are certainly competent to describe their observations; however, the Board finds the objective medical findings by skilled professionals are more persuasive. In summary, the Board finds that, as of March 1, 2009, the Veteran is not entitled to a higher or separate evaluation under Diagnostic Codes 5256, 5257, 5258, and 5261. However, he is entitled to a higher evaluation of 20 percent under Diagnostic Code 5260 and a separate 10 percent evaluation under Diagnostic Code 5259 during this time period. III. Extraschedular Consideration In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's right patellofemoral syndrome is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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 and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, which consists primarily of pain, limitation of motion, the dislocation and removal of semilunar cartilage, grinding, popping, and locking. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. As such, it cannot be said that the available schedular evaluations for the disability are inadequate. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected right patellofemoral syndrome under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Prior to January 5, 2009, an initial rating in excess of 10 percent for right patellofemoral syndrome is denied. Prior to January 5, 2009 a separate initial rating of 20 percent for dislocated semilunar cartilage of the right knee is granted, subject to the laws and regulations governing the award of monetary benefits. As of March 1, 2009, an initial rating of 20 percent, but not higher, is granted for right patellofemoral syndrome, subject to the laws and regulations governing the award of monetary benefits. As of March 1, 2009, a separate 10 percent rating for the symptomatic removal of semilunar cartilage of the right knee is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs