Citation Nr: 1319559 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-46 651A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a higher initial disability rating (evaluation) for service-connected degenerative joint disease of the lumbar spine (back disability), in excess of 20 percent for the period prior to February 9, 2011, and in excess of 40 percent from February 9, 2011. 2. Entitlement to a higher initial disability rating (evaluation) for service-connected lumbar radiculopathy of the left lower extremity (LLE radiculopathy), in excess of 40 percent. 3. Entitlement to a higher initial disability rating (evaluation) for service-connected degenerative joint disease of the left knee (left knee disability), in excess of 10 percent. 4. Entitlement to a higher initial disability rating (evaluation) for service-connected left knee laxity, in excess of 10 percent. REPRESENTATION Appellant represented by: Graham C. Showalter, Esq. ATTORNEY FOR THE BOARD William Alan Nelson II, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1979 to December 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In a January 2009 decision, the Philadelphia RO granted service connection and assigned an initial 20 percent rating for back disability, initial 10 percent rating for LLE radiculopathy, initial 10 percent rating for left knee disability, and an initial 10 percent rating for left knee laxity, all effective August 21, 2008, the date of grant of service connection (date of receipt of claims for service connection). In March 2009, the Veteran entered a notice of disagreement (NOD) with the initial ratings assigned in the January 2009 rating decision. Because the Veteran has disagreed with the initial ratings assigned following the grant of service connection for back and left knee disabilities, LLE radiculopathy, and left knee laxity, the Board has characterized the issues as ones of entitlement to higher initial disability ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). Thereafter, in September 2009, the Philadelphia RO granted a 20 percent rating for LLE radiculopathy for the entire initial rating period beginning August 21, 2008. In June 2012, the Philadelphia RO granted a 40 percent rating for LLE radiculopathy for the entire initial rating period beginning August 21, 2008, and a staged 40 percent rating for back disability for the initial rating period beginning February 9, 2011, the date of a VA examination. Although the RO granted higher ratings for service-connected LLE radiculopathy and back disability, inasmuch as higher ratings are available during each period, and a veteran is presumed to seek the maximum available benefit for a disability, the claims for higher disability ratings remain viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a total disability rating by reason of individual unemployability due to service-connected disability (TDIU) is considered part and parcel of an increased-rating claim when the issue of unemployability is raised by the record. In this case, the Veteran has already been granted entitlement to TDIU. Accordingly, further consideration of a TDIU is not warranted. The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. For the initial rating period prior to February 9, 2011, the Veteran's service-connected back disability did not manifest forward flexion of the thoracolumbar spine 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes of intervertebral disc syndrome. 2. For the initial rating period from February 9, 2011, the Veteran's service-connected lumbar spine disability did not manifest unfavorable ankylosis of the entire thoracolumbar spine. 3. For the entire initial rating period, LLE radiculopathy was manifested by no more than severe incomplete paralysis of the affected nerves with muscle atrophy. 4. For the entire initial rating period, the Veteran's service-connected left knee disability manifested pain on motion and X-ray evidence of arthritis, but did not manifest left knee flexion limited to 45 degrees, extension limited to 10 degrees, left knee ankylosis, impairment of the tibia and fibia, or genu recurvatum. 5. For the entire initial rating period, the Veteran's service-connected left knee laxity did not manifest moderate lateral instability. CONCLUSIONS OF LAW 1. For the initial rating period prior to February 9, 2011, the criteria for an initial disability rating in excess of 20 percent for back disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237-5243 (2012). 2. For the initial rating period from February 9, 2011, the criteria for an initial disability rating in excess of 40 percent for back disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5237-5243 (2012). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria are met for a rating of 60 percent for service-connected LLE radiculopathy. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.124a, Diagnostic Code 8520 (2012). 4. The criteria for a rating in excess of 10 percent for service-connected left knee disability are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b), 4.40, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2012). 5. The criteria for a rating in excess of 10 percent for service-connected left knee laxity have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes (DCs). 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. 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 (2012). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson, 12 Vet. App. at 126. It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. In determining if a higher rating is warranted on this basis, pain itself does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in sections 4.40 and 4.45. See Mitchell. 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. See 38 C.F.R. § 4.7. Initial Rating for Back Disability Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 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. A 20 percent rating is provided for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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. A 40 percent disability rating is provided for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2) (See also Plate V) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4) instructs to round each range of motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a. The Diagnostic Codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also diagnostic code 5003); 5243 Intervertebral disc syndrome. Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (effective September 26, 2003) provides a 10 percent disability rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. DC 5010 is for arthritis due to trauma, substantiated by X-ray findings and provides for rating as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. DC 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 (DC 5200, etc.). 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 DC 5003. 38 C.F.R. § 4.71a, DC 5003. The Veteran is in receipt of a 20 percent rating for service-connected back disability for the initial rating period prior to February 9, 2011, and a rating of 40 percent thereafter, under the provisions of 38 C.F.R. § 4.71a, DC 5243. Initial Rating Period prior to February 9, 2011 In a February 2008 private treatment record, the Veteran reported chronic low back pain. The private examiner reported a normal gait; the private examiner also reported positive straight leg raise on left at 25 degrees, tender left sacroiliac joint (SI), and positive Patrick's maneuver on left. The private examiner diagnosed lumbar disc displacement L4-L5 and L3-L4. In a March 2008 private treatment record, the private examiner reported a normal gait. In a June 2008 private treatment record, the private examiner reported back was symmetrical on examination and there was no deformity, midline tenderness, or costovertebral angle (CVA) tenderness; however, there was mild to moderate tenderness of paralumbar muscles. In a July 2008 private treatment record, the private examiner reported no cervical or thoracic tenderness and no tenderness to palpation in paraspinal lumber region. The private examiner also reported pain with range of motion of flexion and extension of the low back, with flexion being worse than extension, but did not report any specific ranges of motion. In a September 2008 private treatment record, the private examiner reported poor range of motion of the back with spasm in the lumbar area. The October 2008 VA examination of the spine reflects that the Veteran suffered functional limitations of limited walking and impairment of activities of daily living. The VA examiner reported stiffness and weakness, but that the Veteran did not use any assistive devices for ambulation. The VA examiner reported no periods of flare-ups or prescribed bedrest in the past year. The VA examiner opined that the Veteran had an unsteady gait. The diagnosis was degenerative disc disease of the lumbar spine. A range of motion summary in October 2008 indicated that the Veteran's flexion was 0 to 40 degrees. Extension was 0 to 10 degrees. Right and left lateral flexion were 0 to 20 degrees. Right and left rotation were 0 to 25 degrees. There was no noted additional limitation on motion with repetitive use due to pain, weakness, impaired endurance, or incoordination. In a June 2009 private treatment record, the private examiner reported lumbar spine moved well and there was tenderness to percussion of the left side lumbar spine paraspinal muscles. The private examiner diagnosed osteoarthritis of the lumbar spine. Here, the Board finds that, based on measures of range of motion of the thoracolumbar spine, the Veteran's back disability does not meet or more nearly approximate the criteria for an initial rating in excess of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine. For a 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine, the evidence must show forward flexion of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. The October 2008 VA examination report reflects that the Veteran had forward flexion to 40 degrees. On repetitive use, the VA examiner opined that there was no additional limitation of motion due to pain. The Board has also considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. For example, the October 2008 VA examination report reflects specific findings of no additional limitation of motion with repetitive use, and no additional limitation on motion with repetitive use due to weakness, impaired endurance, or incoordination. Even with consideration of additional limitation of motion due to pain, the range of motion does not more nearly approximate forward flexion of the thoracolumbar spine 30 degrees or less, which is required for the 40 percent rating. The specific clinical measures of ranges of motion, including the VA examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain. For these reasons, the Board finds that, for the rating prior to February 9, 2011, the criteria for an initial disability rating in excess of 20 percent for back disability have not been met. 38 C.F.R. §§ 4.3, 4.7. Initial Rating Period from February 9, 2011 The February 2011 VA examination of the spine reflects that the Veteran reported symptoms of stiffness, weakness, and back pain. The VA examiner reported the gait as normal and reported no lumbar lordosis or thoracolumbar spine ankylosis. The diagnosis was degenerative disc disease of the lumbar spine. A range of motion summary in February 2011 indicated that the Veteran's flexion was 0 to 25 degrees. Extension was 0 to 12 degrees. Right lateral flexion was 0 to 25 degrees. Left lateral flexion was 0 to 20 degrees. Right rotation was 0 to 30 degrees. Left rotation was 0 to 30 degrees. There was no noted additional limitation on motion with repetitive use due to pain, weakness, impaired endurance, or incoordination. Based upon these findings, and the Veteran's reported symptoms and limitations of motion and function, the Board finds the assignment of a rating in excess of 40 percent for lumbar spine disability is not warranted for the initial rating period from February 9, 2011, as the requirement of unfavorable ankylosis of the entire thoracolumbar spine has not been met at any time during the initial rating period from February 9, 2011. 38 C.F.R. § 4.71a, DC 5237. Overall flexion was found to be 25 degrees. The February 2011 VA examination report reflects no additional limitation of motion on repetitive use. The evidence also does not show that the Veteran has incapacitating episodes requiring bedrest prescribed by a physician and treated by a physician. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. Here, the Board notes the Veteran's reported impairment of function in occupational settings, such as limited prolonged sitting and standing, and has considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. For example, the February 2011 VA examination report reflects specific findings of limitation of flexion to 25 degrees, and no additional limitation on motion with repetitive use due to weakness, impaired endurance, or incoordination. The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain. For these reasons, the Board finds that the weight of the evidence is against a finding of a rating in excess of 40 percent for back disability for the initial rating period from February 9, 2011. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Initial Rating for LLE Radiculopathy The Veteran is in receipt of a 40 percent rating for service-connected LLE radiculopathy for the entire initial rating period, under the provisions of 38 C.F.R. § 4.71a, DC 8520. Under DC 8520, complete paralysis of the sciatic nerve warrants an 80 percent rating. Incomplete paralysis is assigned ratings of 10 to 60 percent, depending on the severity of the claimant's symptoms. A 60 percent rating is assigned for severe paralysis with marked muscular muscle atrophy. A 40 percent rating is appropriate for moderately severe paralysis. Moderate paralysis warrants a 20 percent rating, and a 10 percent rating is assigned for mild paralysis. The rating schedule does not define the terms "mild," "moderate," "severe," or "marked," as used in this diagnostic code to describe the degree of deformity of the foot. Instead, adjudicators must evaluate all of the evidence and render a decision that is "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); 38 C.F.R. §§ 4.2, 4.6. The Board notes that the term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis. 38 C.F.R. § 4.123. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. After a review of all the evidence, both lay and medical, the Board finds that the evidence is at least in relative equipoise on the question of whether, for the entire initial rating period, the Veteran's symptoms more nearly approximated the criteria for a higher disability rating of 60 percent for service-connected LLE radiculopathy. In a December 2007 private neurology study, the private examiner reported no evidence of a mononeuropathy or polyneuropathy in the left leg. The private examiner also reported motor nerve conduction studies of the left tibeal and peroneal nerves were normal and left sural sensory study was normal. In a February 2008 private treatment record, the Veteran reported back pain that radiated down his left side to his buttocks and leg; he denied any incontinence of the bowel or bladder. The private examiner reported heel-toe standing on the left foot was decreased, with reported muscle atrophy of the lower left distal lateral quadriceps; the private examiner reported strength of the lower extremities was 5/5 bilaterally. The private examiner also reported tender left SI joint and positive Patrick's maneuver on the left. In a March 2008 private treatment record, the private examiner reported motor strength 5/5 and sensory and gait were intact. In an April 2008 private treatment record, the private examiner reported motor strength of 5/5 and diminished sensation to touch at L4 and L5 dermatomes with no trophic changes of the skin. In a June 2008 private treatment record, the private examiner reported the Veteran's lower extremities as normal, with good strength in both legs and positive heel-toe walking. In a July 2008 private treatment record, the private examiner reported sciatic tension sign was positive on the left and reported strength was: 5/5 hip flexion bilaterally, 5/5 knee flexion/extension bilaterally, and 4/5 dorsiflexion/plantar flexion on left. The private examiner also reported sensation to light touch was dull on left anterior thigh. In a separate July 2008 private treatment record, the private examiner reported slight atrophy of the Veteran's left thigh and calf. In a September 2008 private treatment record, the private examiner reported positive straight leg raise and left thigh and calf had atrophied. In an October 2008 VA spine examination, the Veteran reported shooting back pain that radiated down his left lower extremity. The VA examiner reported 2+ deep tendon reflexes and numbness in the entire left lower extremity related to the L4 level. The VA examiner also reported muscle tone and strength of the lower extremities was normal. The VA examiner diagnosed degenerative disc disease of the lumbar spine with left lower extremity radiculopathy. In a December 2008 private treatment record, the private examiner reported atrophy of the quadriceps muscle consistent with nerve damage. In a January 2009 private treatment record, the private examiner reported normal muscle strength of the extremities with straight-leg raising equivocal on the left. In an April 2009 private treatment record, the private examiner reported decreased strength of the left lower extremity. In a February 2011 VA spine examination, the Veteran reported back pain that radiated down his left side to the foot. He reported no loss of control of bowel, but reported problems with gait and balance. The VA examiner reported numbness, parathesias, and leg and foot weakness. The VA examiner reported all reflexes were normal except for left knee jerk and left ankle jerk that were reported as hypoactive. On sensory examination of the Veteran's left lower extremity, vibration, position sense, pain or pinprick, and left touch were all decreased in the left foot. The VA examiner reported normal muscle tone and no muscle atrophy; however, the VA examiner subsequently reported slight left quadriceps atrophy. In light of the Veteran's subjective complaints of constant pain and numbness and the objective evidence of diminished reflexes, decreased sensation, and muscle atrophy, the Board finds that the evidence is in relative equipoise regarding whether the criteria for the 60 percent rating under DC 8520 are met for the entire initial rating period. In this respect, the evidence shows that the LLE radiculopathy results in disability that is more than moderate. Not only is there decreased sensation, but the disability is also shown to cause pain, weakness, numbing, and there is objective evidence of muscle atrophy of the left thigh and left calf. Fortunately, there is no complete paralysis shown by the evidence of record, including no indication of any type of foot drop or loss of movement or impaired range of motion. In addition, even though sensation and reflexes were found to be diminished on examination, they still were present. 38 C.F.R. § 4.124a, DC 8520. In this case, the Board finds that the evidence reflects that the Veteran's LLE radiculopathy manifests in no worse than severe incomplete paralysis, with marked muscle atrophy, in his left lower extremity. Resolving all reasonable doubt in the Veterans favor, the Board finds that the Veteran's symptoms more nearly approximate the criteria for the 60 percent rating for LLE radiculopathy under DC 8520 for the entire initial rating period. 38 C.F.R. § 4.124a. Initial Ratings for Left Knee Disability and Left Knee Laxity With respect to the left knee disability, 38 C.F.R. § 4.71a, DCs 5256 through 5262, set forth relevant provisions. Specifically, DC 5256, which governs ankylosis of the knee, provides a 30 percent rating for knee ankylosis in a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is provided for knee ankylosis in flexion between 10 and 20 degrees. A 50 percent rating is provided for knee ankylosis in flexion between 20 degrees and 45 degrees. A 60 percent rating is provided for knee ankylosis that is extremely unfavorable, in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a. DC 5257 governs other impairment of the knee. It assigns respective ratings of 10, 20, and 30 percent for slight, moderate, or severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a. DC 5258 provides for a maximum 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. DC 5259 provides a maximum 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. DCs 5260 and 5261 set forth rating schedules for limitation of motion of the leg. 38 C.F.R. § 4.71a, DCs 5260, 5261. With respect to limitation of leg flexion, DC 5260 provides a zero percent rating for flexion limited to 60 degrees, 10 percent for flexion limited to 45 degrees, 20 percent for flexion limited to 30 degrees, and a maximum of 30 percent for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. DC 5261, which governs limitation of leg extension, provides a zero percent rating for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and a maximum of 50 percent for extension limited to 45 degrees. 38 C.F.R. § 4.71a. The knee is considered a major joint. 38 C.F.R. § 4.45(f). Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Under DC 5262, impairment of the tibia and fibula characterized by malunion with moderate knee or ankle disability warrants a 20 percent evaluation, while malunion with marked knee or ankle disability warrants a 30 percent rating. Impairment of the tibia and fibula manifested by nonunion with loose motion, requiring a brace, warrants a maximum 40 percent rating. 38 C.F.R. § 4.71a. DC 5003 is for arthritis due to trauma, substantiated by X-ray findings and provides for rating as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5003. DC 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 (DC 5200, etc.). 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 DC 5003. 38 C.F.R. § 4.71a, DC 5003. Limitation of motion and instability of the knee may be rated separately. See VAOPGCPREC 9-98; VAOPGCPREC 23-97. When evaluating the symptoms under DC 5257, the provisions of 38 C.F.R. §§ 4.40 and 4.45 regarding the effects of functional loss due to pain do not apply, as that diagnostic code is not based on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7, 9 (1996). The Veteran is in receipt of a 10 percent rating for service-connected left knee disability for the entire initial rating period, under the provisions of 38 C.F.R. § 4.71a, DC 5260-5010. The 10 percent disability rating is based upon X-ray evidence of arthritis with limited and painful motion, under the provisions of 38 C.F.R. § 4.71a, DC 5260-5010. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown after a hyphen). The Veteran is also in receipt of a 10 percent rating for service-connected left knee laxity for the entire initial rating period, under the provisions of 38 C.F.R. § 4.71a, DC 5257. In a June 2008 private treatment record, the private examiner reported lower extremities were normal with good strength in both legs. In a July 2008 private treatment record, the private examiner reported 5/5 strength with knee flexion/extension bilaterally and gait was intact. In an October 2008 VA knee examination, the Veteran reported weakness, stiffness, and swelling of the left knee. On physical examination, the VA examiner reported edema, but no effusion, redness, or heat. The VA examiner also reported mild laxity and weakness of the left knee. In the October 2008 X-Ray, the VA examiner reported no fracture or malalignment was identified. The diagnosis was moderate degenerative joint disease of the left knee. A range of motion summary in October 2008 indicated that the Veteran's extension was to 0 degrees and flexion was to 80 degrees, without pain. On repetitive use, the VA examiner opined that there was no additional limitation of motion. There was also no noted additional limitation on motion with repetitive use due to weakness, impaired endurance, or incoordination. The VA examiner also reported drawer test and McMurray's test were negative. In a December 2008 private treatment record, the private examiner reported extensor mechanism and joint ligaments were stable. The private examiner also reported joint line pain, both medial and lateral. A December 2008 MRI reflected medical meniscus tear, interosseus ganglion seen in the tibia, cartilage injury in the medial compartment, mild effusion, and a small synovial cyst. In a January 2009 private treatment record, the private examiner reported crepitus with tenderness to palpation of the medial joint line of the left knee without swelling. An April 2009 private treatment record reflects crepitus in the left knee with mild tenderness to palpation of the medial joint line; however, the private examiner also reported no effusions and full range of motion. In a May 2009 private treatment record, the private examiner reported no effusion, warmth, or redness. There was proximal medial tibial pain on palpation, but no laxity. The private examiner reported range of motion from -3 to 120. In a February 2011 VA knee examination, the Veteran reported left knee symptoms of: instability, stiffness, weakness, swelling, and effusions. The Veteran also reported episodes of dislocation or subluxation one to three times per month and episodes of weekly flare-ups that would last for hours; however, the Veteran reported no episodes of "locking." The Veteran also reported functional limitations of being unable to stand or walk for prolonged periods of time. The diagnosis was degenerative joint disease and laxity of the left knee. On physical examination, the VA examiner reported no episodes of dislocation. A range of motion summary in February 2011 indicated that the Veteran's extension was to 0 degrees and flexion was to 60 degrees, with pain. On repetitive use, the VA examiner opined that there was no additional limitation of motion. There was also no noted additional limitation on motion with repetitive use due to weakness, impaired endurance, or incoordination. The VA examiner also reported no left knee ankylosis. With regard to the Veteran's left knee disability, after reviewing all the evidence, the Board finds that the Veteran's symptoms more nearly approximate a 10 percent rating under DC 5260-5010, but no more. The Board also finds that the Veteran's left knee laxity symptoms more nearly approximate a 10 percent rating under DC 5257, but no more. The Board has considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in); 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. For example, a range of motion summary in October 2008 indicated that the Veteran's flexion was 0 to 80 degrees, without pain. Extension was to 0 degrees, without pain. The October 2008 VA compensation examination report also reflects specific findings of no additional limitation of motion with repetitive use, and no additional limitation on motion with repetitive use due to weakness, impaired endurance, or incoordination. A range of motion summary in February 2011 indicated that the Veteran's flexion was 0 to 60 degrees, with pain. Extension was to 0 degrees, without pain. The February 2011 VA compensation examination report also reflects specific findings of no additional limitation of motion with repetitive use, and no additional limitation on motion with repetitive use due to weakness, impaired endurance, or incoordination. Even with consideration of the pain on repetitive use, the Board finds that the flexion is not shown to meet the criteria for a 20 percent rating under DC 5260 (which is 30 degrees). The specific clinical measures of ranges of motion, including examiner's findings and opinions regarding additional limitations of motion due to such factors, as well as the Veteran's reports of pain and other orthopedic factors have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain. The Board notes there is no medical evidence of malunion or nonunion of the tibia and fibula, semilunar, dislocated cartilage with frequent episodes of "locking," pain and effusion into the joint, or ankylosis associated with the right knee disability that would support a higher evaluation under the criteria set forth in DCs 5256, 5258, or 5262. 38 C.F.R. § 4.71a, DCs 5256, 5258, 5262. The evidence of record does not reflect that there has been removal of cartilage from the knee; however, even if such evidence was found, the maximum rating under DC 5259 for removal of cartilage that is symptomatic is 10 percent. 38 C.F.R. § 4.71a, DC 5259. In addition, there has not been any evidence of genu recurvatum; therefore DC 5263 is also not applicable. 38 C.F.R. § 4.71a, DC 5263. The Veteran may also genuinely believe that the severity of his left knee laxity merits a higher rating. However, as a layperson, lacking in medical training and expertise, the Veteran cannot provide a competent opinion on a matter as complex as whether his left knee laxity is "moderate" in nature. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Thus, his opinion is far outweighed by the detailed opinions provided by the VA medical professionals, which show that there is only a slight instability of the left knee. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As the medical evidence is devoid of a finding of moderate instability or recurrent subluxation of the left knee, a 20 percent evaluation is not warranted for left knee laxity. Given the two separate Diagnostic Codes used to evaluate the Veteran's left knee disabilities, the Board has carefully reviewed the policy against pyramiding of disability awards set forth in 38 C.F.R. § 4.14. As the General Counsel has explained, however, separate disability ratings may be assigned for "additional disability." The regulation itself prohibits evaluating the same manifestation twice. In this case, as explained above, although the Veteran's knee pain is multi-factorial, and difficult, if not impossible, to attribute which portion of his pain is due to which cause, the symptoms and manifestations can be separately and distinctly identified. He has limitation of knee motion due to osteoarthritis, which is rated under the provisions of DC 5260. He also has other impairment in his left knee manifested by instability, which is rated under the provisions of DC 5257. The Veteran's problems, as a whole, are considered within the two evaluations. Based upon these findings, for the entire initial rating period, the evaluative framework of the assignment of a 10 percent rating for limited motion, with pain, of the left knee should remain in effect, as the evidence does not show flexion limited to 45 degrees, extension limited to 10 degrees, left knee ankylosis, impairment of the tibia and fibula, or genu recurvatum. The Veteran does have some noncompensable limitation of motion; however, this is encompassed in the current 10 percent rating under DC 5260-5010. For these reasons, the preponderance of the evidence is against the claim for an initial disability rating in excess of 10 percent for service-connected left knee disability for any period. The Board also finds that for the entire initial rating period, the evaluative framework of the assignment of a 10 percent rating for left knee laxity should remain in effect, as the evidence does not reflect moderate instability of the left knee. For these reasons, the preponderance of the evidence is against the claim for an initial disability rating in excess of 10 percent for service-connected left knee laxity for any period. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath, 1 Vet. App. at 593. The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the Board finds that the schedular rating criteria contemplates the Veteran's service-connected back disability, LLE radiculopathy, left knee disability, and left knee laxity. The service-connected back disability rating criteria specifically provide for ratings based on the presence of painful arthritis, limitation of motion of the spine (including due to pain and other orthopedic factors; see 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca), and incapacitating episodes. In addition, the criteria provide for higher ratings if certain symptoms are present. Here, those symptoms are not present. The service-connected LLE radiculopathy rating criteria specifically provide for ratings based on the presence of numbness, tingling, and muscle atrophy. In addition, the criteria provide for higher ratings if certain symptoms are present. Here, those symptoms are not present. The service-connected left knee rating criteria specifically provide for ratings based on the presence of arthritis, and limitation of motion of the knee, including due to pain and other orthopedic factors and left knee instability. In addition, the criteria provide for higher ratings if certain symptoms are present. Here, those symptoms are not present. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the Veteran's service-connected disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied with respect to the increased rating issue decided herein. The RO sent the Veteran a letter in August 2008 that informed him of the requirements needed to establish increased evaluation for right ankle disability. The notice letter advised the Veteran that VA used a published schedule for rating disabilities that determined the rating assigned and that evidence considered in determining the disability rating included the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. In accordance with the requirements of VCAA, the VA letter informed the Veteran what evidence and information he was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. 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 claim. 38 U.S.C.A. § 5103A. VA has obtained 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 issues of higher initial ratings for back disability, LLE radiculopathy, left knee disability, and left knee laxity. VA provided the Veteran with examinations in October 2008 and February 2011. Treatment records were reviewed, the Veteran's history was taken, and complete examinations with clinical measures were conducted. Conclusions reached and diagnoses given were consistent with the examination report. For these reasons, the Board finds that the Veteran has been afforded adequate examinations on the issues of higher initial ratings for back disability, LLE radiculopathy, left knee disability, and left knee laxity. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board also notes that the Veteran was scheduled for a VA knee examination in October 2012 to determine the severity of his left knee disability and left knee laxity. The Veteran was notified of the examination but failed to appear. The Veteran nor his representative have given any explanation for the Veteran's inability to make the most recently scheduled examination in October 2012, and he has not called the RO to request a new examination date. Thus, the evidence that would have been obtained on examination cannot be considered. As this case involves the application of initial ratings following the grant of service connection arising from an original compensation claim, the claims for left knee disability and left knee laxity have been rated based on the evidence of record. 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 claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. 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 For the rating period prior to February 9, 2011, an initial rating in excess of 20 percent for service-connected back disability is denied. For the rating period from February 9, 2011, an initial rating in excess of 40 percent for service-connected back disability is denied. An initial 60 percent rating, but not higher, for the service-connected LLE radiculopathy is granted, subject to the regulations governing the payment of VA monetary benefits. An initial rating in excess of 10 percent for service-connected left knee disability (beyond the laxity issue) is denied. An initial rating in excess of 10 percent for service-connected left knee laxity is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs