Citation Nr: 1319685 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 10-00 993 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for the service-connected internal derangement, left knee (hereinafter "left knee internal derangement"). 2. Entitlement to an evaluation in excess of 10 percent for the service-connected degenerative changes, left knee (hereinafter "left knee degenerative changes"). 3. Entitlement to a compensable evaluation for the service-connected residuals, status-post hematoma, left knee with scars (hereinafter "left knee residuals with scars"). 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) on an extraschedular basis. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from June 1980 to May 1983. This matter initially came to the Board of Veterans' Appeals (hereinafter "Board") on appeal from a rating decision dated in July 2007 by the Department of Veterans Affairs (hereinafter "VA") Regional Office (hereinafter "RO") in Houston, Texas. In November 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge (hereinafter "VLJ"). A transcript of the hearing is associated with the record. In January 2013, the Board remanded the case to the RO via the Appeals Management Center (hereinafter "AMC") in Washington, D.C. for additional development of the record, to include obtaining any outstanding VA and non-VA treatment records, and requesting VA examination and medical opinion. The record shows substantial compliance with the January 2013 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). In evaluating this case, the Board has not only reviewed the physical claims file, but has also reviewed the eFolder on Virtual VA (hereinafter "Virtual VA") to ensure a complete assessment of the evidence. Additional, pertinent medical evidence was added to Virtual VA in March 2013, which was considered by the AMC in the April 2013 supplemental statement of the case (hereinafter "SSOC"). As such, the Board will proceed to consider the appeal on the merits. See 38 C.F.R. § 20.1304(c) (2012). As will be discussed in greater detail below, the issue of entitlement to a TDIU on an extraschedular basis has been reasonably raised by the record, and is presently in appellate status before the Board as a component of the increased rating claims on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of entitlement to a TDIU on an extraschedular basis is REMANDED to the RO via the AMC. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matters on appeal have been accomplished. 2. For the entire period of the appeal, the Veteran's left knee internal derangement symptomatology has been productive of no more than slight recurrent subluxation or lateral instability. 3. For the entire period of the appeal, the Veteran's left knee degenerative changes symptomatology has been productive of functional loss due to pain; but not with limitation of flexion to 30 degrees, or with any limitation of extension, any ankylosis of the left knee, any impairment of the tibia and fibula, or any semilunar cartilage removal. 4. For the entire period of the appeal, the Veteran's left knee residuals with scars symptomatology has been productive of benign skin neoplasms; but not with scars, not of the head, face and neck, that are deep or cause limited motion, and that cover an area or areas exceeding 6 square inches; or, with scars, not of the head, face and neck, that are superficial and do not cause limited motion, and that cover an area or areas of 144 square inches or greater; or, with any superficial and unstable scars; or, with any superficial and painful on examination scars. CONCLUSIONS OF LAW 1. The criteria for the assignment of an evaluation in excess of 10 percent for service-connected left knee internal derangement have not been met. See 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1-4.25, 4.40, 4.45, 4.71a, Diagnostic Code (hereinafter "DC") 5257 (2012). 2. The criteria for the assignment of an evaluation in excess of 10 percent for service-connected left knee degenerative changes have not been met. See 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1-4.25, 4.40, 4.45, 4.71a, DCs 5010-5260 (2012). 3. The criteria for the assignment of a compensable evaluation for service-connected left knee residuals with scars have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.25, 4.118, including DCs 7199-7819, 7801-7804 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code (hereinafter "38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations (hereinafter "38 C.F.R.") and the precedential rulings of the United States Court of Appeals for the Federal Circuit (hereinafter "Federal Circuit") (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (hereinafter "Court") (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issues under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. A Veteran bears the "'evidentiary burden' to establish all elements of a claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). The Board's duty is to first determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). If credible, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438, J. Lance dissenting; Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Duties to Notify and Assist The Veterans Claims Assistance Act (hereinafter "VCAA") describes VA's 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1). In a freestanding claim for an increased evaluation, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VCAA letters dated in May 2007, June 2009, July 2009, September 2009 and February 2013, collectively explained the evidence necessary to substantiate the claim for an increased rating for the left knee disabilities, and informed the Veteran of his and VA's respective duties for obtaining evidence. The Veteran was also advised of the type of evidence needed to substantiate the claims for increased evaluations, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned, in compliance with Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The May 2007, June 2009, July 2009 and September 2009 letters explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-491 (2006). As noted, the claims were readjudicated in the April 2013 SSOC. Accordingly, prejudicial error in the timing or content of VCAA notice has not been established and any error is not outcome determinative. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). Further, if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome by the following: (1) based on the communications sent to the Veteran over the course of this appeal, he clearly has actual knowledge of the evidence he is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what is needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). VA has a duty to assist veterans in obtaining evidence necessary to substantiate their claims. The claims file contains post-service medical treatment records, Social Security Administration (hereinafter "SSA") records, and reports of VA examinations and addenda (also known in the record as a Disability Benefits Questionnaire or "DBQ") (July 2009, September 2009, November 2009, February 2010, June 2011 and April 2013). With respect to the VA examinations, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination reports generally reflect review of the claims file, examination of the Veteran, and description and evaluation of his disabilities in accordance with the criteria for rating disabilities of the knee. In particular, these examination findings are sufficient for proper application of the relevant rating criteria and are adequate for the purpose of adjudication of the left knee disabilities. As discussed below, although the April 2013 VA examiner indicated that the Veteran's range of motion test results would have to be discarded because the Veteran was unwilling to cooperate with what was required of him during the examination, the Board finds that no further range of motion testing is needed to ascertain the nature and severity of the Veteran's left knee disabilities, as the examiner used other methods of testing to determine the level of the Veteran's left knee impairment. Moreover, the Veteran refused to perform repeated range of motion testing during the examination. Based on this and earlier dated medical evidence of record documenting similar findings, further examination would be fruitless. The Board notes that the Veteran has reported that he is in receipt of Workers' Compensation benefits. He also identified a CT scan report for his left knee from an "outside doctor" during his Board hearing. However, he has not identified specific records to be obtained pertaining to his Workers' Compensation claim, nor has he identified the "outside doctor" who is in possession of the CT scan report. Also, he has not completed any VA Form 21-4142, Authorization and Consent to Release of Information to the Department of Veterans Affairs, so that VA may obtain information pertaining to his Workers' Compensation claim and/or private CT scan report. The Board notes that "[t]he duty to assist is not always a one-way street. If a [V]eteran wishes help, he cannot passively wait for it . . . ." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Thus, no further development of the record is required in this regard. As stated above, in January 2013, the Board remanded the case for additional development of the record, to include obtaining any outstanding treatment records and providing VA examination and medical opinion. The claims file reflects that attempts to obtain additional medical records have been made and VA treatment records have been uploaded to Virtual VA, and a VA examination and opinion have been obtained in April 2013. Further, the Agency of Original Jurisdiction (hereinafter "AOJ") has had the opportunity to review the newly submitted evidence and has issued the April 2013 SSOC in consideration of that evidence. As such, the Board finds that the development directed in the prior remands has been substantially completed. Dyment v. West, 13 Vet. App. 141, 146-47 (1999). At the November 2012 hearing, the undersigned VLJ and representative for the Veteran outlined the issues on appeal and engaged in a colloquy as to substantiation of the claim, including identifying relevant types of evidence. Overall, the hearing was legally sufficient and the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran has not made the RO, the AMC or the Board aware of any additional evidence that must be obtained in order to fairly decide the claims on appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of these issues have been obtained and the case is ready for appellate review. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). The Merits of the Claim-Entitlement to Increased Ratings In February 2007, the Veteran filed a claim for entitlement to increased ratings for his service-connected left knee disabilities and associated residuals. He contends that he is entitled to a disability rating in excess of 10 percent for his service-connected degenerative changes, left knee (evaluated under Diagnostic Code 5010-5260); to a disability rating in excess of 10 percent for his service-connected derangement, left knee (evaluated under Diagnostic Code 5257); and to a compensable disability rating for his service-connected residuals, status-post hematoma, left knee, with scars (currently evaluated under Diagnostic Code 7199-7819, and previously evaluated under Diagnostic Code 5299-5019). See 38 C.F.R. §§ 4.20, 4.71a, and 4.118 (2012). The Board must analyze the evidence from the earliest possible date upon which such increases could be awarded, namely, one year prior to the RO's receipt of his February 16, 2007, increased rating claims. See 38 C.F.R. § 3.400(o)(2); accord Hart v. Mansfield, 21 Vet. App. at 509-10 (2007). The 10 percent evaluation was assigned under Diagnostic Code 5010-5260 for degenerative changes of the left knee based on a finding of functional loss due to pain. To warrant a rating in excess of 10 percent, the Veteran's leg flexion must be limited to at least 30 degrees; his extension must be limited to at least 15 degrees; he must experience semilunar dislocated cartilage with frequent episodes of locking, pain and effusion to the joint; he must experience impairment of the tibia and fibula with moderate knee or ankle disability; or he must experience ankylosis of a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a. The 10 percent evaluation was assigned for the left knee internal derangement under Diagnostic Code 5257 based on a finding of slight, recurrent subluxation or lateral instability. To warrant a rating in excess of 10 percent, the Veteran must experience moderate, recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. The noncompensable evaluation was assigned for the left knee residuals with scars based on a finding that the Veteran's scars were not disfiguring, did not limit motion, did not have pain on examination, did not have frequent loss of covering of skin over the scars, and did not impair function. To warrant a compensable rating, the Veteran's scars, not of the head, face or neck, must be deep or cause limited motion, covering an area or areas exceeding 6 square; or, must be superficial and not cause limited motion, covering an area or areas of 144 square inches or greater; or, must be superficial and unstable; or, must be superficial and painful on examination. 38 C.F.R. § 4.118. After a full review of the record, and as further explained below, the Board finds that the preponderance of the evidence weighs is against the assignment of increased evaluations for these left knee disabilities and associated residuals. Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2012). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In evaluating the severity of a particular disability it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as in this case, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Ratings shall be based, as far as practicable, upon the average impairments of earning capacity. However, from time to time, VA will readjust this schedule of ratings in accordance with experience. To accord justice in an exceptional case in which the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that 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). All potential applicable diagnostic codes, whether or not raised by a claimant, must be considered. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). However, "disability ratings are assigned based on a 'condition,' rather than on any symptoms of a particular condition." Cullen v. Shinseki, 24 Vet. App. 74, 80-81, 84 (2010). Thus, separate disability ratings under the same diagnostic code are not assignable "for different symptoms of an underlying spinal condition, such as pain, ankylosis, or muscle spasms." Id. In other words, "within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise." Id. However, separate ratings may be assignable under different diagnostic codes where a disability involves distinct conditions. Id. It is important to note generally that the joining of schedular criteria by the conjunctive "and" in a diagnostic code does not always require all criteria to be met, except in the case of diagnostic codes that use successive rating criteria, where assignment of a higher rating requires that elements from the lower rating are met. Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). See also Tatum v. Shinseki, 23 Vet. App. 152 (2009) (indicating the joining of criteria by the conjunctive "and" in a diagnostic code does not always require all criteria to be met, except, as here, in the case of a diagnostic code that uses successive rating criteria, where assignment of a higher rating requires that elements from the lower rating are met.) The Veteran's service-connected left knee degenerative changes and left knee internal derangement disabilities are currently rated pursuant to 38 C.F.R. § 4.71a, under the General Rating Formula for Diseases and Injuries of the Knee and Leg (DCs 5256-5263). 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 (2012). When an evaluation of a disability is based on limitation of motion, VA must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Although pain may cause a functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). With any form of arthritis, painful motion is an important factor of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. VA's 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). However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2012). VA's General Counsel 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). In VAOPGCPREC 9-98, VA's General Counsel reiterated 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, the 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 Veteran'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 Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Diagnostic Code 5010 provides that traumatic arthritis is to be rated as degenerative arthritis. Diagnostic Code 5003 in turn provides that degenerative arthritis (that is established by X-ray findings) will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Diagnostic Code 5256 provides a 60 percent rating will be assigned for extremely unfavorable ankylosis of the knee in flexion at an angle of 45 degrees (hereinafter "º") or more; a 50 percent rating will be assigned for ankylosis of the knee in flexion between 20º and 45º; a 40 percent rating will be assigned for ankylosis of the knee in flexion between 10º and 20º; and a 30 percent rating will be assigned for ankylosis of the knee with favorable angle in full extension, or in slight flexion between 0º and 10º. See 38 C.F.R. § 4.71a, DC 5256 (2012). Diagnostic Code 5257 provides a 30 percent rating will be assigned for severe, recurrent subluxation or lateral instability of the knee; a 20 percent rating will be assigned for moderate recurrent subluxation or lateral instability of the knee; and a 10 percent rating will be assigned for slight recurrent subluxation or lateral instability of the knee. See 38 C.F.R. § 4.71a, DC 5257 (2012). Diagnostic Code 5258 provides a 20 percent rating for cartilage, semilunar, dislocated with frequent episodes of "locking," pain and effusion into the joint; and Diagnostic Code 5259 provides a 10 percent rating for cartilage, semilunar, removal of, symptomatic. See 38 C.F.R. § 4.71a, DCs 5258 and 5259 (2012). Diagnostic Code 5260 provides a 30 percent rating for flexion of the leg limited to 15º; a 20 percent rating for flexion limited to 30º; a 10 percent rating for flexion limited to 45º; and a 0 percent rating for flexion limited to 60º. See 38 C.F.R. § 4.71a, DC 5260 (2012). Diagnostic Code 5261 provides a 50 percent rating for extension of the leg limited to 45º; a 40 percent rating for extension limited to 30º; a 30 percent rating for extension limited to 20º; a 20 percent rating for extension limited to 15º; a 10 percent rating for extension limited to 10º; and a 0 percent rating for extension limited to 5º. See 38 C.F.R. § 4.71a, DC 5261 (2012). Diagnostic Code 5262 provides a 40 percent rating for nonunion of the tibia and fibula with loose motion, requiring a brace; a 30 percent rating for malunion with marked knee or ankle disability; a 20 percent rating for malunion with moderate knee or ankle disability; and a 10 percent rating for malunion with slight knee or ankle disability. See 38 C.F.R. § 4.71a, DC 5262 (2012). Diagnostic Code 5263 provides a 10 percent rating for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). See 38 C.F.R. § 4.71a, DC 5263 (2012). The Veteran's service-connected left knee residuals with scar disability is currently rated pursuant to 38 C.F.R. § 4.118, under the Schedule for Rating the Skin (DCs 7800-7833). The Veteran's residuals of the left knee with scars, status-post hematoma are an unlisted condition in the list of diagnostic codes. Where a particular disability for which the Veteran has been service-connected is not listed, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical area and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27; Lendenmann v. Principi, 3 Vet. App. 345, 349-50 (1992); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). When rating by analogy, the diagnostic code is "built- up" by assigning the first two digits from that part of the schedule most closely identifying the part of the body involved and then assigning "99" for the last two digits for all unlisted conditions. See 38 C.F.R. § 4.27. Then, the disability is rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. See 38 C.F.R. §§ 4.20, 4.27 (2012). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). The Board's selection of a Diagnostic Code under which to rate a claimant's disability by analogy is considered a factual determination and is reviewed under the Court's "arbitrary and capricious" standard. 38 U.S.C. § 7261(a)(3)(A); Butts v. Brown, 5 Vet. App. 532, 539 (1993) (en banc). The Board must provide an adequate statement of reasons or bases for its analysis under a particular section of the Diagnostic Code. Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). The Board's duty to provide an adequate statement of reasons or bases is heightened in cases in which a condition is assigned a rating by analogy to other conditions. See Suttman v. Brown, 5 Vet. App. 127, 134 (1993). The Board finds the Veteran's service-connected residuals of the left knee with scars is best rated by analogy under the schedular criteria of 38 C.F.R. § 4.118, DC 7819, which concerns benign skin neoplasms. See 38 C.F.R. § 4.27. This is, in fact, the same diagnostic code provision that the RO rated the condition under in the December 2009 rating decision, when it was no longer rated by analogy under the schedular criteria of 38 C.F.R. § 4.71a, DC 5019, which concerns bursitis. Additionally, while the Veteran's appeal was pending, 38 C.F.R. § 4.118 for rating skin disabilities was amended, effective October 23, 2008. See 73 Fed. Reg. 54708-01, 54710 (September 23, 2008). Under the revised regulations, scars other than of the head, face, or neck, are rated under Diagnostic Codes 7801 to 7805. This new regulation, however, indicates that the revised provisions are applicable only to claims received on or after October 23, 2008. Accordingly, because the Veteran's claim was received before that date, these revisions do not apply to the present case. 73 Fed. Reg. 54708 (Sept. 23. 2008). Rather, this appeal will be considered solely under the criteria effective as of the February 2007 claim. Under Diagnostic Code 7801, scars, other than the head, face, or neck, that are deep or that cause limited motion are assigned a 10 percent rating if they cover an area or areas exceeding 6 square inches (39 square centimeters). A 20 percent rating is warranted if they cover an area or areas exceeding 12 square inches (77 square centimeters). A 30 percent rating is warranted if they cover an area or areas exceeding 72 square inches (465 square centimeters). A 40 percent evaluation is warranted if they cover an area or areas exceeding 144 square inches (929 square centimeters). Note (1) Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with §4.25 of this part. Note (2) A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801 (2007). Under Diagnostic Code 7802, scars, other than the head, face, or neck, that are superficial and that do not cause limited motion, and that cover an area or areas greater than 144 square inches (929 square centimeters) are assigned a 10 percent rating. Note (1) Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with §4.25 of this part. Note (2) A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802 (2007). Under Diagnostic Code 7803, scars that are superficial and unstable are assigned a 10 percent rating. Note (1) An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) A superficial scar is one not associated with soft tissue damage. 38 C.F.R. § 4.118, DC 7803 (2007). Under Diagnostic Code 7804, scars that are superficial and painful on examination are assigned a 10 percent rating. Note (1) A superficial scar is one not associated with soft tissue damage. Note (2) In this case, a 10-percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation (See §4.68 of this part on the amputation rule). 38 C.F.R. § 4.118, DC 7804 (2007). In 2006, the Veteran was treated for complaints of pain in the left thigh, left heel and support tenderness above the left patella. In July 2006, he underwent an X-ray study of the left knee, which revealed an impression of medial joint space narrowing with eburnation of the articular surface, and no evidence of fracture or effusion. Beginning in January 2007, he began treatment with physical therapy at VA for his left knee disabilities, during which he was prescribed a transcutaneous electrical nerve stimulation (hereinafter "TENS") unit, underwent stretching and strengthening exercises to the left quadriceps and hamstring, used "heat/cold" treatments, and was prescribed a medial unloader brace. His predominant complaint was chronic, aching pain, which affected his ability to negotiate stairs, stand and walk, and which was accompanied by popping in his left knee. The Veteran indicated that he did not have physical therapy after undergoing a surgical repair procedure for a meniscus tear in 1996; however, he had previously been issued a knee brace, which afforded him mild pain relief. He also reported that his knee buckled and he experienced falls on average of every other month. During one such physical therapy session in January 2007, the Veteran was observed to have no atrophy in the quadriceps, or left knee effusion. Palpation revealed pain along the left knee medial joint line, pain superior to the patella, and left knee crepitus; however, there was no tenderness to patellar palpation. Active and passive range of motion testing revealed decreased knee flexion limited by pain. On neurologic examination, the Veteran's motor strength was 4/5 throughout his left lower extremity, and was limited by pain. His sensation was intact to light touch throughout, and his reflexes were normal throughout. It was observed that the Veteran had no clonus, he had a negative Lachman's, and he had no ligamentous instability with varus or valgus stress. However, he had pain with varus and valgus stress, worse with varus stress than valgus stress, he was unable to perform an Apley's compression test because he was unable to tolerate lying on his stomach secondary to patellar pain, and he had antalgic gait. X-ray imaging performed in July 2006, showed an impression of medial joint space narrowing with eburnation of the articular surface, with no evidence of fracture or effusion. The Veteran was diagnosed with left knee osteoarthritis, obesity, left knee arthralgia secondary to left knee osteoarthritis and obesity, and gait abnormality. A March 2007 physical therapy session note indicates the Veteran was observed to have endomorphic posture, and range of motion testing was from 0º to 90º, with pain at end range, and strength of 4+/5 in the left quadriceps and hamstring muscles. Light touch testing was grossly intact, and the Veteran was assessed with osteoarthritis of the left knee. A March 2008 VA primary care note reveals the Veteran reported that he was unable to perform his work as scaffolder due to his left knee pain. He requested evaluation for knee replacement surgery. An April 2008 VA orthopedic surgery note shows he complained of left knee pain, and that he had finished 6 weeks of physical therapy for left lower extremity/left quadriceps strengthening, which had not helped. He described his knee as very painful, and noted that wearing a brace helped some. He indicated that his main pain occurred over the medial knee, posteriorly, and suprapatellar. He also experienced tenderness to palpation over the medial collateral ligament (hereinafter "MCL"), but the external mechanism was observed to be intact, and there was no apparent varus/valgus laxity. He had a negative Lachman's test, but the practitioner noted that the Veteran would not fully relax, so there was no way to truly examiner the ligamentous stability. There was mild effusion observed but no erythema, and range of motion test results were from 0º to 90º, without medial or lateral joint line tenderness to palpation. On X-ray the practitioner noted there were no fractures or dislocations. An April 2008 X-ray report indicated findings of medial joint space slightly narrowed, but articular margins intact and normal soft tissues. A June 2008 VA orthopedic surgery note, indicates the Veteran complained of left knee pain after undergoing an MRI scan in May 2008, and with taking the stairs. He was observed to be unable to fully extend the knee, and reported pain and swelling. The practitioner noted the Veteran had undergone three physical therapy sessions in 2007. The May 2008 MRI study revealed results were suboptimal due to lack of visualization of the lateral portion of the lateral meniscus. There was a discrete linear signal at the posterior portion of the body of the lateral meniscus noted, which appeared blunted. The practitioner indicated that this might have represented a tear or history of partial meniscectomy. Mild arthrofibrosis was found on Hoffa's fat pad, but the anterior cruciate ligament (hereinafter "ACL"), the posterior cruciate ligament (hereinafter "PCL"), the MCL and the lateral collateral ligament (hereinafter "LCL") complexes and extensor mechanism were all observed to be unremarkable. No significant joint effusion or Baker's cyst was identified; however, there was mild soft tissue edema anterior to the patella that the practitioner indicated might have represented prepatellar bursitis, but there was no abnormal marrow signal observed. The Veteran was diagnosed with left knee patella pain, was referred for physical therapy and received a steroid injection to the left knee. An October 2008 VA orthopedic surgery note, shows the Veteran was treated for prepatellar tendonitis. He had previously undergone a steroid injection at his last visit, which lasted for approximately 1 week; however, lawn cutting and fixing the air conditioning irritated the knee. He complained of pain with using stairs, squatting and kneeling. He also reported intermittent swelling, but denied locking or giving way. He took Ibuprofen with little relief. Physical examination results included observation that the skin was intact over the left knee with no erythema, and no effusion noted. Range of motion testing was characterized as "full," and there was no pain to McMurray's or negative anterior drawer sign noted. The Veteran was diagnosed with left knee pain, and was referred for physical therapy, offered a cortisone injection, which he declined, and was prescribed Ibuprofen and Diclofenac for his pain. VA physical therapy notes, dated in November 2008 and December 2008, also show treatment for prepatellar tendonitis. The Veteran had steroid injections during his prior visits, which relieved his pain for approximately 1 week at a time. He again described pain with using stairs, squatting, and kneeling, and took Ibuprofen with little relief. He reported that his occupation was as a scaffold helper, but reported that he was not employed. On physical examination, it was noted that he had endomorphic posture, and range of motion testing for the left knee was from 0º to 90º, with pain at end range. His strength was observed to be 4+/5 in the left quadriceps/hamstring. He complained of mild tenderness to palpation over medial aspect of left knee, but no edema was noted. His light touch was described as grossly intact. He admitted to intermittent swelling, but denied locking or giving way. He took Ibuprofen with little relief, and also continued to treated his left knee with heat and cold, and with a TENS unit. He indicated that his symptoms were partially relieved by medication and rest, and were aggravated by the end of the work day. He could not perform prolonged standing, walking or stairs, and experienced popping in left knee. A VA radiographic report, dated in January 2009, reveals an impression of minimal joint space narrowing, with sclerosis of the articular surface, and no evidence of fracture or effusion. A VA orthopedic surgery note, dated in January 2009, shows the Veteran complained of left knee symptoms that were worse than prior to his undergoing therapy. The Veteran characterized his pain as non-predictable in its onset, and starting in the middle anterior surface of the knee and radiating to the hip. The Veteran noted that the pain was not alleviated by Ibuprofen, Diclofenac or steroid injections. He complained that his pain woke him every night. He noted that he could not squat, kneel, put weight on the left knee or work around the house, and had to leave his professional occupation, because of his left knee. He also complained of muscle spasm. On physical examination, the orthopedist observed the Veteran's left knee had no edema, his active range of motion was from 15º to 70º, his passive range of motion was from 15º to 80º, and he was without pain on adduction. However, he did experience severe pain on abduction, and there was some crepitus of the knee on motion. An MRI scan report included an impression of discrete linear signal at the posterior portion of the body of the lateral meniscus, which appeared blunted, and which might have represented a prior history of a partial meniscectomy or tear. The orthopedist noted the existence of a correlation with the prior surgical history, and mild prepatellar bursitis was diagnosed. On X-ray, no abnormality was noted. The Veteran was evaluated with left knee pain, imaging not showing any ligament, cartilage or bone abnormality. It was determined that surgery was not an option, but the Veteran was prescribed a new bionic air brace. A VA physical therapy note dated in January 2009, indicates the Veteran was diagnosed with osteoarthritis involving the left knee. On follow-up evaluation it was noted that he had prepatellar tendinitis. His pain was characterized as constant ache, partially relieved by rest/medications. The activities affected were prolonged walking, standing and using stairs, which caused symptoms of popping in the left knee. Range of motion testing indicated pain at end range, but was within full limits. The practitioner noted there was functional weakness when the Veteran was in pain. A VA radiographic report, dated in May 2009, reveals an impression of no evidence of acute bony abnormality, minor narrowed joint space on the medial side of kidney likely due to degenerative change, no other bony or joint abnormality, and no evidence of effusion. A VA orthopedic surgical note, dated in May 2009, reveals an MRI scan showed lateral meniscus tear and mild prepatellar bursitis. The Veteran reported that he did not believe his knee pain symptoms had improved. On physical examination of the left lower extremities, the orthopedist noted no effusion or prepatellar swelling was observed in the left knee. There was mild tenderness to palpation over the mid-patella, and tenderness to palpation over the midsole of the left foot that radiated to the left leg. There was no lateral joint line tenderness, but there was some medial joint line tenderness to palpation, not reproduced with distraction. There was a negative straight leg raise test, and range of motion was from 0º to 110º in the left knee. The Veteran was assessed with left knee pain with improving range of motion, and it was determined that no surgical intervention was needed. Among the SSA records associated with the SSA claim for disability benefits was an evaluation of the Veteran's left knee by "Dr. Nalluri" in July 2009. During this evaluation, the Veteran reported that his symptoms had increased in severity from a previous evaluation. He was unable to dress himself, or to perform various activities of daily living such as mowing the lawn. It was noted that he was unable to drive due to his hands and not his left knee. On physical examination, it was noted that the Veteran had been heavily limping on his left side and needed assistance getting onto the examination table. On examination of the left knee, Dr. Nalluri reported there was no cyanosis, edema or calf tenderness present; however, the Veteran was observed to have "severe" limitation of movement in range of motion of the knee. There was no effusion present, but he had a heavy limp while wearing a brace. There was tenderness present in the patellar region, and the Veteran was unable to perform squatting and heel-toe walking. The Veteran was assigned a diagnostic impression of a history of left knee pain, status-post arthroscopic surgery with partial relief, that had gotten worse over a period of time, and which prevented him from being able to participate in activities. Range of motion testing of the left knee was flexion to 120º and extension to 0º. Left knee frontal and lateral views taken concurrently with the evaluation in July 2009, showed no bone or soft tissue abnormalities, and the joint space was well-maintained. The Veteran was diagnosed with an impression of normal left knee, with no sign of joint effusion. Also in July 2009, the Veteran underwent a VA joints examination to evaluate the nature and severity of his left knee disabilities. Prior to addressing the Veteran's medical history, or physical findings, the VA examiner noted that the Veteran's complaints were "very theatrical" and that he had pain and limitation of motion that were "totally out of proportion to his X-rays and MRI pathology" that was noted during the examination. Further, the examiner noted that the Veteran had applied for Social Security disability, which was pending. The Veteran described current complaints of locking with the knee in a totally straight position; however, the examiner noted it did not lock in any other position. The Veteran complained of severe trouble going up and down stairs, and significant trouble bending the knee. He indicated that he had a sense of the knee giving way on him, but denied falling. He reported that any prolonged standing aggravated the knee, that the knee remained swollen "all the time," and that prolonged sitting caused stiffness and pain. He noted that he had a lack of endurance, was very sedentary, and did very little, although the examiner noted that he failed to describe any weakness, dislocations or subluxations. The Veteran was using a TENS unit on the knee, with some relief, and tried several types of braces in the past with no benefit. He also had a history of treatment with Cortisone and Synvisc injections, which had been limited, with improvement lasting for only a few days. The Veteran indicated that any activity tended to aggravate his knees and caused chronic and continuous flare-ups; however, the examiner noted there were no incapacitating events, the Veteran had no reinjury or further surgery on the knee since his 1996 repair of a partially torn meniscus, and there was no history of inflammatory arthritis. The examiner noted the Veteran took Diclofenac, an anti-inflammatory, for his knee pain, but did not feel it was of any benefit. He also used a cane and occasionally walked with a walker. The examiner noted the Veteran reported last being employed as a carpenter in 2005, and had extreme limitations in his activities of daily living. For example, he noted that any prolonged standing or walking aggravated the knee, and so he spent most of his time sitting at home. However, as noted, there was no history of inflammatory arthritis or neoplasms. On physical examination, the examiner observed the Veteran was tender and jumped "anywhere you touch him in or about the joint." The examiner noted that this could be up in the mid-thigh or on the calf. The Veteran was described as hypersensitive all over, although there was no obvious effusion identified and the quadriceps muscles were described as "equal." The examiner noted there was tenderness to palpation over the top of the patella consistent with some mild patellar bursitis; however, there was no swelling there, or masses. The examiner indicated the Veteran had spasms in the quadriceps and the hamstring during the examination, but the knee was stable to varus valgus stress testing, with a negative Lachman's test, negative anterior posterior drawer test, and no joint line tenderness. The examiner observed the Veteran had significant difficulty trying to relax, and any time he was touched he would tense up. Range of motion testing revealed flexion from 0º to 95º, with pain throughout the range of motion, but no increased pain, fatigue, weakness or incoordination with repetitive motion. Motor function was described as 5/5 bilaterally, and straight leg testing was positive on the left, with sensation intact throughout. The examiner indicated that X-ray weight bearing testing of the left knee showed some very minimal medial joint space narrowing with no evidence of an acute bony abnormality, and no other bone or joint abnormality, or evidence of effusion. The Veteran underwent an MRI of the knee in May 2008, which showed a discrete linear signal at the posterior portion of the lateral meniscus which appeared blunted and was believed to most likely represent a prior history of a partial meniscectomy. The examiner noted there was mild prepatellar bursitis as well. The examiner concluded that the Veteran had pain with any activity of the leg, had a positive straight leg raising, and complained of some back pain as well as some radicular pain from the buttocks down the leg. The examiner opined that "the pain and disability [were] totally out of proportion to X-ray and MRI findings." The examiner noted that for this reason electromyography (hereinafter "EMG") and nerve conduction studies were ordered of the left lower extremity to rule out some type of nerve injury, neuritis, and neuropathy versus radiculopathy coming from the back. Again, the examiner opined that the Veteran's pain and disability were totally out of proportion to any physical findings, X-ray findings, or MRI findings. In September 2009, the Veteran underwent the EMG study ordered on VA examination in July 2009. The VA practitioner who performed the study indicated that the study was incomplete due to the Veteran's poor tolerance. However, there was no evidence of right tibial motor neuropathy and no evidence of right sural sensory neuropathy, and the practitioner concluded that the EMG study was incomplete to rule out lumbosacral radiculopathy. In September 2009, the Veteran underwent another VA examination of his left knee. Here, the examiner reviewed a specific history for the Veteran's status-post hematoma of the left knee. The Veteran reported that his status-post hematoma had existed since 1982, and occurred while the Veteran was serving on physical training during active duty. He reported symptoms of weakness, stiffness, swelling, heat, redness, giving way, lack of endurance, locking fatigability, deformity, tenderness, pain and dislocation. He denied symptoms of drainage, effusion and subluxation. He reported experiencing flare-ups of pain as often as once a day, lasting for one day, precipitated by physical activity and alleviated by rest and anti-inflammatory pills. The Veteran indicated that during his flare-ups he experienced functional impairment, including an inability to climb, run or stand for too long, and limited bending ability. He reported difficulty with standing and walking for too long, which was accompanied by pain and swelling. The Veteran also described symptoms of bad muscle spasms in the left leg, and pain running from the lower part of the back to the bottom of the left foot, which was treated by a TENS unit, which did not help. The Veteran reported being hospitalized and having surgery in May 1996 to repair a torn meniscus, with a residual of extreme pain. The Veteran also noted that he underwent Cortisone shots at a VA hospital on an uncertain date, which did not help. He denied that his condition resulted in any incapacitation, and noted that he did not undergo any joint replacement surgery. He described his overall functional impairment as being unable to climb stairs, bend his knee to a certain degree, stand for long, or walk for long. On physical examination of the skin, it was observed that the Veteran had no sign of skin disease, however there was a linear scar precisely located on the left knee, measuring 3 centimeters by 0.1 centimeters in length. The examiner noted the scar was not painful on examination, there was no skin breakdown, and it was superficial with no underlying tissue damage. The examiner indicated that inflammation was absent, edema was absent, there was no keloid formation, the scar was not disfiguring, and it did not limit the Veteran's function or motion. A second scar was identified that was also linear, and precisely located on the left knee. The entire scar measured 1 centimeter by 1 centimeter, and was not painful on examination. There was no skin breakdown noted, the scar was superficial without underlying tissue damage, inflammation was absent, edema was absent, there was no keloid formation, the scar was not disfiguring, and did not limit the Veteran's function or motion. On physical examination of the musculoskeletal system, the Veteran's posture was observed to be normal, although on tandem gait he walked with a limp. The examiner noted the Veteran's leg length from the anterior superior iliac spine to the medial malleolus was 101 centimeters on the right and left sides. Examination of the feet did not reveal any sign of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear patterns. It was noted that for ambulation the Veteran required a brace on the left knee and a cane due to his left knee pain. He did not require crutches, corrective shoes, a wheelchair, prosthesis or a walker. Examination of the left knee showed findings of tenderness, locking pain and crepitus; but no evidence of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, or subluxation. There was no genu recurvatum or ankylosis. Range of motion testing revealed flexion to 120º and extension to 0º, with repetitive motion possible, and without additional degree of limitation. The examiner noted that the joint function was additionally limited by pain on repetitive use, and that pain had the major functional impact. The examiner indicated that joint function was not additionally limited after repetitive use by fatigue, weakness, lack of endurance or incoordination. The medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test, and the medial lateral meniscus ligaments stability test were all within normal limits for the left knee. Further, X-ray findings of the left knee were within normal limits. The Veteran was diagnosed with status-post hematoma of the left knee. The subjective factors were history of left knee hematoma, and the objective factors were status-post surgery. There was an additional diagnosis of scars due to surgery that were located at the left knee. The examiner noted that the only residual of the status-post hematoma of the left knee was left knee pain. The examiner opined that the effect of the disability on the Veteran's usual occupation was none, and the effect of the disability on the Veteran's daily activity was left knee pain worse with movement. An accompanying addendum opinion, dated in November 2009, indicates observations that the Veteran was noted to have significant pain and disability that was totally out of proportion to his X-ray and MRI findings of the knee on examination in July 2009, for which he was sent for an EMG and nerve conduction study to rule out nerve injury, neuritis and neuropathy versus radiculopathy. The Veteran had EMG and nerve conduction studies performed in July 2009, which revealed incomplete findings due to the Veteran being unable to complete the test due to his pain. The examiner noted that there was no evidence of right tibial motor neuropathy or sensory neuropathy in the lower extremity, and that the EMG study was deemed incomplete to rule out lumbosacral radiculopathy. The examiner reviewed the Veteran's MRI scan results and opined that the Veteran's pain complaints were totally out of proportion to the physical examination as well as X-ray and MRI evidence. The examiner noted that the Veteran had minimal medial joint space narrowing of the left knee, and concluded that he should be rated as "minimal." In February 2010, the Veteran underwent another VA joints examination. Here, he provided a history for status-post hematoma with scars, and described overall functional impairment due to difficulty with weight bearing activities. However, it was noted that the Veteran was not undergoing any treatment for his condition. On history of activities and functions, the Veteran was observed to be able to brush his teeth, take a shower, drive a car, dress himself and walk. He was unable to vacuum, cook, climb stairs, take out the trash, shop, garden, or push a lawn mower due to his pain. It was noted that he was unemployed since 2005. Physical examination of the skin revealed abnormal findings. Specifically, three identical scars were located on the left knee, which were characterized as linear superficial without underlying tissue damage, and measuring 1 centimeter by 0.5 centimeter. The examiner noted the scars were not painful on examination, there was no skin breakdown, inflammation, edema, or keloid formation. The scars were not disfiguring and did not limit the Veteran's motion or function. Physical examination of the left knee revealed findings of tenderness and guarding of movement of the left knee, but no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, malalignment, drainage, subluxation, locking pain, genu recurvatum, crepitus or ankylosis. Range of motion testing included flexion to 50º and extension to 0º, with repetitive range of motion possible, without any additional degree of limitation. The examiner noted that the Veteran was unable to perform stability tests for the left knee because he could not adequately flex the knee for testing. The Veteran was diagnosed with active degenerative changes, left knee; with active internal derangement, left knee; and with asymptomatic status post-hematoma with scars. The examiner opined that the effect of the Veteran's "condition" on his usual occupation was deceased weight bearing and lifting ability from musculoskeletal issues, and difficulty with sedentary activity given pain and stiffness with prolonged periods in one position. The effect of the Veteran's "condition" on his daily activity was decreased weight bearing and lifting ability from musculoskeletal issues and difficulty with sedentary activity given pain and stiffness with prolonged periods in one position. In March 2010, the Veteran was awarded SSA disability benefits since January 2009 for, among other things, his "severe impairment" of "status-post left knee surgery with residual problems." An accompanying "Physical Residual Functional Capacity Assessment," indicates the Veteran could sit, and stand and/or walk with normal breaks for about 6 hours in an 8 hour work day. He had postural limitations of being unable to climb, balance, stoop, kneel, crouch or crawl. On his "Functional Report," the Veteran indicated that he was unable to drive due to his left knee, and only left his house twice a week on average. A February 2011 VA history and physical indicates the Veteran reported left leg pain related to his left knee disabilities, and symptoms of occasional episodes where his left leg locked up and he became unsteady, and that he ambulated with a cane. Also, within days of treatment in February 2011, the Veteran was assigned a 35 on the Morse Fall Scale and a 45 on the Morse Fall Scale, indicating a moderate risk for falls and a high risk for falls, respectively. These treatment records do not include an explanation as to why the Veteran was found to be at risk for falls, and did not show that the risk was related to his service-connected left knee disabilities. A VA examination took place in June 2011, which generally shows the Veteran's complaints of symptoms of weakness, stiffness, heat, giving way, lack of endurance, fatigability, tenderness and pain in the left knee. He denied experiencing swelling, drainage, effusion, subluxation and dislocation. He also reported experiencing flare-ups, precipitated by physical activity and alleviated by rest and Hydrocodone, as often as 3 times per week, each time lasting for 3 hours. During these flare-ups he experienced functional impairment of pain, and experienced difficulty with standing and walking, which was relieved by a TENS unit. He denied his disability resulted in any incapacitation that for the past 12 months, and denied undergoing any joint replacement. He reported that his overall functional impairment was pain, which occurred when bending, climbing or standing. Examination of the skin revealed findings of no scar based on the skin examination, and no evidence of rashes or lesions. Examination of the musculoskeletal system revealed the Veteran had a normal gait; normal, steady walk; no unusual shoe wear pattern; and did not require any assistive device for ambulation. His disability was not found to cause generalized muscle weakness, wasting or atrophy. Regarding knee stability, the examiner noted that the left knee stability tests were within normal limits for anterior and posterior cruciate ligaments, medial and lateral collateral ligaments, and the medial and lateral meniscus. Also, the left knee showed no signs of subluxation, edema, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, or guarding of movement. Range of motion testing revealed flexion to 90º and extension to 0º. Repetitive motion was found to be possible, with flexion to 90º and extension to 0º, and there was no additional degree of limitation. The examiner opined that the Veteran's joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The Veteran was diagnosed with active internal derangement of the left knee with degenerative changes, with objective and subjective factors of decreased range of motion, locking, crepitus and pain. The examiner opined that the Veteran's functional impairment caused by his disabilities, and the effect of that impairment on his ability to perform physical and sedentary activities of employment were mainly his knee pain made it difficult to stand or walk for long periods of time without discomfort, and his back pain made it difficult to stand or sit for extended periods of time and limited lifting. However, the examiner ultimately opined that the effect the Veteran's "condition" had on his usual occupation as a construction worker would be his knee and back pain that affect his ability to work. However, the effect of the "condition" on daily activities was characterized as "minimal." Since then, the Veteran has testified before the Board, and asserted that his left knee symptoms were more severe than the results of his previous examination indicated. Specifically, the Veteran reported that he is unable to stand for long periods of time, to walk or to run, and that his range of motion was severely limited by his pain, which produced steady throbbing and was made worse by swelling. He indicated that he has been prescribed Vicodin to treat his pain, that he currently requires the use of a cane, and has previously required the use of a brace and of a TENS unit. He also reported that he has undergone physical therapy and injections to the knee to relieve his symptomatology. Further, he indicated that he had 4 scars, 3 of which were visible, and 1 of which was indented and painful to touch. He described occasional, transient bruising and swelling at the left knee. In April 2013, the Veteran underwent a VA knee and lower leg conditions examination, in which he was diagnosed with degenerative joint disease of the left knee. The Veteran provided a history of pain in the knee, pain with stair climbing, and intermittent swelling; however, the examiner observed that on physical examination there was no tenderness or swelling described. The Veteran reported feeling weakness and stiffness in the morning, but the examiner observed there was no hematoma or discoloration in the left knee. The examiner indicated that the Veteran used a brace and a cane on a regular basis to assist him with his mobility impairment. On physical examination, range of motion testing revealed flexion was to 45º without objective evidence of painful motion; and there was no limitation of extension or painful motion on extension. The examiner noted that the Veteran was limping on the left with walking from the waiting room to the office, but that passively observing him in the office, he had no limp. The examiner indicated that the Veteran had no joint swelling or tenderness, and used extreme strength to prevent flexion, which would not have happened if he had pain with motion or true limited motion. The examiner indicated that range of motion test results would have to be discarded. The examiner noted that, except for minimal degeneration, the Veteran had no X-ray or MRI scan evidence of his symptoms and range of motion test results. The examiner noted that the Veteran was unable to perform repetitive range of motion testing with three repetitions because he was unwilling to continue with his testing. The examiner indicated that this component of the examination would have to be discounted. However, the examiner noted that the Veteran did not have additional limited range of motion of the knee and lower leg following repetitive-use testing; and did not have any functional loss and/or functional impairment in the knee and lower leg. Also, the Veteran did not have tenderness or pain to palpation for the joint line or soft tissue of the knee, muscle strength testing was characterized as "normal stretch" with both flexion and extension of the left knee, and joint stability was found to be normal on joint stability testing ("Lachman's test," "Posterior drawer test," and application of valgus/varus pressure to the knee in extension and 30º flexion). The examiner observed there was no evidence or history of recurrent patellar subluxation/dislocation, the Veteran did not have shin splints, and he had not undergone joint replacement, arthroscopic or other surgical procedures related to the left knee. However, there was evidence of a meniscal tear, for which the Veteran had undergone a left meniscectomy in 1996, and currently experienced residuals. On diagnostic testing, the examiner noted that imaging studies had been performed, and there was evidence of degenerative or traumatic arthritis; however, there was no X-ray evidence of patellar subluxation. The examiner noted that the Veteran was unemployed, but opined that his knee and lower leg disability did not impact his ability to work. The examiner also performed an evaluation of the Veteran's scars related to his left knee disability, and he was diagnosed with two arthroscopic surgery scars, characterized as "very faint and small," related to surgery performed in 1996. The examiner observed that these scars were not painful or unstable, they were not due to burns, nor was the total area of the related scars greater than 39 square centimeters (6 square inches). The scars were located superior to the patella, and were linear, with each measuring .05 centimeters long. The examiner observed there were no superficial, non-linear scars, and no deep non-linear scars present on physical examination. Neither of the scars resulted in limitation of function, and they were not associated with muscle or nerve damage. The examiner opined that the scars did not impact the Veteran's ability to work. It is the Board's fundamental responsibility to evaluate the probative value of all medical and lay evidence. See Owens v. Brown, 7 Vet. App. 429 (1995); Gabrielson v. Brown, 7 Vet. App. 36 (1994); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (observing that the evaluation of medical evidence involves inquiry into, inter alia, the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches). In the evaluation of evidence, VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the Veteran. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (holding that credibility can be impeached generally by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character). It has also been observed that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence." Madden v. Brown, 125 F. 3d 1447, 1481 (Fed. Cir. 1997). In consideration of the evidence of record, the Board finds that the VA examination opinions to be the most persuasive and probative evidence concerning the claim. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). The Board notes the Veteran's subjective complaints of intermittent swelling, pain, giving way and instability, along with reports of painful, depressed scars on the left knee. The Veteran is competent to report the nature and extent of his knee musculoskeletal and skin symptoms, to include describing his overall functional loss. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, on this record, the lay assertions alone are not sufficient to establish the presence of joint instability or recurrent subluxation, ankylosis, flexion limited to 30º, extension limited to 15º, semilunar cartilage dislocation, semilunar cartilage removal, tibia and fibula impairment, genu recurvatum, or arthritis of the right knee, which might otherwise entitle him to an evaluation in excess of 10 percent. Furthermore, the Board finds that the Veteran is not a credible or reliable historian in recounting his current level of left knee impairment, as it has been noted on several examinations that he was clearly exaggerating his physical reactions while undergoing range of motion and EMG testing. Several VA examiners have characterized the Veteran as overly sensitive, and have noted that his grossly exaggerated reactions to physical examination of his left knee have rendered their results unusable. Also, these examiners have explained that the Veteran's diagnostic test results are wholly inconsistent with the level of impairment he asserts he experiences, because X-ray testing and MRI scans have generally been negative for signs of any significant impairment. Instead, the Board relies upon the findings of the VA examiners, and particularly the April 2013 examiner, to provide a more detailed and objective disability picture of the Veteran's left knee disabilities, as their results were based on objective diagnostic tests, including X-ray studies and MRI scans. As a general matter, a medical examiner is not required to comment on every favorable piece of evidence in a claims file. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). Furthermore, for the reasons discussed above, the lay statements asserting the Veteran experienced severe symptoms of pain, limitation of motion and instability are not found competent or credible, as the Veteran has consistently failed to report on the severity of his symptoms, or to allow for VA examiners to adequately evaluate the extent of his left knee disabilities. Any deficiency in the VA examiner's factual foundation or explanation is consequently immaterial. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a VA examination report "must be read as a whole" to determine an examiner's rationale); Acevedo v. Shinseki, 25 Vet. App. 286, 293-942012); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Moreover, the April 2013 VA examiner made it very clear that the Veteran was uncooperative during range of motion testing on physical examination, which made it difficult to obtain accurate range of motion test results; the Board finds that further testing in this regard is therefore not warranted. Accordingly, the probative value of the VA examiners' opinions is not materially diminished in this respect. See Nieves-Rodriguez, 22 Vet. App. at 304. Such medical opinions, which are factually accurate, fully articulated, and based on sound reasoning, carry significant weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board, in its own lay capacity (as with the Veteran), is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. See, e.g., Monzingo, 26 Vet. App. 97, 106 (2012). Accordingly, a remand to obtain additional range of motion testing is not warranted. The Board has considered whether "staged" ratings are appropriate for any of the left knee disabilities. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The record does not support assigning different percentage ratings for the service-connected left knee disabilities and associated residuals during the period of the appeal. In light of the foregoing, the Board finds that the schedular requirements for an evaluation in excess of 10 percent for left knee derangement and left knee degenerative changes are not met. There is no evidence that the symptoms associated with the Veteran's knee disabilities have worsened, improved, or changed in any other respect during the rating period under consideration and therefore a 20 evaluation is not warranted for any part of the rating period. Also, the schedular requirements for a compensable evaluation for the left knee residuals with scars are not met. There is no evidence that the symptoms associated with the Veteran's knee disability has worsened, improved or changed in any other respect during the rating period under consideration, and therefore a 10 percent evaluation is not warranted for any part of the rating period. Even factoring in additional limitation of motion due to pain and flare-ups, the flexion and extension findings fail to meet the levels for 20 percent evaluations under Diagnostic Codes 5260 and 5261 and as such separate evaluations for flexion and extension are not warranted. 38 C.F.R. § §4.45, 4.71a, Diagnostic Codes 5242; DeLuca, 8 Vet. App. at 202. Nor is there evidence of the involvement of two or more major joints or 2 or more minor joints with occasional incapacitating exacerbations to warrant an increased 20 percent evaluation under Diagnostic Code 5010. The evidence reflects the Veteran meets the criteria for a 10 percent rating under Diagnostic Code 5260, but meets the criteria for a noncompensable rating under Diagnostic Code 5261, as he has at times had flexion limited to 45º but has generally had extension limited to 0º. The Veteran is already in receipt of a 10 percent rating under Diagnostic Code 5257. The question is whether there is evidence of more than slight recurrent subluxation or instability. The record reflects the evidence fails to support a finding of moderate recurrent subluxation or lateral instability, as the Veteran has consistently denied such symptoms. In this regard, as noted, the clinical record and VA examination reports show that tests, such as Lachman's, drawer, McMurray's tests, were negative. Further, at no time in the clinical record have the Veteran's left knee residuals with scars been productive of scars, not of the head, face and neck, that are deep or cause limited motion, and that cover an area or areas exceeding 6 square inches; or, of scars, not of the head, face and neck, that are superficial and do not cause limited motion, and that cover an area or areas of 144 square inches or greater; or, of any superficial and unstable scars; or, of any superficial and painful on examination scars. Apart from his hearing testimony, the Veteran has never described painful or deep scars, and physical examination testing results do not corroborate the Veteran's subjective complaints. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the medical evidence does not support evaluations in excess of 10 percent for the service-connected left knee derangement and left knee degenerative changes, or a compensable evaluation for the service-connected left knee residuals with scars, the preponderance of the evidence is against the assignment of any higher rating and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Additional Considerations 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. Schedular ratings are based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. 38 C.F.R. § 4.15. To afford justice in exceptional situations, however, an extraschedular rating may also be assignable. 38 C.F.R. § 3.321(b). The Board may not, in the first instance, assign an increased rating on an extraschedular basis, but may determine whether referral for extraschedular consideration is warranted, provided that it articulates the reasons or bases for that determination. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). This determination follows a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). 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, the level of severity and symptomatology of a veteran's service-connected disability must be compared with the established criteria found in the rating schedule for that disability. Id. If the rating criteria reasonably describe a veteran's disability level and symptomatology, the disability picture is contemplated by the rating schedule. Therefore, the assigned schedular evaluation is adequate and no referral is required. Id. If the schedular evaluation does not contemplate the level of disability and symptomatology, and is found inadequate, the second step of the inquiry requires the Board to determine whether the exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-16. The first two steps should be undertaken by comparing the disability picture of each service-connected disability with the criteria in the rating schedule for that disability. The Board should compare the service-connected disability picture with the criteria in the rating schedule for that disability. Johnson v. Shinseki, --- Vet. App. ----, 2013 WL 1224810, Vet. App., March 27, 2013 (NO. 10-1785). Extraschedular consideration is undertaken on the basis of each individual service-connected disability. Based on this disability-by-disability approach, the Board is not required to consider whether a veteran is entitled to referral for extraschedular consideration of his service-connected disabilities on a collective basis. Id. If analysis of the first two steps shows that the rating schedule is inadequate to evaluate the disability picture and that picture shows the related factors discussed above, the final step requires that the disability be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. 111. Here, the rating criteria reasonably describe the Veteran's left knee disability levels and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. It is noted that the symptoms listed in the rating criteria are demonstrative and not exhaustive; thus, the rating criteria actually consider many other orthopedic symptoms. See Mauerhan, 16 Vet. App. 436; see also 38 C.F.R. § 4.130. Overall, the occupational and social impairment caused by the Veteran's left knee disabilities and associated residuals, as described above, are accounted for by the rating criteria. Thus, the assigned schedular evaluation is adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. ORDER Entitlement to an evaluation in excess of 10 percent for service-connected left knee internal derangement is denied. Entitlement to an evaluation in excess of 10 percent for service-connected left knee degenerative changes is denied. Entitlement to a compensable evaluation for service-connected left knee residuals with scars is denied. REMAND The Board finds that remand is necessary for further evidentiary development, including a new VA examination to ascertain the impact of all of his service-connected disabilities on his unemployability and referral for entitlement to extraschedular consideration. The record clearly shows the Veteran is unemployed and has been so since 2005. It also shows that starting in 2009, he began to report that he was unemployable due to his left knee disabilities. A TDIU is a rating, not a disability. It merely means that a veteran has met certain qualifications entitling him to a total disability rating. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). A Veteran may be awarded TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. See 38 U.S.C.A. § 1155 (2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.26 (2012). Consideration may be given to his level of education, special training, and previous work experience in making this determination, but not to his age or the impairment caused by any nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012); see also Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). A TDIU may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a) (2012). In addition, there must be evidence that the disabled person is unable to secure or follow a substantially gainful occupation. See 38 C.F.R. §§ 3.340, 3.341, 4.16. The claims file shows that the Veteran's service-connected disabilities consist of (1) internal derangement, left knee, rated 10 percent disabling; (2) degenerative changes, left knee, rated 10 percent disabling; (3) lumbar strain with intervertebral disc syndrome associated with internal derangement, left knee, rated as 10 percent disabling; (4) right knee strain associated with internal derangement, left knee, rated as 10 percent disabling; (5) peripheral neuropathy left lower extremity associated with lumbar strain with intervertebral disc syndrome, rated as 10 percent disabling; (6) hemorrhoids, rated as noncompensable; and residuals, status-post hematoma, left knee, with scars, rated as noncompensable. The combined disability rating is 40 percent from December 18, 2009. Thus, he does not meet the criteria of 38 C.F.R. § 4.16(a) and a grant of TDIU on a schedular basis is not warranted. Consequently, the only remaining question in this case is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, for purposes of a possible extraschedular evaluation. 38 C.F.R. § 4.16(b). The Board emphasizes that entitlement to an extraschedular rating under 38 C.F.R. § 3.321(b)(1) and a TDIU extraschedular rating under 38 C.F.R. § 4.16(b), although similar, are based on different factors. See Kellar v. Brown, 6 Vet. App. 157, 162 (1994). An extraschedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran's disabilities. Exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. In contrast, 38 C.F.R. § 4.16(b) merely requires a determination that a particular Veteran is currently rendered unable to secure or follow a substantially gainful occupation by reason of his or her service-connected disabilities. See VAOPGCPREC 6-96. The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed under 38 C.F.R. § 4.16(b). The Board itself cannot assign an extraschedular rating in the first instance. See Thun v. Shinseki, 572 F.3d 1366 (2009). Although Thun only dealt with ratings under § 3.321(b)(1), the analysis in those cases is analogous to TDIU ratings under § 4.16(b) as well, in view of that section's similar requirement of referral to the Director of VA's Compensation and Pension Service, in addition to Court precedents requiring consideration of § 4.16(b) when the issue is raised in an increased-rating case. See Stanton v. Brown, 5 Vet. App. 563, 570 (1993); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). That is, since the Board itself cannot assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case to the Director of Compensation and Pension (hereinafter "C&P") Services for an extraschedular evaluation when the issue is either raised by the claimant or is reasonably raised by the evidence of record. See Thun v. Peake, 22 Vet. App. 111, 115 (2008); Barringer v. Peake, 22 Vet. App. 242 (2008). If, and only if, the Director of C&P Services (hereinafter "Director") determines that an extraschedular evaluation is not warranted, does the Board then have jurisdiction to decide the extraschedular claim on the merits. In fact, the Court held that although the Board is precluded from initially assigning an extraschedular rating, there is no restriction on the Board's ability to review the adjudication of an extraschedular rating once the Director of C&P determines that an extraschedular rating is not warranted. Anderson v. Shinseki, 22 Vet. App. 423, 427-8 (2009). See also Floyd v. Brown, 9 Vet. App. at 96-97 (1996) (stating that once Board properly refers an extraschedular rating issue to Director of C & P for review, appellant may "continue[ ] to appeal the extraschedular rating aspect of this claim"); see also 38 U.S.C.A. §§ 511(a), 7104(a) ("All questions in a matter ... subject to decision by the Secretary shall be subject to one review on appeal to the Board."). In December 2009, the filed an informal claim for TDIU based on his nonservice-connected depression, as well as for nonservice-connected nerve damage in the right hand, right arm, and left hand (characterized as carpal tunnel syndrome), which was denied in an April 2010 rating decision, issued in May 2010 by the RO. In a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, received in March 2011, the Veteran indicated his left knee disabilities prevented him from securing and following any substantial gainful occupation, and that the highest level of schooling completed was 2 years of college. In a May 2012 rating decision, issued in June 2012, the RO again denied entitlement to a TDIU. Notably, in neither instance did the RO refer the Veteran's claim to the Director of C&P for an extraschedular evaluation. However, review of the clinical record shows findings that the Veteran's left knee disabilities and associated residuals, as well as his lumbar spine disability, appear to impact his employability. Starting in January 2009, the Veteran reported that he had to leave his professional occupation, because of his left knee. The July 2009 VA examiner noted the Veteran reported last being employed as a carpenter in 2005, and had extreme limitations in his activities of daily living. For example, he noted that any prolonged standing or walking aggravated the knee, and so he spent most of his time sitting at home. The September 2009 VA examiner opined that the effect of the left knee disability on the Veteran's usual occupation was none, and the effect of the disability on the Veteran's daily activity was left knee pain worse with movement. However, on VA examination in February 2010 and June 2011, the VA examiners essentially opined that the effect of the Veteran's left knee disabilities on his usual occupation was deceased weight bearing and lifting ability from musculoskeletal issues, and difficulty with sedentary activity given pain and stiffness with prolonged periods in one position. The effect of the Veteran's left knee disabilities on his daily activity was decreased weight bearing and lifting ability from musculoskeletal issues and difficulty with sedentary activity given pain and stiffness with prolonged periods in one position. The more recent VA examination report, dated in April 2013, reflects an opinion that the Veteran's knee and lower leg disability did not impact his ability to work. However, the examiner failed to provide further explanation or rationale for this finding. Thus, the Board finds that a new VA examination is necessary to evaluate the severity of the Veteran's service-connected disabilities to include their impact on his ability to work. Furthermore, the evidence of record before the Board at present indicates that the Veteran's disability picture is arguably exceptional and exhibits other related factors such as marked interference with his employment, which warrants referral for consideration of assignment of a TDIU on an extraschedular basis. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 115 (2008). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC must schedule the Veteran for a general medical examination to ascertain the impact of all of his service-connected disabilities on his unemployability. A copy of this remand and all relevant medical records should be made available to the examiner, to include any pertinent records in Virtual VA. The examiner is asked to confirm whether paper and/or electronic records were available for review. The examiner must evaluate and discuss the effect of all of the Veteran's service-connected disabilities on the Veteran's employability. The examiner should opine as to whether it is as likely as not (i.e., a 50 percent or more probability) that the Veteran's service-connected disabilities, without consideration of his nonservice-connected disabilities or age, render him unable to secure or follow a substantially gainful occupation. A complete rationale for any opinion expressed should be provided. If an opinion cannot be expressed without resort to speculation, discuss why such is the case. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. 2. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the claim of entitlement to a TDIU. If the benefit remains denied, the RO/AMC should refer the matter to the Undersecretary for Benefits or to the Director of Compensation and Pension Services for extraschedular consideration. 38 C.F.R. § 3.321(b)(1). Then, if otherwise in order, provide the Veteran and his representative with a supplemental statement of the case and afford them a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs