Citation Nr: 1320157 Decision Date: 06/21/13 Archive Date: 07/02/13 DOCKET NO. 07-12 676 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for an upper respiratory disorder, to include sinusitis. 2. Entitlement to an initial disability rating in excess of 10 percent for patellofemoral syndrome of the right knee. 3. Entitlement to an initial disability rating in excess of 10 percent for patellofemoral syndrome of the left knee. 4. Entitlement to service connection for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active service from June 1984 to June 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2005 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Houston, Texas. The issue of entitlement to service connection for a heart disability was originally developed for appellate review; however, service connection for a heart disability, characterized as left ventricular hypertrophy, was ultimately granted by the RO in a February 2013 rating action. Therefore, this issue is no longer before the Board. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in August 2009. A copy of the transcript of that hearing is of record. In December 2009, September 2011, and August 2012, the Board remanded this case for additional development. The purposes of these remands have been met and the case is ready for appellate consideration. The Board found the issue of entitlement to a TDIU rating to be part and parcel of the Veteran's appeal in its September 2011 remand of this matter. The issue of entitlement to a TDIU rating is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An upper respiratory disorder, to include sinusitis, was not manifest in service and is not currently shown. 2. The Veteran's service-connected right knee disability is manifested by slight limitation of motion, and pain; it has not been manifested by limitation of flexion to 60 degrees or less or limitation of extension to more than 5 degrees and there is no objective evidence of instability, swelling, recurrent subluxation, or dislocated semilunar cartilage with recurrent episodes of locking with effusion into the joint. 3. The Veteran's service-connected left knee disability is manifested by slight limitation of motion, and pain; it has not been manifested by limitation of flexion to 60 degrees or less or limitation of extension to more than 5 degrees and there is no objective evidence of instability, swelling, recurrent subluxation, or dislocated semilunar cartilage with recurrent episodes of locking with effusion into the joint. CONCLUSIONS OF LAW 1. The criteria for service connection for an upper respiratory disorder, to include sinusitis, have not been met or approximated. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for an initial rating in excess of 10 percent for patellofemoral syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5003, 5014, 5257, 5260, 5261 (2012); VAOPGCPREC 23-97; VAGCOPPREC 9-98; VAOPGCPREC 9-04. 3. The criteria for an initial rating in excess of 10 percent for patellofemoral syndrome of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5003, 5014, 5257, 5260, 5261 (2012); VAOPGCPREC 23-97; VAGCOPPREC 9-98; VAOPGCPREC 9-04. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R."); and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue 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. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (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). VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 ("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 & Supp. 2012); 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 medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA has satisfied its duty to notify by issuing VCAA letters from the RO to the Veteran dated in September 2004, November 2004, March 2006, January 2010, April 2010, and August 2012. These letters advised the Veteran of what evidence was required to substantiate his service connection and increased rating claims. In addition, the March 2006, January 2010, and April 2010 letters from the RO further advised the Veteran of the elements of a disability rating and an effective date, which are assigned when service connection is awarded. Dingess, 19 Vet. App. at 473, 486. Also, with regard to the Veteran's increased evaluation claims, this appeal arises from disagreement with an initial evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated and additional VCAA notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Filing a notice of disagreement (NOD) begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as the disability evaluation assigned) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). The Veteran was provided with a statement of the case (SOC) in March 2007, and supplemental statements of the case (SSOCs) in July 2011, April 2012, and March 2013. With respect to Pelegrini, supra, written notice was provided in September and November 2004, prior to the appealed from rating decision, along with the subsequent notice provided in March 2006, January 2010, April 2010, and August 2012, after the decision that is the subject of this appeal. With respect to any timing deficiency, the Board notes that the case was subsequently readjudicated in July 2011, April 2012, and March 2013 SSOCs and, as such, the Veteran has not been prejudiced thereby. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records, reports of post-service VA medical treatment, including the Veteran's Virtual VA folder which includes VA Medical Center (VAMC) outpatient treatment records, dated from October 2006 to October 2012, and VA examination reports, dated in November 2004 (QTC), December 2005 (QTC), May 2010, May 2011, and September 2012. There is no indication in the record that any additional evidence relevant to the issues decided herein is available and not part of the claims file. The Board also notes substantial compliance with the remand directives in its previous remands in December 2009, September 2011, and August 2012. See Stegall v. West, 11 Vet. App. 268 (1998). Specifically, in the December 2009 remand, the RO was directed to provide the Veteran a VA examination that was pertinent to his service-connected bilateral knee disabilities. The purpose of the examination was to determine the current severity of the Veteran's right and left knee disabilities. The RO was also directed to provide the Veteran with a VA examination in order to determine the etiology of any sinusitis. Specifically, the examiner was requested to opine whether the Veteran's sinusitis began during service, was aggravated during service, or was otherwise related to any incident of service. In addition, in the September 2011 remand, the Board noted that the Veteran had applied for disability benefits from the Social Security Administration (SSA). Thus, upon remand, the RO was to obtain any decision from the SSA that was pertinent to the Veteran's claim, including any evidence relied on for the SSA decision. In May 2010, the Veteran underwent a VA examination that was pertinent to his service-connected bilateral knee disabilities. Moreover, also in May 2010, the Veteran underwent a VA examination that was pertinent to his claim for service connection for sinusitis. In January 2012, the RO requested that the SSA furnish the medical and administrative records used in making the Veteran's SSA claim determination. In the return response, the SSA stated that the requested records could not be sent because there were no medical records. According to the SSA, either the Veteran did not file for disability benefits or he filed for disability benefits but no medical records were obtained. In the August 2012 remand, the Board stated that in regard to the Veteran's service-connected bilateral knee disabilities, the evidence of record showed a possible service-related meniscal injury to the knees and locking, pain, and effusion. If such pathology and symptoms were demonstrated, a 20 percent rating could be warranted for each knee. Thus, the RO was directed to afford the Veteran a new VA examination to determine the current severity of his bilateral knee disabilities. In addition, with respect to the Veteran's sinusitis, the Board noted that the opinion from the examiner from the May 2010 VA examination that the Veteran had increased nasal secretions which were related to in-service exposure to jet fuel, lacked a complete explanation. The Board could find no clinical findings that correlated with the Veteran's description of increased nasal secretions since discharge from service. Thus, a clarifying examination and opinion was warranted. The examiner was requested to indicate whether there was clinical evidence that the Veteran had increased nasal secretions. If so, the examiner was requested to report whether such would be considered a manifestation of sinusitis or other respiratory disorder, and a diagnosis for the disorder had to be provided. In addition, the examiner was requested to state whether he/she agreed with the May 2010 examiner that the disorder was due to exposure to chemicals including jet fuels during active service. The examiner also had to provide an opinion as to whether the Veteran had a current upper respiratory disorder. In September 2012, the Veteran underwent a VA orthopedic examination for his service-connected bilateral knee disabilities. The examiner specifically reported that the Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition. Also in September 2012, the Veteran underwent a VA examination that was pertinent to his claim for service connection for an upper respiratory disorder. Following the physical examination, the examiner stated that the examination was normal and that he was unable to diagnose any upper respiratory condition. The examiner further reported that there was no clinical evidence of increased nasal secretions on the examination. Regardless, the examiner opined that it was less likely than not that any increased nasal secretions were a manifestation of sinusitis or of any other respiratory disorder, and that such a disorder would also be less likely than not (less than 50/50 probability ) related to chemicals or jet fuels during active service. In light of the above, there has been substantial compliance with the prior remand directives. See Stegall, 11 Vet. App. at 268; D'Aries v. Peake, 22 Vet. App. 97, 105 (2008)(holding that there must be substantial compliance with the terms of a Court or Board remand). The Veteran was afforded a Travel Board hearing before the undersigned VLJ in August 2009, in which he presented oral argument. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the undersigned VLJ set forth the issues to be discussed at the hearing and sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. The VLJ notified that Veteran that in order to substantiate his service connection claim, he had to show that he had an upper respiratory disorder that was related to his period of active service. In addition, in order to substantiate his increased rating claims, he had to show that the ratings assigned to his service-connected bilateral knee disabilities were not high enough in light of the amount of functional impairment that his disabilities caused. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of those elements. Consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record VA fulfilled its VCAA duties to notify and assist the Veteran, and thus, no additional assistance or notification is required. The Merits of the Claims Service Connection Claim The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of the inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. 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. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau, supra, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding 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"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. 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). Service connection may be established for disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, supra (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker, supra. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), such as the Veteran in this case, then the more relaxed continuity-of-symptomatology standard does not apply, and the "nexus" requirement of the three-element test must be met. Id. The Veteran contends that during service, he had sinus problems and infections. He maintains that he currently has sinusitis that is related to his period of active service. However, since a preponderance of the evidence is against his claim for service connection for an upper respiratory disorder, to include sinusitis, it will be denied. The Veteran's service treatment records show that he was treated on numerous occasions for upper respiratory infections. In June 1986, the Veteran was treated for a viral upper respiratory infection. In May 1986, he was treated for sinus congestion. In August 1988, he was treated for an upper respiratory infection with right ear otitis and tympanic membrane inflammation. In October 1991, he was treated for a diagnosed upper respiratory infection with possible early bronchitis. Treatment included antibiotics. In November 1992, he was treated for a sore throat and congestion. The assessment was viral syndrome with pharyngitis. In August 1994, the Veteran sought treatment for an upper respiratory infection. The diagnosis was rule out bronchitis and early otitis media. He was noted to have a cough and ear pain. The sinuses were nontender. The lungs were clear. The service treatment records include private treatment records which reflect that in November 2003, the Veteran was treated for an upper respiratory infection. At that time, his nares showed thick drainage that was clear. In May 2004, the Veteran underwent a retirement examination. At that time, he denied any sinusitis, or chronic or frequent colds. The Veteran's sinuses, mouth and throat, head, face, neck, and scalp, and nose were all clinically evaluated as "normal." In September 2004, the Veteran filed a claim of entitlement to service connection for sinusitis. In November 2004, the Veteran underwent a VA examination which was conducted by QTC Services. Examination of his head, ear, nose, and throat showed that his nasal septum was in the midline. There was no posterior pharyngeal erythema. Oral mucosa was intact. The Veteran testified at a Travel Board hearing before the undersigned VLJ in August 2009. He stated that during service, he had problems with his sinuses and developed numerous sinus infections. He indicated that after his discharge, he continued to have problems with his sinuses. According to the Veteran, he currently had sinusitis that was related to his period of active service. In May 2010, the Veteran underwent a VA examination. He stated that he was a medic during service and had worked around weapons and airplanes throughout his military career. The examiner noted that the Veteran was exposed to jet fuel during service and that his nasal secretions had increased since his military service. It was the examiner's opinion that such increased nasal secretions were as likely as not a "cause of military exposure." A VA examination was conducted in May 2011. At that time, the Veteran stated that he had the following upper respiratory symptoms four times a year: runny nose, stuffiness, sneezing, and post-nasal drainage. He indicated that he also had two sinus infections per year. The Veteran noted that he initially developed sinus symptoms in approximately 1998. According to the Veteran, he was diagnosed with sleep apnea in 2008. Upon physical examination, there were no signs of nasal obstruction. There was no tissue loss, scarring or deformity of the nose. VA x-rays were taken of the Veteran's nasal bones. The x-rays were reported to show normal nasal bones and nasal spines. Following the physical examination and a review of the x-rays, the examiner diagnosed the Veteran with sinusitis per Veteran's statements. However, the examiner stated that there were no significant clinical findings on the current examination which were consistent with sinusitis or allergic rhinitis. The examiner further noted that he could not resolve the issue of whether the Veteran's claimed sinusitis was related to his military service without resorting to mere speculation. According to the examiner, there was insufficient objective data to opine on the question of service connection. In September 2012, the Veteran underwent a VA examination. The examiner stated that he had reviewed the Veteran's claims file. The Veteran's service treatment records showed treatment for viral syndrome with sore throat and congestion in November 1992; an upper respiratory infection in October 1991; and sinus congestion and sinus infection in May 1986. The Veteran indicated that he had seasonal allergies and hayfever with runny nose, congestion, and sneezing. The physical examination showed that the Veteran's nose was normal with no discharge, polyps, or lesions. The nares were patent, bilaterally. Examination of the Veteran's throat showed no lesions. Following the physical examination, the examiner stated that the examination findings were normal and that he was unable to diagnose any upper respiratory condition. The examiner reported that there was no clinical evidence of increased nasal secretions on the examination. Regardless, the examiner opined that it was less likely than not (less than 50/50 probability), that any increased nasal secretions were a manifestation of sinusitis or of any other respiratory disorder. Such a disorder would also be less likely than not (less than 50/50 probability ) related to chemicals or jet fuels during active service. To the extent that the Veteran's service treatment records show treatment for possible bronchitis and otitis media, the Veteran had previously filed claims for service connection for bilateral otitis media and bronchitis (a lower respiratory disorder). However, these claims were denied in an August 2012 Board decision. Thus, these issues are separate from the Veteran's current claim for service connection for an upper respiratory disorder, to include sinusitis, and have already been addressed. Regarding the Veteran's claim for service connection for an upper respiratory disorder, to include sinusitis, the threshold question that must be addressed here, as in any claim seeking service connection, is whether the Veteran indeed has the disability for which service connection is sought, i.e., an upper respiratory disorder, to include sinusitis. In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that a current disability may be shown although the disability resolves during the course of the claim, as long as the Veteran has a disability at the time the claim is filed or during the pendency of the claim. The Veteran's service treatment records show that he was treated on numerous occasions for upper respiratory infections and that the symptomatology for such infections included sinus congestion. However, the records are negative for any evidence showing that he was actually diagnosed with sinusitis or any other upper respiratory disability during service. In fact, upon the Veteran's May 2004 retirement examination, the Veteran denied any sinusitis and his sinuses, mouth and throat, head, face, neck, and scalp, and nose were all clinically evaluated as "normal." These medical records are highly probative both as to the Veteran's subjective reports and their resulting objective findings. They were generated with a view towards ascertaining the Veteran's then-state of physical fitness and are akin to statements of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rationale that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Of even greater significance is that a competent and credible diagnosis of an upper respiratory disorder, to include sinusitis, is not currently shown and has not been shown during the pendency of this appeal. See McClain, supra. The Board has carefully considered the May 2010 VA examination report, where the examiner diagnosed the Veteran with increased nasal secretions and related such increased nasal secretions to the Veteran's in-service exposure to jet fuel. However, this opinion is or limited probative value. Firstly, and similar to mere pain, increased nasal secretions are symptoms and not a disability in and of itself. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (symptoms alone, without a diagnosed or identifiable underlying malady or condition, do not in and of themselves constitute a disability for which service connection may be granted). No underlying disability manifested by increased nasal secretions has been diagnosed. In fact, in the September 2012 VA examination, the examiner specifically concluded that it was less likely than not (less than 50/50 probability) that any increased nasal secretions were a manifestation of sinusitis or of any other respiratory disorder. He also noted that such a disorder would be less likely than not (less than 50/50 probability) related to chemicals or jet fuel during active service. Therefore, because the symptom of increased nasal secretions does not constitute an independently ratable disability, service connection for it cannot be granted. The basis of the examiner's opinion is unclear. While the May 2011 VA examination report, the examiner diagnosed the Veteran with sinusitis, the examiner reported that the diagnosis was based on the history as related by the Veteran only. A bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Although the Court held in Kowalski v. Nicholson, 19 Vet. App. 171 (2005), that VA cannot reject a medical opinion solely on the basis of a history supplied by the Veteran, it observed that the critical question is whether that history was accurate. See e.g., Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (reliance on a Veteran's statement renders a medical report incredible only if the Board rejects the statements of the Veteran). The Veteran's history as reported to the examiner was not accurate. There is no competent evidence of record showing that the Veteran has been diagnosed with sinusitis. The only evidence of record supporting the Veteran's claim that he has been diagnosed with sinusitis is his own lay opinion that he has sinusitis. He is competent to describe the symptoms he experiences, such as nasal and sinus congestion, and the Board accepts his statements as credible. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau, supra ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). However, he is not competent to give an opinion as to whether these symptoms are the result of sinusitis or another upper respiratory disability, as such issue involves highly complex medical questions concerning an internal physical process. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation, as contrasted with the situations contemplated by Jandreau and Barr, supra (lay testimony is competent to establish the presence of varicose veins). Here, the Veteran's lay opinion that he has sinusitis or another upper respiratory disability is not competent evidence and cannot be considered as evidence favorable to his claim. Given that the Veteran is not competent to opine on the complex medical question of whether he has sinusitis, and the fact that the examiner from the May 2011 VA examination diagnosed the Veteran with sinusitis based on the Veteran's reported history that he had been diagnosed with sinusitis, the May 2011 diagnosis of sinusitis was not based on a full factual foundation. The diagnosis is not therefore probative. See Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997); see also Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (an opinion based on an inaccurate factual premise has no probative value). The examiner himself questioned the legitimacy of the sinusitis diagnosis. The examiner stated that even though he was diagnosing the Veteran with sinusitis based on the Veteran's reported history, the examiner noted that there were no significant clinical findings on the examination which were consistent with sinusitis or allergic rhinitis. In addition, to the extent that he accepted the diagnosis of sinusitis, he could not resolve the issue of whether the Veteran's claimed sinusitis was related to his military service without resorting to mere speculation. A finding of service connection may not be based on a resort to speculation or even remote possibility. See 38 C.F.R. § 3.102 (2012). In the September 2012 VA examination, the examiner concluded that the examination results were normal and that he was unable to diagnose any upper respiratory condition. In addition, he reported that there was no clinical evidence of increased nasal secretions on the examination. Even if such increased nasal secretions were shown, the examiner opined that it was less likely than not that such increased secretions were a manifestation of sinusitis or of any other respiratory disorder. The Board finds that this VA medical opinion is persuasive and assigns it great probative weight. The opinion was rendered by a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. In addition, the examiner was able to interview the Veteran and he was aware of the Veteran's symptoms. The examiner also reviewed the Veteran's claims file, including the most pertinet evidence therein, and provided an explanation for his opinion. See Nieves-Rodriguez, 2 Vet. App. 295 (2008) (discussing factors for determining probative value of medical opinions. In sum, the Board finds that the detailed opinion from the VA examiner in September 2012 substantially outweighs the lay statements from the Veteran that he currently has an upper respiratory disability, to include sinusitis. The question of whether the Veteran has an upper respiratory disability, to include sinusitis, is a complex medical question and the Veteran does not have or claim to have any specialized knowledge in the field of medicine. Therefore, answering such a question is beyond his competence. The preponderance of the evidence is against the claim and the claim will be denied. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. In reaching the conclusion above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for service connection for an upper respiratory disability, to include sinusitis, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Increased Rating Claims Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2 (2012). If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 589, 592. Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The Veteran's service treatment records show that in November 1998, the Veteran was treated for pain in his left knee. The assessment was of a medial collateral ligament strain and probable meniscal tear to the left knee. In the Veteran's May 2004 retirement examination, crepitus was shown in both knees. The Veteran reported that he had bilateral knee pain. In November 2004, the Veteran underwent a VA examination which was conducted by QTC Services. The examiner stated that the Veteran had been experiencing bilateral patellofemoral pain syndrome since 1992. The condition occurred gradually, with painful and weak knees which would give way. The symptoms of the condition were pain and stiffness. The symptoms occurred constantly. According to the Veteran, his condition did not cause incapacitation. The Veteran treated his condition with medications and knee bracing. The functional impairment was difficulty walking with flared pain. The condition did not result in any time lost from work. The Veteran's usual occupation was as a laboratory technician. He was not currently employed and had not worked since September 2004. The Veteran was able to take a shower, vacuum, drive a car, cook, climb stairs, dress himself, take out the trash, walk, shop, perform gardening activities, and push a lawn mower. Upon physical examination, the Veteran did not require an assistive device for ambulation. The general appearance of the Veteran's knees was within normal limits. In regard to range of motion of both knees, flexion was to 125 degrees, with pain at 125 degrees, and extension was to 0 degrees. Range of motion was additionally limited by pain and pain had the major functional impact. Range of motion was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. The Drawer and McMurray's tests were within normal limits, bilaterally. Examination of the bilateral knees revealed crepitus. Motor and sensory examinations were within normal limits. X-rays of the Veteran's knees were reported to be within normal limits. Following the physical examination and a review of the Veteran's x-rays, the examiner diagnosed the Veteran with bilateral patellofemoral syndrome. The examiner noted that the subjective factors were knee pain and the objective factors were range of motion. In a November 2005 rating action, the RO granted service connection for patellofemoral syndrome of the right knee and assigned a noncompensable disability rating under Diagnostic Code 5257, effective from July 1, 2004. See 38 C.F.R. § 3.400(b)(2) (the effective date of an award of service connection will be the day following the date of separation from service-if the veteran filed a claim within one year after service). The RO also granted service connection for patellofemoral syndrome of the left knee and assigned a noncompensable disability rating under Diagnostic Code 5257, effective from July 1, 2004. Id. In December 2005, the Veteran underwent a VA examination which was conducted by QTC Services. He stated that due to his bilateral knee disability, he had swelling and pain in his knees, and his knees would give way. The Veteran denied any incapacitation. He indicated that he took medication to relieve the pain. The functional impairment was pain and weakness. According to the Veteran, he had lost two day of work per year due to his bilateral knee disability. Upon physical examination, the Veteran's gait was within normal limits and he did not require an assistive device for ambulation. The appearance of both knees was within normal limits. Examination of both knees revealed crepitus. In regard to range of motion of the right knee, flexion was to 120 degrees, with pain at 120 degrees, and extension was to 0 degrees. In regard to range of motion of the left knee, flexion was to 125 degrees, with pain at 125 degrees, and extension was to 0 degrees. Range of motion was additionally limited by pain and pain had the major functional impact. Range of motion was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. The Drawer and McMurray's tests were within normal limits, bilaterally. X-rays of the Veteran's knees were reported to be within normal limits. The diagnosis was patellofemoral syndrome of the bilateral knees. In a March 2007 rating action, the RO increased the disability rating for the service-connected right knee disability from noncompensable to 10 percent disabling under Diagnostic Code 5299-5024, effective from July 1, 2004. The RO also increased the disability rating for the service-connected left knee disability from noncompensable to 10 percent disabling under Diagnostic Code 5299-5024, effective from July 1, 2004. In the August 2009 Travel Board hearing, the Veteran stated that he had pain and locking in his knees. According to the Veteran, due to his bilateral knee disability, he could no longer run. He noted that occasionally, he wore braces on his knees for stability. A VA examination was conducted in May 2010. The examiner stated that the Veteran took anti-inflammatory medication for his joint complaints. The Veteran worked part-time as a lab technician in a hospital. He worked about 20 hours per week. The Veteran last worked full-time two years previously. He had been reduced to part-time work due to his difficulty with prolonged standing because of his bilateral knee condition. The Veteran walked two to three miles a day without difficulty. Prolonged standing for more than 15 to 20 minutes aggravated his knees. He had swelling in both knees. According to the Veteran, he had a sense that his left knee was hyperextending and a sense of both knees giving way but he had experienced no falls. The Veteran stated that he wore knee supports. The Veteran indicated that he had a sense of catching and locking in the knees. He described minor flare-ups with increased activities but no incapacitating events. The Veteran denied any surgery or hospitalization for either knee. On examination of the left knee, there was a palpable medial osteophyte and medial joint line tenderness with negative McMurray's test and no effusion. Quadriceps were equal with good tone. The left knee was stable to varus valgus stress testing both on extension, as well as at 30 degrees of flexion. Lachman's test and the anterior posterior Drawer's test were negative. There were no posterior masses. Range of motion was from 0 to 120 degrees, both active, passive, and against resistance. There was no pain, fatigue, weakness, or incoordination with repetitive motion but he did have crepitus throughout range of motion. The Veteran had a slow non-antalgic gait. Motor function was 5/5 in all muscle groups in both legs. On examination of the right knee, there was pseudolaxity with varus valgus stress testing both on extension, as well as at 30 degrees flexion secondary to degenerative changes in the meniscus and loss of joint space height but there was no effusion. Lachman's test and the anterior posterior Drawer's test were negative. There was medial joint line tenderness with a negative McMurray's test. There were no posterior masses. Range of motion was from 0 to 125 degrees, both active, passive, and against resistance. There was no pain, fatigue, weakness, or incoordination with repetitive motion but he did have crepitus throughout range of motion. In the May 2010 VA examination report, the examiner gave conflicting statements regarding the Veteran's x-rays. While he stated that the x-rays of the Veteran's knees were negative, he also reported that the x-rays showed joint space narrowing consistent with early degenerative changes in both knees. However, the actual x-ray reports showed no evidence of an acute fracture or dislocation and no joint space narrowing or degenerative spurring was noted. There was also no joint effusion. A VA examination was conducted in September 2012. The examiner stated that he had reviewed the Veteran's claims file. The Veteran stated that he worked part-time as a laboratory technician, approximately 40 hours a month. According to the Veteran, since his prostate cancer, he had no stamina and he tired easily. The Veteran indicated that his left knee was worse than his right knee. He denied any surgery, injections, or prescribed pain medications. The Veteran also denied any flare-ups. He noted that he used braces occasionally. The Veteran described a sense of giving way and occasional locking sensation but his knees did not actually lock on him. Prolonged standing and weather changes aggravated his bilateral knee pain. If he sat too long, his knees became stiff. The physical examination showed that bilateral flexion of the knees was to 135 degrees with no objective evidence of painful motion. Bilateral extension of the knees was to 0 degrees with no objective evidence of painful motion. The Veteran was able to perform three repetitions with no additional limitation in range of motion. There was no functional loss and/or functional impairment of either knee/lower leg. There was tenderness and/or pain to palpation for joint line or soft tissues of both knees. Muscle strength testing was 5/5, bilaterally. There was no instability and Lachman's test was normal, bilaterally; posterior drawer test was normal, bilaterally; and valgus/varus testing was normal, bilaterally. There was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran did not have any shin splints. The Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition. The Veteran had not undergone a meniscectomy. In response to the question of whether due to the Veteran's bilateral knee disability, he experienced functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis, the examiner responded "no." The examiner stated that x-ray studies had been taken of the Veteran's knees and that they were negative for any degenerative or traumatic arthritis. There was also no x-ray evidence of patellar subluxation. Following the physical examination, the examiner diagnosed the Veteran with bilateral patellofemoral syndrome. The examiner indicated that the Veteran's bilateral knee disability did not impact his ability to work. He noted that the Veteran had mild patellofemoral syndrome of both knees. According to the Veteran, his complaints of fatigue and weakness were related to his prostate cancer. The examiner stated that the Veteran's bilateral knee condition did not prevent him from working at a light to sedentary job, and that the assessed disability level would be minimal. As the Veteran has taken issue with the initial rating assigned following the grant of service connection, separate ratings may be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). Thus, the Board must evaluate the relevant evidence since July 1, 2004. The Veteran's service-connected bilateral knee disability is characterized as patellofemoral syndrome of the knees. This disability is not listed on the Rating Schedule, and the RO assigned Diagnostic Code 5299 pursuant to 38 C.F.R. § 4.27, which provides that unlisted disabilities requiring rating by analogy will be coded first the numbers of the most closely related body part and "99." See 38 C.F.R. § 4.20 (2012). The RO determined that the most closely analogous diagnostic code is 38 C.F.R. § 4.71a, Diagnostic Code 5024. Under Diagnostic Code 5024, tenosynovitis shall be rated based on limitation of motion of the affected part, as degenerative arthritis under 38 C.F.R. § 4.71a, Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2012). Arthritis due to trauma under Diagnostic Code 5010 substantiated by x-ray findings is rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. In the absence of limitation of motion, a 10 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5260 provides for the evaluation of limitation of flexion of the knee. See 38 C.F.R. § 4.71a. A noncompensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for the evaluation of limitation of extension of the knee. See 38 C.F.R. § 4.71a. A noncompensable rating is warranted when leg extension is limited to 5 degrees. A 10 percent rating is warranted when it is limited to 10 degrees, a 20 percent rating is warranted when it is limited to 15 degrees, a 30 percent rating requires extension limited to 20 degrees; a 40 percent rating requires extension limited to 30 degrees; and a 50 percent rating requires extension limited to 45 degrees. 38 C.F.R. § 4.71, Plate II, shows that normal flexion and extension of the knee is from zero degrees to 140 degrees. It is possible to receive separate ratings for limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) for disability of the same joint. See VAOPGCPREC 9-2004 (Sept. 17, 2004). VA General Counsel Opinions VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCPREC 9-98 (Aug. 14, 1998) provide guidance on when separate ratings for knee disability may be assigned under the limitation of motion codes in addition to ratings under Diagnostic Code 5257 for subluxation/instability or under Diagnostic Code 5258-9 for cartilage impairment. Essentially, these opinions suggest that separate compensable ratings may be assigned when reported limitation of knee motion shown is compensable or when there is X-ray evidence of arthritis together with a finding of painful motion. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban, 6 Vet. App. at 259, 261-62. Under Diagnostic Code 5257, a 10 percent rating is warranted for impairment of the knee with slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for impairment of the knee with moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for impairment of the knee with severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate," and "severe" as used in this code are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. In considering the applicability of other diagnostic codes that may also be separately rated, the Board notes that Diagnostic Codes 5258-9, which concerns injury to cartilage of the knee. Under Diagnostic Code 5259, a 10 percent disability rating is warranted for symptomatic removal of the semilunar cartilage. Under Diagnostic Code 5258, a 20 percent disability rating is warranted when there is dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. The General Counsel has suggested in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve symptomatology caused by tears and displacements of the menisci that may be rated separately from symptoms caused by arthritis. The Board has considered the evidence of record but finds that entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the right knee is not warranted. The Board also finds that entitlement to an initial rating in excess of 10 percent for patellofemoral syndrome of the left knee is not warranted. The current 10 percent ratings are assigned for painful motion of each knee with some limitation. To warrant an increased evaluation under Diagnostic Code 5260 for limitation of flexion of the leg, there needs to be medical evidence of limitation of flexion that more nearly approximates 30 degrees than 45 degrees. However, in the November 2004 VA (QTC) examination, flexion was to 125 degrees, bilaterally. In addition, in the December 2005 VA (QTC) examination, flexion of the right knee was to 120 degrees and flexion of the left knee was to 125 degrees. Moreover, in the May 2010 VA examination, flexion was to 120 degrees, bilaterally, and in the September 2012 VA examination, flexion was to 135 degrees, bilaterally. Thus, an initial evaluation in excess of 10 percent is not warranted for the Veteran's right knee disability or left knee disability under Diagnostic Code 5260. An increased evaluation is further warranted when extension of the leg is more nearly limited to 15 degrees than to 10 degrees. However, upon a review of the November 2004 (QTC), December 2005 (QTC), May 2010, and September 2012 VA examination reports, the Veteran had full extension of both of his knees to 0 degrees in each examination. Thus, an initial evaluation in excess of 10 percent is not warranted for the Veteran's right knee disability or left knee disability under Diagnostic Code 5261. Under VAOPGCPREC 9-04, separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same joint. In this case however, there is no compensable loss of flexion or extension of either the right knee or the left knee. As stated above, Diagnostic Code 5257 is used to rate recurrent subluxation or lateral instability. However, in this case, the competent medical evidence of record is negative for any evidence of sustained instability or subluxation of either knee. While the Veteran maintains that his knees give way, and that he wears braces on his knees he has denied actually falling and most importantly, the May 2010 VA examiner stated that right knee had pseudolaxity with varus valgus stress testing, and Lachman's test, the anterior posterior Drawer's test, and McMurray's test were all negative. The examiner also reported that for the left knee, it was stable to varus valgus stress testing and Lachman's test, the anterior posterior Drawer's test, and McMurray's test were all negative. Moreover, in all of the other VA examination reports of record, no instability has been found. Specifically, in the November 2004 and December 2005 VA (QTC) examination reports, the Drawer and McMurray's tests were within normal limits, bilaterally. In the September 2012 VA examination report, the examiner stated that there was no instability and that all of the stability testing was normal. Consequently, since there is no medical evidence of recurrent subluxation or lateral instability, a separate compensable evaluation is not warranted for either knee disability due to impairment of the knee. With respect to potential application of other criteria, the Board notes that there is no evidence of ankylosis, dislocation of the semilunar cartilage, or impairment of the tibia and fibula for evaluation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, or 5262 (2012). In the Veteran's service treatment records, it was noted in November 1998 that the Veteran had a probable meniscal tear to the left knee. However, in the September 2012 VA examination, the examiner specifically stated that the Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition. Thus, without evidence of a current meniscal condition, the application of Diagnostic Code 5258 is not warranted. In addition, with respect to the question of whether the Veteran has arthritis in either knee, under Diagnostic Code 5003, degenerative arthritis must be confirmed by x-ray to qualify as a ratable entity. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Upon a review of the evidence of record, there are no x-ray reports documenting arthritis in either knee. In the May 2010 VA examination report, although the examiner gave conflicting statements regarding the Veteran's x-rays and suggested that the x-rays showed joint space narrowing consistent with early degenerative changes in both knees, the actual x-ray reports showed no evidence of joint space narrowing or degenerative spurring. In addition, in the November 2004 and December 2005 VA (QTC) examination reports, x-rays of the Veteran's knees were reported to be within normal limits. Moreover, in the September 2012 VA examination report, the examiner stated that x-rays studies taken of the Veteran's knees had been negative for any degenerative or traumatic arthritis. Thus, because arthritis of the knees has not been shown by the medical evidence of record, separate evaluations are not warranted. See VAOPGCPREC 23- 97, 62 Fed. Reg. 63604 (1997 The Board has further considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.40 and 4.45 would warrant higher ratings. See DeLuca, 8 Vet. App. at 202. However, higher ratings in excess of 10 percent for the Veteran's knees are not warranted with consideration of these provisions. The Veteran's complaints of discomfort and pain have been considered and have been taken into account in the assignment of the 10 percent evaluations for his service- connected right and left knee disabilities. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Although the Veteran has pain on motion, he has not had any decrease in range of motion with repetitive testing times three. Thus, although pain has been the primary problem experienced by the Veteran, the available medical evidence does not suggest that loss of function due to pain, weakness, etc. equate to limitation of flexion to 30 degrees or less or limitation of extension to 15 degrees or more. Although the Board is required to consider the effect of pain when making a rating determination, which has been done in this case, it is important to emphasize that the Rating Schedule does not provide a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194 (1997); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). An initial disability rating in excess of 10 percent for patellofemoral syndrome of the right knee is not warranted at any time since the initial grant of service connection. See Fenderson, 12 Vet. App. at 125-26. The preponderance of the evidence is against the claim for an initial disability rating in excess of 10 percent for patellofemoral syndrome of the right knee. The Board also finds that an initial disability rating in excess of 10 percent for patellofemoral syndrome of the left knee is not warranted at any time since the initial grant of service connection. See Fenderson, 12 Vet. App. at 125-26. The preponderance of the evidence is against the claim for an initial disability rating in excess of 10 percent for patellofemoral syndrome of the left knee. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine does not apply and the claims must be denied. 38 U.S.C.A. § 5107(b); Ortiz, supra; Gilbert, supra. Extraschedular Consideration The Board has considered whether referral for an extraschedular rating is appropriate under the provisions of 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As described above, the manifestations of the Veteran's bilateral knee disabilities are contemplated by the schedular criteria discussed above; no examiner has reported an exceptional disability picture with symptoms not represented in the rating schedule. The Veteran works part-time as a laboratory technician. In the May 2010 VA examination, he noted that his knees interfered with his ability to work full-time. However, in the September 2012 VA examination, the Veteran reported that his problems with fatigue and weakness were due to his prostate cancer, not his bilateral knee disability. In addition, the examiner indicated that the Veteran's bilateral knee disability did not impact his ability to work and that he was able to work at a light to sedentary job. In sum, there is no indication that the average industrial impairment from the disabilities would be in excess of that contemplated by the assigned ratings. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. ORDER Entitlement to service connection for an upper respiratory disorder, to include sinusitis, is denied. Entitlement to an initial disability rating in excess of 10 percent for patellofemoral syndrome of the right knee is denied. Entitlement to an initial disability rating in excess of 10 percent for patellofemoral syndrome of the left knee is denied. REMAND A TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. With respect to the Veteran's claim for a TDIU rating, the Veteran contends that his service-connected disabilities prevent him from engaging in any type of gainful employment and that as a result, he should be awarded a TDIU disability rating. The Veteran's service-connected disabilities are as follows: left ventricular hypertrophy (30 percent disabling); prostate cancer, status post radical prostatectomy (20 percent disabling); osteoarthritis and rotator cuff strain of the right shoulder (20 percent disabling); patellofemoral syndrome of the right knee (10 percent disabling); patellofemoral syndrome of the left knee (10 percent disabling); tinnitus (10 percent disabling); gastroesophageal reflux disease (10 percent disabling); right ear hearing loss (noncompensable); tinea versicolor (noncompensable); erectile dysfunction (noncompensable); and scar of the suprapubic area (noncompensable). In addition, the RO has granted 38 U.S.C.A. § 1114 (k) (1) special monthly compensation based on loss of use of creative organ. The combined service-connected disability rating is 70 percent from November 1, 2006. In determining the combined rating, the Board has considered the bilateral factor for the knees. See 38 C.F.R. §§ 4.25, 4.26. Regardless, because the Veteran does not have a disability rated at 40 percent or more, he does not satisfy the threshold minimum percentage rating requirements for a TDIU under 38 C.F.R. § 4.16(a). If, however, a Veteran fails to meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director, Compensation and Pension Service for extra-schedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b). See also Fanning v. Brown, 4 Vet. App. 225 (1993). 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. 38 C.F.R. § 4.16(b). In this case, although the Veteran has undergone numerous VA examinations wherein the examiners have addressed the impact of certain service-connected disabilities on the Veteran's ability to work, no examiner has considered whether all of the Veteran's service-connected disabilities, collectively, rendered the Veteran unable to secure of follow a substantially gainful occupation. Thus, the Board finds that such an opinion is warranted. See Friscia v. Brown, 7 Vet. App. 294 (1995). Accordingly, the case is REMANDED for the following action: 1. For purposes of entitlement to a TDIU, the RO/AMC must schedule the Veteran for a VA examination to determine if the Veteran's service-connected disabilities render him unable to secure and follow a substantially gainful occupation. In making this determination, the examiner must NOT consider the effect of any nonservice-connected disabilities and advancing age (60). (a) The examiner must review the claims folder, and; (b) The examiner is advised that the Veteran alleges that he is unemployable due to his service-connected disabilities. He works part-time as a laboratory technician but due to his service-connected prostate cancer, he does not have a lot of stamina and is weak and fatigued. 2. After completion of the above development, IF THE VETERAN STILL DOES NOT SATISFY THE THRESHOLD MINIMUM PERCENTAGE RATING REQUIREMENTS FOR A TDIU under 38 C.F.R. § 4.16(a), the RO/AMC MUST SUBMIT the claims for TDIU and an initial rating for bilateral hearing loss to the Under Secretary for Benefits or Director of Compensation and Pension Service for an extra-schedular evaluation under both 38 C.F.R. § 4.16(b) and 38 C.F.R. § 3.321(b). THE RO/AMC IS ADVISED THAT IT MUST CONSIDER BOTH 38 C.F.R. §§ 3.321(b)(1) AND 4.16(b): Under 38 C.F.R. § 3.321(b)(1), TDIU 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. Under 38 C.F.R. § 4.16(b), TDIU requires a determination that a particular Veteran is rendered unable to secure or follow a substantially gainful occupation by reason of his or her service-connected disabilities. See VAOPGCPREC 6-96. Under 38 C.F.R. § 4.16(b), all of the Veteran's service-connected disabilities, as well as his employment history, educational and vocational attainment, and all other factors having a bearing on his employability (or lack thereof) should be considered. THE EXTRA-SCHEDULAR EVALUATION MUST ADDRESS BOTH 38 C.F.R. § 4.16(B) AND 38 C.F.R. § 3.321(B). 3. Thereafter, the RO/AMC must consider all of the evidence of record and adjudicate the TDIU claim on both a schedular basis and an extra-schedular basis under 38 C.F.R. § 4.16(b) and 38 C.F.R. § 3.321(b). If the benefit sought is not granted, issue a Supplemental Statement of the Case and allow the Veteran and his representative an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter or matters 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). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs