Citation Nr: 1320672 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 07-14 196 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to a disability rating in excess of 30 percent for residuals of a total left knee arthroplasty. ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from September 1973 to September 1976 and from August 1977 to July 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The case was most recently before the Board in October 2012, at which time the claim was remanded for additional development and adjudicative action. The case has since been returned to the Board for further appellate action. FINDING OF FACT The Veteran's residuals of a left knee total arthroplasty disability have not been manifested by severe painful motion or weakness in the affected extremity; unfavorable ankylosis with flexion between 10 and 20 degrees or worse; any limitation of extension; nonunion of the tibia and fibula requiring a brace, or any lateral instability or recurrent subluxation. CONCLUSION OF LAW The criteria for a disability evaluation in excess of 30 percent for residuals of a total left knee arthroplasty are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5055, 5256-5262 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided "at the time" that or "immediately after" VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in a letter mailed in August 2005 and the cover letter sent with a supplemental statement of the case in April 2008. Although the Veteran was not provided complete notice until after the initial adjudication of the claim, the Board finds that there is no prejudice to him in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the originating agency readjudicated the Veteran's claim. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). In addition, the Veteran was afforded VA examinations in May 2011, January 2012, and February 2012. The Board finds that the reports of these examinations, taken together with the other evidence of record, adequately address the nature of the residuals of a total knee arthroplasty to allow for the Board's adjudication of the claim for a higher rating for this disability. The examiners provided sufficient detail and supported their conclusions with analyses fully supported by review of the evidence presented. Further, the evidence considered was sufficient and encompassed the evidence of record. There is no indication that the Veteran's disability has increased in severity since the most recent February 2013 examination. The Board concludes that no further examination is required. As noted above, the Board remanded the Veteran's claim in October 2012 for additional development and adjudicative action. Specifically, the Board directed that the originating agency obtain all outstanding VA and private treatment records pertinent to the Veteran's claim. VA treatment records dated up until April 2013 have been obtained. As noted earlier, the Veteran was afforded a VA examination in February 2013 and the Board finds the VA examination to be adequate with which to decide the claim on appeal. Therefore, the Board finds that the agency of original jurisdiction has substantially complied with the prior remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West,13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Accordingly, the Board will address the merits of the claims. Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. 8 C.F.R. § 4.71a, Diagnostic Code 5003. Flexion of the leg limited to 60 degrees warrants a 0 percent rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5055 provides criteria for evaluating impairment arising from the prosthetic replacement of a knee joint. For one year following the implantation of a knee prosthesis, a 100 percent disability rating is assigned. Thereafter, the minimum disability rating which may be assigned post-knee replacement is 30 percent. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, adjudicators are instructed to rate by analogy to Diagnostic Codes 5256 (knee ankylosis), 5261 (limitation of leg extension), or 5262 (impairment of the tibia and fibula). Ankylosis of a knee warrants a 30 percent evaluation if it is at a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent evaluation is warranted if the ankylosis is in flexion between 10 and 20 degrees. A 50 percent evaluation is warranted if the ankylosis is in flexion between 20 and 45 degrees. A 60 percent evaluation is warranted where there is ankylosis of the knee, in an extremely unfavorable position, in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256. 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 is provided for malunion of the tibia and fibula with marked knee or ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate II. VA's General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998). Moreover, the General Counsel has also held that separate ratings may be assigned for disability of the same joint under Diagnostic Codes 5260 (for limitation of flexion) and 5261 (for limitation of extension). VAOGCPREC 9-2004 (September, 2004). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. In this regard the Board notes that where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran claims that his service-connected left knee disability is more severe than what is reflected by the currently assigned 30 percent disability rating. By way of history, the Veteran has received compensation for this disability since August 1995. On August 26, 2004, the Veteran underwent a total knee arthroplasty (TKA) and subsequently filed a claim for an increased disability rating in September 2004. The RO awarded a temporary 100 percent rating for his disability due to the need for convalescence following surgery for the period from August 26, 2004, to September 30, 2005. Thus, the Board will not address this period, as the Veteran has already been awarded the maximum rating for this time period. In the October 2005 rating decision, the RO assigned a 30 percent rating effective from October 1, 2005. The Veteran has appealed the assignment of the 30 percent rating for his left knee, which is the issue currently before the Board. Turning to the merits of the claim, an October 2005 VA treatment record shows the physical assessment of the left knee post TKA surgery. The examination revealed a well healed, mid line scar with some hypertrophy consistent with a keloid-type wound. There was no evidence of erythema or warmth. The Veteran demonstrated left knee range of motion from zero to 100 degrees. The Veteran described his left knee symptomatology in statements submitted in support of his claim. On his February 2006 notice of disagreement, the Veteran reported that he was unable to walk longer than five minutes or stand due to problems with his left knee. In a February 2006 statement, the Veteran reported experiencing numbness in his left leg/knee. He stated that he was unable to stand or walk for prolong periods or walk substantial distances. A March 2006 VA joints examination report for an unrelated disability documents the Veteran's report that he was unable to walk due to his left knee disability. He was noted to use a cane, primarily due to his left knee condition. The Veteran also reported that he retired two years prior, first because of his knee and due to a right hip disorder. VA treatment records show treatment of the Veteran's left knee symptomatology following his TKA. During a November 2006 orthopedic consultation, the Veteran reported that he was doing fine but that he experienced numbness in his left foot that increased with ambulation. Otherwise, he had no report of pain in his knee and had good functioning. The physical examination revealed a well healed incision on the left knee. His range of motion was from zero to 100 degrees and the left knee was stable to varus and valgus testing. The X-ray examination did not reveal any loosening of the left knee components. Additional VA treatment records document the Veteran's report of left knee pain. A February 2008 physical examination revealed tenderness. An October 2008 record shows the Veteran's report of left knee pain, which along with his back pain, affected his walking and enjoyment of life. In August 2011, the Veteran reported that his left knee and right hip pain affected his walking and standing. A May 2011 VA examination report reflects the Veteran's history of problems with his knee that began in the 1970's when he felt a "pop" while on a ten mile run. His medical history included two arthroscopic surgeries while in service and a total knee replacement in August 2004. The Veteran's disability later required manipulation under anesthesia in November 2004. He reported having difficulty since the manipulation, as he experienced swelling and giving way of the knee. He denied any locking or a history of subluxation or dislocation. He reported that he could walk up to a mile and stand for twenty minutes; anything beyond these parameters made him feel worse. Flare ups of his symptoms occurred when he "steps the wrong way," and could last up to a week. The severity of his flare ups ranged from mild to severe, and the Veteran was unable to estimate the range of motion loss with a flare. He stated that he last worked in 2004 or 2005 for the post office unloading trucks, but he had difficulty with the amount of standing required for the job and also experienced swelling in his knee. The Veteran stated that he had used a cane for ambulation for the past eight years and had used a scooter since August 2010. On the physical examination, the Veteran walked with a slow gait and used a cane. Left knee flexion was from zero to 90 degrees, with stiffness at the end range of flexion. Extension of the left knee was to zero degrees. There was no change in the left knee range of motion with repetitive testing. A moderate amount of crepitus and swelling were noted. There was no evidence of increased warmth, palpable tenderness, or ligamentous laxity. McMurray's test was negative. The examiner noted the presence of a superior/inferior linear scar measuring 19 cm in length by 1 cm to 1.5 cm in width. The scar was nontender. The examiner noted that an X-ray examination in 2006 did not show any signs of loosening, infection, dislocation, or fracture. X-rays taken during the May 2011 examination were interpreted as revealing a normal left knee joint with total knee replacement and no complications. The examination resulted in diagnoses of left total knee replacement and left knee osteoarthritis. The examiner characterized the severity of the Veteran's left knee disability as moderate. During a November 2011 VA orthopedic consultation, the Veteran reported having increased left knee pain and swelling. The associated physical examination revealed effusion and warmth in the joint, slight varus alignment, and left knee range of motion from zero to 100 degrees. He underwent a left knee aspiration. A January 2012 VA examination report reflects the Veteran's history of an in-service left knee injury, a total knee replacement in 2004, and subsequent manipulation under anesthesia secondary to diminished range of motion. At the time of the examination, the Veteran reported experiencing swelling and popping of his knee, but he denied experiencing any locking, giving way, or a history of subluxation or dislocation. He stated that oxycodone helped his symptoms, but the medication bothered his stomach. Reportedly, the Veteran could walk approximately one mile, but walking beyond a mile or standing in one place for more than a few minutes made his knee worse. Flare ups occurred with increased activity, and he stated that he must sit down more with a flare. The Veteran estimated his range of loss with a flare as "quite a bit." On the physical examination, a mild amount of swelling and increased warmth were noted for the left knee. There were no areas of palpable tenderness. Flexion was to 90 degrees, with stiffness at the end of flexion, and extension was to zero degrees. There was no change with repetition and the Veteran tolerated three repetitions of the range of motion testing. The examiner noted the Veteran to have functional loss secondary to diminished range of motion and stiffness. Although the examiner noted the Veteran's estimation of some increased pain, incoordination, weakened movement, and excessive fatigability on use, the examiner did not provide any objective findings or a medical opinion in this regard. Instead, he noted that the Veteran was unable to estimate any additional range of motion loss due to these factors. Muscle strength was graded as 5- to knee flexion and extension. There was no evidence of ligamentous laxity and McMurray's test was negative. A mild amount of crepitus was noted for the left knee. The Veteran did not report a history of subluxation or dislocation or a history of any meniscal condition. The examiner noted that the Veteran used a cane on a constant basis due to a right hip disability and his left knee, and that the Veteran began using a wheelchair two years prior on an occasional basis for longer periods of use. X-rays preformed in November 2011 were reviewed and showed status post cruciate sacrificing three compartment left knee arthroplasty without change in alignment or hardware failure. The examiner also noted the presence of a scar measuring 18 cm by 0.4-0.6 cm in width due to the Veteran's knee replacement surgery. The examiner described the scar as nontender, linear, superficial, and without skin breakdown. The scar did not cause pain. During the January 2012 examination, the Veteran reported that he last worked two years prior driving a forklift. He described having pain due to keeping his knee bent and estimated that he missed approximately fifty to sixty days in the last year that he worked due to knee pain. The examiner commented that the Veteran would have difficulty with positions that required more than occasional standing or walking. He also noted that if the Veteran was using a cane, he would have difficulty carrying objects that required the use of both hands. According to the examiner, the Veteran would have no difficulty with sedentary positions provided that he was given proper ergonomic modifications and allowed to change positions frequently. An April 2012 VA physical examination revealed that the Veteran demonstrated full range of motion of the left knee and that the joint was stable and without effusion. A December 2012 VA record shows the Veteran's additional report of left knee pain and giving way. The physical examination revealed that the left knee was stable to varus and valgus testing and without effusion. The X-ray examination revealed progressive subsistence of the tibial tray. The examiner rendered a diagnosis of left TKA with progressive subsidence and symptoms of left lower extremity numbness likely stemming from the lumbar spine. (Here the Board notes that the Veteran has been awarded separate evaluations for neurological impairment in the right and left lower extremities due to his service-connected low back disability. As these disabilities are not presently on appeal, they are not discussed in the analysis below.) In February 2013, the Veteran underwent an additional VA examination to assess the severity of his left knee disability. At the time of the examination, the Veteran stated that he continued to have constant pain and that his left leg was numb from the knee to the toes. Although he stated that he walked with a cane, he reportedly was able to get around the house without using his cane. The examiner noted that the Veteran's medical records showed that he had fluid withdrawn from his left knee in 2011. Review of his records from 2012 indicated that his left knee had medial settling (subsidence) and that there is a possible need for revision. The Veteran reported having severe flare ups of his left knee symptoms, which occurred randomly two to three times per month. His flare ups were precipitated by walking and lasted a few seconds. The Veteran did not report experiencing any loss of motion during a flare up. Additionally, the examiner noted that the Veteran constantly used a cane and occasionally used a scooter due to a status post right hip placement disability and his left knee degenerative joint disease status post replacement. The physical examination revealed tenderness or pain to palpation of the left knee. The Veteran demonstrated left knee flexion to 90 degrees and left knee extension to zero, both without any objective evidence of painful motion. On repetitive motion testing, the Veteran demonstrated left knee flexion to 90 degrees and extension to zero degrees. There was no additional limitation in the range of motion of the knee following repetitive testing. The examiner noted that the Veteran has functional impairment or additional limitation of the left knee range of motion after repetitive use. Contributing factors were identified as less movement than normal, mild swelling, disturbance of locomotion, mild warmth in the left knee, and stiffness at 90 degrees of flexion of the knee. Joint stability tests (Lachman, posterior drawer, and valgus/varus testing) were normal for the left knee. There was no evidence or history of recurrent subluxation or dislocation. The examiner noted that the Veteran did not have a meniscal condition. The examiner identified the residuals of his left total knee replacement surgery as swelling, warmth, limited motion, and recent medial settling of the left knee TKA. The associated imagining studies of the knee did not reveal evidence of degenerative or traumatic arthritis or evidence of patellar subluxation. The examiner noted that diagnostic testing completed in September 2012 revealed a left TKA without evidence of malalignment, periprosthetic fracture, or new abnormal lucency about the hardware to suggest failure or loosening. The examiner diagnosed left knee degenerative joint disease, status post total knee replacement. The examination also revealed the presence of a linear scar on the left knee. The examiner responded "no" to the question of whether the scar was painful and/or unstable, or of a total area greater than 39 square cm (6 square inches). The scar measured 18 cm by 0.4-.06 cm in width, and was nontender. The examiner described the scar as superficial. The scar did not cause the Veteran pain, and there was no skin breakdown. The examiner determined that the scar did not affect the Veteran's activities of daily living or previous occupation. The February 2013 examiner noted the Veteran's report that he last worked full time at the post office in October 1999 and that he last worked part time as a custodian in 2002. The Veteran stated that he drove a forklift during his last employment and that he experienced pain from keeping his knee bent. He estimated that he lost approximately fifty to sixty days in the last year he worked because of knee pain. The Veteran also stated that he continued to do pressure washing and lawn care and walked at the mall for up to 40 minutes. The examiner opined that the Veteran's left knee degenerative joint disease status post TKA is at least as likely as not impacting the Veteran's ability to participate in physical employment. The examiner explained that the Veteran had limited range of motion, swelling, and a current complication of medial setting requiring surgical intervention. Physical employment was not recommended. The examiner commented, however, that the Veteran's left knee disability was less likely as not impacting his ability to participate in sedentary employment, as the Veteran reported that he still continues to walk for up to forty minutes and can sit without left knee complications, unless he is in a cramped situation. According to the examiner, the Veteran's reported activities indicate that he could participate in sedentary activities. In statements submitted in support of his claim, the Veteran provided further testimony as to his left knee symptomatology. He reported that he has to take two pain pills every four hours to alleviate his pain. The Veteran stated that he experiences severe pain without the use of pain medication. He also stated that "if sedated" he may be able to walk up to 40 minutes, but he would have to force himself. He reported that he has been given a scooter and that he will have to undergo revision surgery for his knee. Having reviewed the foregoing, the Board finds that a disability rating in excess of 30 percent is not warranted for the Veteran's left knee disability. In this case, the residuals of the Veteran's left knee replacement do not warrant the next higher, 60 percent rating under Diagnostic Code 5055. While the record reflects painful motion, with a recent exacerbation of his symptoms, it does not reveal severely painful motion or weakness in the left leg. Range of motion of the left knee was noted to be from 0 to at least 90 degrees, with no objective evidence of pain noted or any additional limitations of the range of motion following repetitive use. The medical professionals have not noted objective evidence of weakness during the numerous examinations of the Veteran's left knee. The Board acknowledges that the Veteran walks with a cane, uses a scooter for extensive walking due, in part, to his left knee disability, and was noted to possibly need additional surgical treatment in the future for his knee. However, the Veteran has also reported that he is able to walk short distances (e.g. around his home) unassisted, ambulate for 40 minutes with the use of pain medications, and perform lawn care. While the evidence shows left knee disability is primarily manifested by pain, it does not indicate chronic residuals of severely painful motion or weakness in the affected extremity, as contemplated in a 60 percent rating under Diagnostic Code 5055. The Board has further considered whether a higher rating is warranted under any other provision of the rating schedule. However, neither the lay nor the medical evidence reflects unfavorable ankylosis with flexion between 10 and 20 degrees or worse; or extension limited to 30 degrees or more; or nonunion of the tibia and fibula requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, 5262. The other Diagnostic Codes pertaining to the knee and leg do not provide for evaluations in excess of 30 percent and, thus, would not afford the Veteran higher evaluations. See 38 C.F.R. §§ 5257, 5256, 5259, 5260, 5263. Given the Veteran's reports of giving way and "popping" of his left knee in May 2011, January 2012, and December 2012, the Board has also considered whether a separate rating may be assigned based on instability of the knee. However, the objective medical evidence as demonstrated in the VA examinations and treatment records fail to show left knee instability during the period on appeal. Indeed, the May 2011 and January 2012 VA examination reports and the December 2012 VA treatment record collectively show that the Veteran's left knee was stable to varus, valgus, and McMurray's testing. The Board recognizes that the May 2011 and January 2012 examinations revealed left knee crepitus. However, these examinations did not show evidence of instability or laxity of the left knee. In fact, there is no objective evidence of subluxation or instability of the left knee, and the Veteran has denied any such impairment on almost all occasions. Therefore, the Board concludes that the requirements for an separate, compensable disability rating on the basis of recurrent subluxation or lateral instability have not been met. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board accepts that the Veteran experiences left knee symptomatology, especially knee pain. See 38 C.F.R. §§ 4.40, 4.45. However, the Board believes that the 30 percent disability evaluations contemplate the degree of pain and functional impairment for the left knee. It is noted that the Veteran has significantly retained range of motion in the left knee following his knee replacement, and the 30 percent rating is the highest rating available based on limitation of flexion, and the Veteran does not have any compensable limitation of extension of the knee. While the Veteran is competent to report that his left knee disability is worse than presently evaluated, whether a disability is sufficient to meet the schedular criteria for the assignment of a higher (or separate) evaluation is a factual determination. Although the Veteran believes he meets the criteria for a higher disability rating, his complaints and the medical findings do not meet the schedular requirements for evaluations higher than 30 percent for the left knee following the TKA, as explained and discussed above. The Board has concluded that the medical evidence, prepared by skilled professionals, is more probative of the degree of disability. The objective evidence also reflects that the Veteran has a residual scar of the left knee. Thus, the Board has considered whether the Veteran is entitled to a separate compensable rating for the surgical scar on his left knee, but finds that he is not. During the pendency of the appeal, the criteria for rating scars were amended for applications received on or after October 23, 2008. 73 Fed. Reg. 54708 (Sep. 23, 2008). The Veteran's claim for an increased rating was filed in September 2004, before the new scar regulatory criteria became effective, such that the former rating criteria apply here. Pertinent skin disability criteria provide that a compensable disability rating is warranted for a scar that is deep or that causes limited motion in an area or areas exceeding 6 square inches (39 square centimeters) (Diagnostic Code 7801); for a superficial scar that does not cause limited motion but which covers an area of 144 square inches (929 sq. cm.) or greater (Diagnostic Code 7802); for an unstable, superficial scar (Diagnostic Code 7803); for a superficial scar that is painful on examination (Diagnostic Code 7804); or for a scar that causes limitation of function of the affected part (Diagnostic Code 7805). 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). Notably, the May 2011, January 2012, and February 2013 examinations revealed a left knee scar, but did not show that the scar was unstable or painful. These examinations did not show that the scar covered an area greater than 39 square cm. There is no indication from the clinical examinations that the scar causes limitation of function of the affected part. Moreover, limitation of motion is already considered in evaluating the overall left knee disability. Therefore, the Veteran's left knee scar does not warrant a compensable rating under any of the provisions of Diagnostic Codes 7801 to 7805. Consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the doctrine of reasonable doubt in reaching this determination; however, as the preponderance of the evidence is against the assignment of a rating higher than what has been assigned, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether the Veteran's claim should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for 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, 115 (2008). In this case, the manifestations of the Veteran's disability are contemplated by the schedular criteria. Therefore, the Board has determined that referral of the claim for extra-schedular consideration is not in order. Finally, although the Veteran has submitted evidence of his medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable solely due to the left knee disability. Indeed, the most recent February 2013 VA examination report includes a medical opinion essentially that the claimed disability would not preclude sedentary employment. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to his service-connected left knee disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). (CONTINUED ON NEXT PAGE) ORDER A disability rating in excess of 30 percent for residuals of a left knee total arthroplasty is denied. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs