Citation Nr: 1320969 Decision Date: 06/28/13 Archive Date: 07/05/13 DOCKET NO. 09-46 806A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Anchorage, Alaska THE ISSUES 1. Entitlement to a rating higher than 40 percent for chronic lumbosacral strain with degenerative disc disease. 2. Entitlement to a rating higher than 10 percent for right knee arthritis with meniscus tear repair. 3. Entitlement to a rating higher than 10 percent for left knee arthritis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and Spouse ATTORNEY FOR THE BOARD M. Mac, Counsel INTRODUCTION The Veteran's private doctor in October 2010 indicated that his right hip arthritis should be considered as secondary to the service-connected low back disability. Thus the issue has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The Veteran served on active duty from January 1982 to July 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of a Regional Office (RO) the Department of Veterans Affairs (VA). The Veteran appealed that decision to the Board, and the case was referred to the Board for appellate review. A June 2008 rating decision increased the rating for the service-connected lumbosacral strain with degenerative disc disease to 20 percent effective December 7, 2007, the date the Veteran's claim for a higher rating was received. In a rating decision in March 2012, the Veteran's service-connected low back disability was increased to 40 percent effective December 7, 2007. Under certain circumstances, the claim for an increased rating for a service-connected disability includes a claim of entitlement to a total disability rating for individual unemployability (TDIU). Rice v. Shinseki, 22 Vet. App. 447 (2009). In the instant case, the record shows that the Veteran filed a claim for a TDIU in November 2010 which the RO denied in a rating decision in February 2011. In June 2011 the Veteran filed another claim for a TDIU, which the RO denied in a rating decision in October 2011. In October 2012 the Veteran filed a third claim for TDIU, which the RO denied in a rating decision in February 2013. The Veteran has not appealed the most recent denial of his claim for TDIU. Consequently, the issue of entitlement to a TDIU is not before the Board. 38 U.S.C.A. § 7105(c); 38 C.F.R. §§ 20.200, 20.201, 20.302. A review of the Virtual VA paperless claims processing system shows that VA records dated from 2011 to 2013 were associated in February 2013, subsequent to the last supplemental statement of the case dated in August 2012. In May 2013, the Veteran through his representative waived initial RO review of this evidence. The Virtual VA paperless claims processing system includes the February 2013 rating decision and other documents, which are either duplicative of the evidence of record or are not pertinent to the present appeal. In June 2011 a hearing was held at the RO in Anchorage, Alaska before the undersigned Veterans Law Judge, who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (d)(1) and who is rendering the determination in this case. A transcript of the hearing testimony is in the claims file. In September 2011, the issues were remanded for further development. As the requested development has been completed, no further action to ensure compliance with the remand directive is required. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. During the appeal period, the low back disability has been manifested by chronic pain and limitation of motion; however, there has been no ankylosis of the thoracolumbar spine and the neurologic manifestations are not related to the service-connected low back disability. 2. During the appeal period, there is painful range of motion in the right knee with flexion primarily ranging from 77 degrees to 120 degrees and extension primarily being at zero degrees. 3. The Veteran is in receipt of a separate 20 percent rating for the right knee instability. 4. During the appeal period, there is painful range of motion in the left knee with flexion primarily ranging from 70 to 120 degrees, extension primarily being at zero degrees, without recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 40 percent for chronic lumbosacral strain with degenerative disc disease have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 2. The criteria for a rating higher than 10 percent for right knee arthritis with meniscus tear have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5261 (2012). 3. The criteria for a rating higher than 10 percent for left knee arthritis have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5010-5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (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 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre-adjudication VCAA notice by letter dated in January 2008. The Veteran was notified of the evidence needed to substantiate the claim for an increased rating as well as what information and evidence must be submitted by the Veteran, what information and evidence would be obtained by VA, and the provisions for disability ratings and for the effective date of the claims. Duty to Assist VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claims. Service treatment records, post-service treatment records, a copy of the hearing transcript, and lay statements have been associated with the record. While the Veteran testified that his in-service surgery reports for both knees are unavailable, a review of the service treatment records shows that these reports are included in the claims folder. In July 2012, the Office of Workers' Compensation Programs confirmed that they did not have any medical records for the Veteran's work related injury in December 2009. Additionally, the Veteran was afforded several VA examinations during the appeal period. In June 2011 he testified that during his VA examinations he was in a lot of pain and had no range of motion and asked for a chaperone to be present during his March 2011 VA examination. The Board has carefully reviewed the VA examinations of record and finds that the examinations in conjunction with the other medical and lay evidence are adequate for rating purposes. Thus, with respect to the Veteran's claim, there is no additional evidence which needs to be obtained. During the Board hearing, the presiding Veterans Law Judge clearly set forth the issues to be discussed and sought to identify pertinent evidence not currently associated with the claims folder. As such, the Board finds that VA fully complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). As the Veteran has not identified any additional evidence pertinent to the claims and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Rating Criteria A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained 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 military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings". Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here the disability has not significantly changed during the relevant time period and a staged rating is unwarranted. Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In evaluating musculoskeletal disabilities, the VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca 8 Vet. App. at 206. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Court also has recently held, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. Currently the low back is evaluated as 40 percent disabling and each knee is evaluated as 10 percent disabling, therefore the analyses below discuss whether the Veteran meets the criteria for a rating higher than 40 percent for his back and a rating higher than 10 percent for each knee. The analyses focus on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board provide reasons for rejecting evidence favorable to the Veteran. The pertinent evidence is addressed in detail below. Additional lay and medical evidence dated from 2006 to 2013 is cumulative of the evidence being presented. Lumbar Spine The Veteran's service-connected lumbar strain has been rated under Diagnostic Code 5237. Disabilities of the spine are rated under either the General Formula for Diseases and Injuries of the Spine (General Formula) or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating. Under the General Rating Formula (for Diagnostic Codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes): a 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1): Objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately, under an appropriate diagnostic code. Note (5): defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in the neutral position (zero degrees) always represents favorable ankylosis. Note (6) Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a. When rated based on incapacitating episodes, a 40 percent rating is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243. The normal findings for range of motion of the lumbar spine are from 0 to 90 degrees for forward flexion; 0 to 30 degrees for extension, lateral flexion ,and rotation. 38 C.F.R. § 4.71a, Plate V. Facts In July 2010 and during his June 2011 Board hearing, the Veteran stated that in December 2009 while he was at work his right leg gave away causing a very bad slip. The left leg gave way causing him to shift weight to the right side and increased pressure on the lower back. He complained of right sided radiating back pain as well as imbalance weight shifting causing radiating pain on the left side. He claimed that severe pain usually lasted 48 to 72 hours and that he developed sciatica as a result of his back injury. The Veteran further testified that he was in bed many days in the past year due to back pain and his doctor told him to stay in bed. The Veteran indicated that the doctor recommended that he stay off his feet for periods of time. The undersigned Veterans Law Judge agreed to hold the record open for 30 days in order to confirm that the doctor prescribed bedrest and for how long. In July 2011, the Veteran clarified that his doctor declined to put in writing that he suggested time off from work to rest. In a statement in July 2011, the Veteran's spouse stated that he had back pain and she had to assist him in getting around. On VA examination in December 2006, the Veteran complained of radiating back pain into the back of his legs. The Veteran did not have any incapacitating episodes for which he had to see a physician. Flexion was 60 degrees with pain, extension was to 30 degrees with pain starting at about 25 degrees. Repetition increased pain but did not change range of motion. Right and left lateral flexion was 30 degrees in both directions with pain and repetition increased the pain. Sensation to light touch vibration and position was normal in the legs and feet. The impression was progressive low back pain with some pain radiating down the back of the legs, which the examiner noted also was associated with minimal degenerative joint disease at the sacroiliac joints. Private medical records in February 2007 show the Veteran injured his back at work in September 2007 while he was unloading a truck. A MRI in November 2007 shows disc degeneration at L3 to L5. There was a mild compression of the anterosuperior endplate of L4. There was a small extrusion of disc in the midline at L4, but without impact on the canal or nerve roots. There was disc protrusion into the right neural foramen at L5-S1 with at least some degree of compression of the exiting L5 root. Records in November 2007 show that there was paresthesias with range of motion. In February 2008 the records show moderate tenderness on palpation over the right L5. Sensory examination was intact. The impression was low back pain with pseudoradicular symptoms in the right lower extremity, a work-related injury in September 2007, and findings from the November 2007 MRI. On VA examination in January 2008 the examiner noted that in September 2007 the Veteran injured his back when he fell five feet off a tractor truck. The examiner found that the November 2007 MRI shows a fracture of the L4 that resulted from this injury. While the examiner indicated that there was a history of urinary incontinence, numbness, paresthesias, leg and foot weakness, and visual dysfunction, the examiner explained that these symptoms were not attributable to the service-connected low back disability. The examiner noted that the Veteran had radiating pain down his right leg. He had flare-ups every one to two months. The motor exam showed active movement against some resistance to active movement against full resistance. The sensory exam essentially was normal with some impairment to pinprick and light touch on the right side. The examiner determined that there was no ankylosis of the cervical spine and thoracolumbar spine. Flexion was 0 to 50 degrees with pain at 50 degrees. Passive range of motion was 55 degrees, with pain at 50 degrees. Resisted isometric movement was normal. There was pain after repetitive use. Extension was 0 to 20 degrees with pain at 20 degrees. Passive range of motion was to 22 degrees with pain at 20 degrees. Resisted isometric movement was normal. There was pain after repetitive use. Lateral right and left flexion was 0 to 20 degrees with pain at 20 degrees. Passive range of motion was 0 to 25 degrees to the right and 0 to 22 degrees to the left with pain at 20 degrees in both directions. Resisted isometric movement was normal. There was pain after repetitive use. Accompanying x-rays show L4 disc bulging. The examiner commented that the Veteran was a seasonal worker and had difficulty working during flare-ups. Private medical records in May 2010 show the Veteran had pain in the right side of his back after he slipped on ice in December 2009. He complained of locking in his back at times. Pinprick sensation was intact. Private medical records also show that the Veteran went to the Emergency Room in May 2010 and complained of right sided back pain that "locks up" on him, which he reported was exacerbated after the fall in December 2009. The diagnosis was low back pain and strain with right-sided radiculopathy. A private MRI report in May 2010 shows an old depression fracture at L4 with degenerative disc disease from L3 to S1. There was mild arthritis throughout the lumbar spine without spinal stenosis. VA progress notes dated in May 2010 show that the Veteran reported that in December 2009 while he was at work he slipped on ice without falling and pulled muscles in his back and neck. The VA examiner provided an assessment of back pain, radiculopathy of the right lower extremity, and muscle spasm to rule out disc condition. In September 2012 the records show the Veteran stated his back locked up and he could not move. He had stabbing and burning pain traveling down his legs. There was no loss of bowel or bladder. VA medical records in May 2010 show the sciatic stretch was positive on the right with radicular complaints down to the knee. There was no foot drop, heel and toe stance was intact. The assessment included back pain and right lower extremity radiculopathy. The records in June 2010 include neurological tests which show that muscle stretch reflexes were 1+/4 in both lower extremities, manual muscle test was 5/5 in both extremities, and sensation to light touch was intact except for an area of numbness to the right leg. A July 2010 record shows the Veteran had radiating back pain down both legs. The records in August 2010 show the Veteran did not have loss of bowel or bladder control. On VA examination in July 2010, the examiner noted that the Veteran fell on ice in December 2009 and injured his right buttock. He complained of right lumbosacral radiating pain and denied incapacitating episodes. Physical examination shows no ankylosis of the thoracolumbar spine. Flexion was 0 to 90 degrees, extension was 10 to 20 degrees, bilateral flexion and rotation was 0 to 20 degrees. There was no pain on active motion but there was pain after three repetitions of range of motion. Reflex exam findings were normal. Sensory exam findings of the right and left lumbosacral nerve were normal to vibration, position sense, pain or pinprick, light touch, with the exception of dysesthesias in the S1 dermatome. Detailed motor exam was normal. Accompanying x-ray shows an old mild compression of L4, degenerative disc disease at L5-S1 with mild retrolisthesis of L5 and possible degenerative disc disease and L3-4 and L4-5 levels. The examiner noted that the Veteran was currently employed but when he did work his low back disability caused decreased mobility, problems lifting and carrying, and increased absenteeism. A private nerve conduction study in October 2010 shows moderate axonal polyneuropathy and no electromyographic evidence of lumbar radiculopathy. The examiner noted that the Veteran complained of numbness and tingling sensation in both legs. On VA examination in January 2011, there was no history of urinary or fecal incontinence. The Veteran complained of radiating pain on the right side described as paresthesia and the examiner noted that there were no foot symptoms. Muscle exam of the lower extremities was normal and the examiner found no spinal ankylosis. Range of motion of the thoracolumbar spine shows flexion was 60 degrees, extension 10 degrees, and sideband 30 degrees. Sensory exam of the lower extremities evaluated the lumbar plexus. The findings were the same for both extremities. Vibration sense was absent in the third to fifth toes, position sense was normal, pain or pinprick was dull plantar of the third to fifth toes, light touch was normal and there was no dysesthesias. Motor exam was normal. The examiner commented that the Veteran's service-connected low back disability affected his employability but did not preclude sedentary employment. On VA examination in March 2011, the examiner noted that a review of the evidence shows that the Veteran fractured the L4 vertebra following the September 2007 fall. The Veteran also reported that he fell on ice in March 2011. The examiner noted that the Veteran had urinary and fecal incontinence that was unrelated to his service-connected back disability and was going to have his prostate evaluated by his primary care provider. The Veteran complained of radiating back pain down his right leg. The examiner found that there were no incapacitating episodes of spine disease and there was no ankylosis of the thoracolumbar spine. Flexion was 0 to 60 degrees, extension was 0 to 20 degrees, lateral flexion to the right and left was 0 to 30 degrees. There was pain on active range of motion and following repetitive motion. Reflex exam findings ranged from hypoactive to normal. The March 2011 VA examiner noted that x-rays in January 2006 show Spina bifida occulta of S1 and did not show any compression fracture. The examiner further noted that the Veteran subsequently fell in September 2007 and the subsequent x-ray shows a compression fracture at L4. The Veteran complained of nerve pain in the right leg since 1988 when he had a low back lifting injury in service, however the examiner noted that he did not complain of nerve pain during a period exam in 1988 nor at the time of his separation examination in 1991. Sensory exam findings on the March 2011 VA examination were the same as the findings on VA examination in January 2011, with the exception of light touch which was decreased in the third to fifth toes in both extremities. Detailed motor exam was normal. The March 2011 VA examiner was of the opinion that the function of any joint was not affected by the nerve disorder. The examiner noted that the EMG in October 2010 shows moderated axonal polyneuropathy and no electromyographic evidence of lumbar radiculopathy, which could be interpreted to indicate a S1 intermittent neuropathy because of positive H reflex rather than axonal polyneuropathy as the Veteran did not have clinical disease or findings of an axonal neuropathy, such as diabetes mellitus. The diagnosis was intermittent S1 radiculopathy due to a work injury in September 2007 when the Veteran fell off a truck. The examiner commented that the decrease of vibration, light touch, and sharpness in the lateral toes have been inconsistent findings. He concluded that the Veteran has a sensory left and right lower extremity neurologic condition. After reviewing the claims folder, reviewing the medical literature and examining the Veteran, the examiner determined hat the Veteran's bilateral lower extremity S1 intermittent radiculopathy was not caused by or the result of his service-connected lumbar spine condition. The examiner explained that the September 2007 work injury caused the L4 compression fracture as x-rays did not show a fracture in 2006 but x-rays in 2008 did reveal the fracture. He determined that the force of the fall caused the bilateral S1 nerve injury. The examiner reiterated that while the Veteran did have radiating back pain in service it resolved as there were no complaints upon separation in 1991 and a private examiner noted in February 2008 that the Veteran did not have back injuries prior to the September 2007 injury. On VA disability benefits questionnaire examination in January 2012, the examiner noted that he was instructed to address the point at which the Veteran's range of motion of the thoracolumbar spine began as well as the effect pain, weakness, and premature or excess fatigability had on the spine with regard to functional limitation of motion. The Veteran stated he has chronic low back pain. He reported that flare-ups impact the function of the thoracolumbar spine with increased activity such as standing too long, sitting too long or climbing. The additional limitation of motion or other functional impairment during flare-up placed the Veteran on be rest. Flexion was 50 degrees with pain. Extension was 20 degrees with pain at 15 degrees. Right and left lateral flexion was 30 degrees with pain. The Veteran was able to perform repetitive-use testing with 3 repetitions and did not have additional limitation in range of motion with repetitive testing. Additional functional impairment included less movement than normal and pain on movement. Muscle strength testing was normal. Reflex exam was normal. Sensory exam was normal. The examiner indicated that the Veteran did not have radicular pain or symptoms due to radiculopathy nor did he have any other neurologic abnormalities or findings related to a thoracolumbar spine condition such as bowel or bladder problems or pathologic reflexes. The examiner further stated that the Veteran did not have intervertebral disc syndrome. The examiner noted that the Veteran had a L4 vertebral fracture from a work injury in September 2007 and the Veteran's thoracolumbar spine disability impacted his ability tor work due to decreased mobility and inability to lift heavy items. A private evaluation in January 2012, shows that flexion in the back was 15 to 20 degrees with pain. Accompanying x-rays show compression fracture of L4 and disc space narrowing from L3 to S1. Analysis The Board points out that the 40 percent evaluation is the maximum rating assignable for limitation of motion of the thoracolumbar spine under the general rating formula, to include the functional equivalent of limitation of motion even when considering all DeLuca factors. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). A rating in excess of 40 percent for a lumbar spine disability requires evidence of unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. In this case, the evidence does not reflect that the Veteran's low back disability resulted in ankylosis, favorable or unfavorable. During the appeal period, flexion primarily ranged from 50 to 60 degrees with pain (there was one instance of flexion being 15 to 20 degrees with pain in January 2012); extension was limited from to 10 to 30 degrees with pain, and right and left lateral flexion was limited from 20 to 30 degrees with pain. Furthermore, VA examiners in January 2008, July 2010, January 2011, and March 2011 specifically noted that there was no ankylosis deformity. While the Veteran has a significant functional decrease in range of motion, the fact remains that the spine is not ankylosed. While the Veteran has reported that his doctor told him to stay in bed due to his service-connected low back disability, there is no evidence, neither lay or medical, of incapacitating episodes, that is, bed rest prescribed by a physician and treatment by a physician, having a total duration of at least 6 weeks during a 12 month period. Thus the Veteran does not meet the criteria for the next higher rating of 60 percent under Diagnostic Code 5243 for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. In this case, the Veteran has complained of radiating pain, numbness, and tingling in his legs. He has had diagnoses of radiculopathy and moderate axonal polyneuropathy. The Board has considered whether a separate rating is warranted for neurologic manifestations, but finds that it is not as the probative evidence shows that the neurological abnormalities are not related to the Veteran' service-connected chronic lumbosacral strain with degenerative disc disease for the following reasons. In September 2007 the Veteran injured his spine at work when he fell five feet off a tractor truck. Subsequently, a MRI in November 2007 showed a fracture of the L4 and disc protrusion into the right neural foramen at L5-S1 with at least some degree of compression of the exiting L5 root. VA examiners in January 2008 and in March 2011 were of the opinion that the fracture was due to the September 2007 injury. The March 2011 VA examiner explained that the Veteran's September 2007 work injury caused the fracture as x-rays in 2006 did not show a fracture but a subsequent x-ray in 2008 revealed the fracture. The examiner noted that while the Veteran complained of nerve pain in the right leg during service, it had resolved by the time he was separated from service. The examiner concluded that the Veteran's bilateral lower extremity S1 intermittent radiculopathy was not caused by the service-connected lumbar condition and determined that the September 2007 fall caused the bilateral S1 nerve injury. The March 2011 VA examiner found that the function of any joint was not affected by the nerve disorder. The Board finds the March 2011 VA opinion to be significantly probative as the examiner carefully reviewed the Veteran's longitudinal medical history and applied medical principles to the facts of the case. This opinion is consistent with the other evidence of record. The Board notes that prior to the September 2007 injury, the Veteran on VA examination in December 2006 complained of radiating pain, however objective findings were normal as sensation to light touch, vibration and position was normal in the legs and feet. The evidence in January 2008 shows bladder impairment and in March 2011 shows bowel and bladder impairment. However in both instances the examiners determined that such impairment was not related to the Veteran's service-connected low back disability. On other VA examinations discussed above there was no finding of bowel or bladder impairment. The Board has also considered the Veteran's statements that describe his pain and locking and his spouse's statements that describe his back pain. The Veteran and generally his spouse are certainly competent to describe their observations and the Board finds their statements are credible. In this case, however, the Board finds the objective medical findings by skilled professionals are more persuasive which, as indicated above, do not support a rating higher than 40 percent for the service-connected chronic lumbosacral strain with degenerative disc disease. However, to the extent that the Veteran attributes neurologic manifestations to the service-connected disability, his is opinion is far less competent and credible than that of the skilled professional. As the criteria for a rating higher than 40 percent for chronic lumbosacral strain with degenerative disc disease have not been demonstrated during the appeal period, the preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Knees During the current appeal period, the Veteran's service-connected right knee and left knee have been rated under Diagnostic Codes 5010-5261. In evaluating the Veteran's current level of disability, the Board will consider all applicable Diagnostic Codes. Diagnostic Code 5010 provides that arthritis, due to trauma, substantiated by x-ray findings be rated as arthritis degenerative. Diagnostic Code 5003 provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (zero percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Diagnostic Codes 5260 and 5261 are used to rate limitation of flexion and of extension of the knee. Under Diagnostic Code 5260, limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating. And limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, limitation of extension of the knee to 5 degrees warrants a zero or noncompensable rating. Limitation of extension of the knee to 10 degrees warrants a 10 percent rating. Limitation of extension of the knee to 15 degrees warrants a 20 percent rating. Limitation of extension of the knee to 20 degrees warrants a 30 percent rating. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight knee impairment, that is, recurrent subluxation or lateral instability. A 20 percent rating is assigned for a moderate degree of impairment, and a maximum rating of 30 percent is assigned for severe impairment. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. VA's General Counsel has provided guidance concerning increased rating claims for knee disabilities. In VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997), it was held that a veteran who has arthritis and instability of the knee might be rated separately under Diagnostic Codes 5003 and 5257, provided that any separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 in order to obtain a separate rating for arthritis. In VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998), the VA General Counsel clarified that when a veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on x-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. The VA General Counsel also has held if the criteria for a compensable rating under Diagnostic Codes 5260 and 5261 are met, separate ratings can be assigned. VAOPGCPREC 9-2004 (September 17, 2004), 69 Fed. Reg. 59990 (2004). Facts A rating decision in September 2010, granted a separate 20 percent rating for right knee instability. The Veteran did not appeal this determination and during the Board hearing in June 2011 confirmed that he was satisfied with the 20 percent rating. Therefore the issue of whether the Veteran meets the criteria for a rating higher than 20 percent for right knee instability is not in appellate status. In June 2011 the Veteran testified that he did not have a meniscus. He stated that his orthopedic surgeon told him that there was nothing visible on MRI and that he was not going to have surgery to prove that he did not have a meniscus. The Veteran further testified that his surgeon he did not have access to the in-service surgical records and that they were unavailable. The Veteran also stated that during the VA examinations he was in a lot of pain and had no range of motion. He claimed that in both knees he has had 60 to 80 degrees of flexion with pain. His spouse testified that he had pain in his knees. In a statement in July 2011, the Veteran's spouse stated that the Veteran had knee pain and she had to assist him in getting around. Service treatment records show that in May 1991 the Veteran had an arthroscopy to repair a tear in his right meniscus. In July 1985 there is an impression of a questionable meniscus tear in the left knee and in August 1985 the Veteran underwent a resection of the synovial plica of the left knee. On VA examination in December 2006, it was noted that knee pain was worse with any kind of lifting and with carrying significant weight or running. Flare-ups could occur more than once a week and could last most of the day or a little longer. The examiner noted that x-rays in January 2006 show arthritis of both knees. The Veteran complained of pain with squatting, which increased with repetitive squatting. McMurray's test was negative. The examiner noted there was no history nor findings of instability in either knee. X-rays in December 2006 show mild to moderate patellofemoral degenerative joint disease and mild tibiofemoral degenerative joint disease bilaterally. On VA examination in January 2008, the examiner noted that the Veteran had arthroscopic surgery on both knees during service. The joint symptoms included instability, pain, weakness, and stiffness in both knees. There were no episodes of dislocation or subluxation. The Veteran complained of locking episodes one to three times per month and constant effusion. He stated he had severe flare-ups that could last one to two days. There was tenderness in both knees. Flexion in the right knee was 0 to 110 degrees, passive range of motion was 0 to 115 degrees, with pain beginning at 110 degrees. There was no additional limitation of motion on repetitive use. Extension of the right knee was -10 degrees, passive extension was -10 to -5 degrees, and range of motion against strong resistance was -15 degrees. There was no additional limitation of motion on repetitive use. As for the left knee, extension was -10 degrees, passive range of motion was -10 to -5 degrees, and against strong resistance was -15 degrees. There was no additional limitation of motion on repetitive use. Flexion in the left knee was 0 to 110 degrees. Passive range of motion was 0 to 115 degrees with pain at 110 degrees. Flexion against strong resistance was 0 to 105 degrees with pain. There was no additional loss of motion on repetitive use. As for the right knee, the examiner stated that there was no joint ankylosis and the meniscus in the right knee was surgically absent. There was no effusion, dislocation, or locking. McMurray's test was negative. There was marked tenderness along the medial joint line. As for the left knee, the examiner reported that there was no instability, the meniscus was surgically absent, there was no effusion, dislocation or locking. McMurray's test was negative. There was marked medial knee joint line tenderness. The examiner commented that the Veteran's bilateral knee disability had a significant effect on his occupational activities to include problems lifting and carrying and his knees gave way at work. Private medical records in August 2009 and September 2009 show the Veteran complained of knee pain, swelling, and locking. Active range of motion in the right knee was 0 to 120 degrees and passive range of motion was 0 to 122 degrees. In the left knee active range of motion was 4 to 120 degrees and passive range of motion was 3 to 120 degrees. VA medical records in September 2010 show that the Veteran's bilateral knee disability interfered with his job as a commercial driver due to pain while pushing on the clutch. Range of motion was 0 to 110 degrees in the right knee and 0 to 100 degrees in the left knee with pain on flexion. VA medical records in February 2011 show that passive and active flexion in the right knee ranged from 80 to 90 degrees and 89 to 109 degrees in the left knee, extension was 0 degrees. In March 2011 flexion at most in the right knee was 77 degrees and 90 degrees in the left, extension was 0 in both knees. In June 2011 passive and active flexion in the knees ranged from 80 degrees to 109 degrees and extension was from -5 to 0 degrees. In September 2011, the records show no effusion in either knee and range of motion was 0 to 90 degrees. In July 2012 the records show no joint effusion and no catching, locking, or instability of the right knee. Range of motion in the right knee was 5 to 100 degrees. There was tenderness to palpation over medial joint line and the knee was nontender laterally. As for the left knee range of motion was 5 to 100 degrees. There was tenderness to palpation over medial joint line and the knee was nontender laterally. Lachman, Drawer and McMurray s tests were negative. There was no instability with varus or valgus stress at zero and 30 degrees. On VA examination in July 2010, the Veteran complained of pain, stiffness, incoordination, locking one to three times per month, and moderately weekly flare-ups in the right knee. There was no weakness or effusion. As for the left knee, the Veteran reported pain, instability, incoordination, locking episodes one to three times per month, and severe weekly flare-ups. There was no giving way, stiffness, weakness, episodes of dislocation or subluxation, or effusion. Physical examination of the right knee shows there was no patellar abnormality, locking, effusion, dislocation, or other knee abnormalities. There was no patellar abnormality, however the examiner noted the meniscus was surgically absent. As for the left knee, the findings show that there was no instability, patellar abnormality and meniscus was surgically absent. Extension and flexion in both knees was 0 to 120 degrees, with pain. The was objective evidence of pain following repetitive motion and there were no additional limitations. There was no joint ankylosis. Accompanying x-rays show tibiofemoral degenerative joint disease bilaterally, which appeared to be of mild to moderate degree. There also was mild patellofemoral degenerative joint disease bilaterally. The examiner noted that the Veteran was unemployed but when he did work his bilateral knee arthritis decreased his mobility and caused increased absenteeism from work. On VA examination in August 2010, the examiner noted that the Veteran stated that he had his meniscus removed in service, however the examiner further noted that the in-service surgery report does not show this. A review of the medical history shows that there was no deformity of the left knee, instability, dislocation or subluxation, locking, or effusion. The examiner noted that the Veteran did complain of the left knee giving way, stiffness, and weakness. As for the right knee there was no deformity, incoordination, episodes of dislocation or subluxation or locking. However there was instability, pain, stiffness, weakness, and weekly locking episodes. The examiner noted that there were no flare-ups of joint disease in both knees. Physical examination of the right knee shows (moderate instability) subpatellar tenderness and no meniscus abnormality. Flexion was in the left knee was 0 to 70 degrees, extension was 0 degrees. There was pain with active motion in both knees. In the right knee flexion was 0 to 80 degrees and knee extension was 0 degrees, There was objective evidence of pain following repetitive motion. There was no joint ankylosis. The Veteran reported that he was laid off due to his back and knee problems. The August 2010 VA examiner reviewed the service treatment records and clarified that it is more likely than not that during service no meniscus was removed from either knee but likely repaired. The examiner noted that there was no record of an operation report for the left knee repair in 1985 but noted that there was a surgery report for a right knee meniscus repair in 1991. The examiner further stated that the Veteran reported that MRI records sent to VA show an absence of menisci in both knees, however the examiner stated that there is no MRI in the claims folder showing a lack of menisci. On VA examination in January 2011, there was tenderness in both knees. Right knee flexion was 80 degrees, extension was 0 degrees with no pain and pain on motion after three repetitions. Flexion in the left knee was 90 degrees and extension was 0 degrees with no pain and pain on motion after three repetitions. The examiner commented that the bilateral knee disability precludes substantial physical employment but does not prevent the Veteran from obtaining substantial sedentary employment. On VA examination in March 2011, the right knee and left knee had healed scars. There were no deformity of the knees, there was no instability, There was pain and stiffness on both knees. There was no weakness, incoordination, episodes of dislocation or subluxation, locking episodes, or effusion. There were flare-ups every two to three weeks. There was subpatellar tenderness in both knees and meniscus abnormality. Flexion in the left knee was 0 to 80 degrees. Extension was 0 degrees. There was pain on motion. Flexion in the right knee was 0 to 60 degrees, extension was 0 degrees. There was pain following repetitive motion. The examiner commented that service treatment records show that the Veteran only had plica removed from his left knee in 1985. On VA disability benefits questionnaire examination in January 2012, the examiner noted that he was instructed to address the point at which pain began as well as the effect pain, weakness, and premature or excess fatigability had on the spine with regard to functional limitation of motion. The examiner indicated that the Veteran did not report that flare-ups impact the function of the knee and/or lower leg. Right knee flexion was 85 degrees with pain. Right knee extension was 0 degrees without objective evidence of pain. Left knee flexion was 90 degrees with pain. Left knee extension was 0 degrees without objective evidence of pain. The Veteran was able to perform repetitive-use testing with 3 repetitions. Right knee post-test flexion was 85 degrees and extension was 0 degrees. Left knee post test flexion was 90 degrees and extension was 0 degrees. The examiner noted that the Veteran did not have additional limitation in range of motion of the knee and lower leg following repetitive-use testing. His functional loss and/or functional impairment after repetitive use included less movement than normal in both knees, pain on movement and interference with sitting and standing. The Veteran did have tenderness or pain to palpation in both knees. Muscle strength testing was normal in both knees. Joint stability tests in the left knee were normal and the examiner could not test medial lateral instability. There was no evidence or history of recurrent patellar subluxation or dislocation. The examiner indicated that the Veteran has had a meniscus condition that has been manifested by joint pain in both knees. The examiner noted that the Veteran has not had a meniscectomy. The Veteran had surgical scars on both knees that were not painful, unstable, or greater than 39 square centimeters. The examiner noted that x-rays do not show patellar subluxation and reported that July 2010 x-rays show tibiofemoral degenerative joint disease bilaterally and mild patellofemoral degenerative joint disease bilaterally. The examiner concluded that the Veteran's bilateral knee disability impacted his ability to work as the Veteran reported that both knees locked, gave way, and ambulation was limited. On private evaluation in January 2012, range of motion in the right knee was 0 to 90 degrees with pain at 45 degrees. Left knee range of motion was 5 degrees to 90 degrees with increasing pain at 45 degrees. Both knees were stable to varus and valgus stress test The examiner noted that the Veteran reported that he had a meniscectomy done for both knees during service. VA records in March 2013 show there was no edema in either knee and there was tenderness over the medial joint line in both knees. Range of motion was 0 to 130 degrees in both knees. There was no instability with varus or valgus stress test at zero and 30 degrees in both knees. Lachman, Drawer, and McMurray s tests were negative. Analysis The AOJ has assigned a 10 percent evaluation based upon Diagnostic Codes 5010-5261. The 10 percent evaluation contemplates pain on motion. 38 C.F.R. § 4.59. The evaluation would also contemplate limitation of extension to 10 degrees. In order to warrant a higher evaluation there must be the functional equivalent of limitation of extension to 15 degrees. A separate evaluation may be assigned for compensable limitation of flexion. Here, it is clear that the Veteran has pain on motion. However, neither the lay nor medical evidence suggest that extension is functionally limited to 15 degrees in either knee. In fact, most examinations disclosed normal extension or minimal impairment of extension. Similarly, a compensable degree of limitation of flexion has not been demonstrated in either knee. At best, there was a report of pain at 45 degrees. However, pain did not limit his functional use to 45 degrees. More importantly, the vast majority of lay evidence demonstrated that he retained functional flexion to 60 degree or better. Accordingly a separate evaluation is not warranted for impairment of flexion. Based on the evidence of record, while there was one instance of flexion in the right knee with pain limited to 45 degrees in January 2012, and one instance of flexion limited to 60 degrees in March 2011, numerous other findings throughout the appeal period show that flexion in the right knee ranged from 77 degrees to 120 degrees, which on multiple occasions included pain. As the criterion for a 20 percent rating for flexion is flexion limited to 30 degrees, the findings pertaining to limitation of flexion do not more nearly approximate or equate to flexion limited to 30 degrees, to include consideration of any additional functional loss due to pain, pain on movement, swelling, atrophy, fatigue, weakness, incoordination, to include during flare-ups and with repeated use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus the Veteran is not entitled to a higher rating under Diagnostic Code 5260. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, the findings do not more nearly approximate the criterion for a compensable rating of 10 percent, as numerous findings reported above do not show that flexion was to limited 45 degrees. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). As for limitation of extension, extension at maximum was - 10 early on, however most of the findings show that extension was 0 degrees, to include pain in multiple instances. As the criterion for a 20 percent rating for extension is extension limited to 15 degrees, the findings pertaining to limitation of extension do not more nearly approximate or equate to extension limited to 15 degrees, to include consideration of any additional functional loss due to pain, pain on movement, swelling, atrophy, fatigue, weakness, incoordination, to include during flare-ups and with repeated use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus the Veteran is not entitled to a higher rating under Diagnostic Code 5261. As there is no showing of a compensable degree of disability as to flexion in the right knee, a separate rating for right knee flexion and extension pursuant to VAOPGCPREC 9-2004 is not warranted. As for the left knee, there was one instance of flexion in the left knee pain at 45 degrees in January 2012, however numerous other findings throughout the appeal period show that flexion in the left knee ranged from 70 degrees to 120 degrees, to include pain on multiple occasions. As the criterion for a 20 percent rating for flexion is flexion limited to 30 degrees, the findings pertaining to limitation of flexion do not more nearly approximate or equate to flexion limited to 30 degrees, to include consideration of any additional functional loss due to pain, pain on movement, swelling, atrophy, fatigue, weakness, incoordination, to include during flare-ups and with repeated use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus the Veteran is not entitled to a higher rating under Diagnostic Code 5260. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, the findings do not more nearly approximate the criterion for a compensable rating of 10 percent, as numerous findings reported above do not show that flexion was limited to 45 degrees. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). As for limitation of extension of the left knee, extension at maximum was 5 in July 2012, however most of the findings show that extension was 0 degrees, to include pain in multiple instances. As the criterion for a 20 percent rating for extension is extension limited to 15 degrees, the findings pertaining to limitation of extension do not more nearly approximate or equate to extension limited to 15 degrees, to include consideration of any additional functional loss due to pain, pain on movement, swelling, atrophy, fatigue, weakness, incoordination, to include during flare-ups and with repeated use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus the Veteran is not entitled to a higher rating under Diagnostic Code 5261. As there is no showing of a compensable degree of disability as to flexion in the left knee, a separate rating for left knee flexion and extension pursuant to VAOPGCPREC 9-2004 is not warranted. X-rays in July 2010 show tibiofemoral degenerative joint disease in both knees. As the Veteran already is in receipt of a rating for painful limited motion under Diagnostic Code 5261, assigning a separate 10 percent rating for limitation of motion under Diagnostic Code 5003 for degenerative arthritis would constitute pyramiding as he would be compensated twice for the same symptomatology. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). As stated above, the issue of whether the Veteran is entitled to a rating higher than 20 percent for right knee instability is not currently before the Board. As for the left knee, the Veteran has complained of instability and the left knee giving way. Nevertheless, the Board finds that the weight of the evidence establishes that the criteria for a separate rating under Diagnostic 5257 is not warranted as the objective findings do not confirm recurrent subluxation or lateral instability. VA examiners in December 2006, January 2008, and July 2010, determined that there was no instability in the left knee. The January 2008 VA examiner and the March 2011 VA examiner noted that there were no episodes of dislocation or subluxation. On VA examination in January 2012, anterior instability and posterior instability joint tests in the left knee were normal. The examiner noted that there was no evidence or history of recurrent patellar subluxation or dislocation. In January 2012 and March 2013 both knees were stable to varus and valgus stress test and Drawer test was negative. For these reasons the weight of the evidence shows that the criteria for a separate rating for recurrent subluxation or lateral instability under Diagnostic Code 5257 for the left knee is not warranted. The medical evidence is more competent and credible than the Veteran's complaints of instability. The Board notes that the Veteran has complained of locking episodes, however the VA examiner in January 2008 determined that there was no ankylosis in the right knee and VA examiners in July 2010 and August 2010 determined that there was no ankylosis in either knee. As during this period there is no evidence of ankylosis, tibia and fibula involvement, or genu recurvatum in either knee, Diagnostic Codes 5256, 5262, and 5263 are not applicable. During the appeal period, some examiners based on history presented by the Veteran indicated that he had meniscus from both knees surgically removed during service. However, service treatment records do not show that the Veteran's meniscus in either knee was removed during service. As outlined above, service treatment records show that in May 1991 the Veteran had an arthroscopy to repair a tear in his right meniscus and in August 1985 he underwent a resection of the synovial plica of the left knee. The VA examiner in August 2010 reviewed the service treatment records and confirmed that no meniscus was removed during service, noting that there was a right knee meniscus repair in 1991 and there was no record of an in-service operation report for left knee meniscus repair. Thus the Veteran's statements that he had meniscus removed during service are not credible as they are inconsistent with the service treatment records. The findings of the VA examiners who relied on the Veteran's inaccurate history are thus not probative. The United States Court of Appeals for Veterans Claims has found that a medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board has also considered Diagnostic Code 5258 for dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint. The Veteran is service connected for a meniscus tear of the right knee. The meniscus is the semilunar cartilage. Throughout the appeal period he has complained of locking episodes and effusion in his right knee. On VA examination in January 2008 the Veteran complained of locking episodes one to three times per month and constant effusion. Private medical records in August 2009 and September 2009 document the Veteran's complaints of swelling and locking. On VA examination in July 2010 and August 2010, the Veteran complained of frequent locking. However objective findings on these and other VA examinations do not include locking and effusion. The Veteran is competent to report what he has experienced or observed. See Layno v. Brown, 6 Vet. App. 465 (1994). However, the lay evidence of locking and effusion is remarkably inconsistent with the medical evidence. Here the lay evidence is less credible and less probative than the findings by medical professionals, which do not support the Veteran's complaints, and an evaluation under Diagnostic Code 5258 is not warranted. As for the left knee, the Veteran is service connected for left knee arthritis (previously rated as left knee plicotomy). As discussed above, during service he underwent left knee surgery to remove a synovial plica. A plica is a ridge or fold of the synovial membrane of the knee joint. See Dorland's Illustrated Medical Dictionary 1311 (28th ed. 1994). Thus Diagnostic Code 5258 is not applicable to the left knee as the evidence discussed above does not show disability or impairment of the cartilage in the left knee. As the probative evidence presented above shows that semilunar cartilage was not removed in either knee, Diagnostic Code 5259 is not for consideration in evaluating either the right knee or the left knee. On VA examination in March 2011, the Veteran had healed scars. On VA examination in January 2012, the examiner noted the Veteran had surgical scars on both knees that were not painful or unstable or greater than 39 square centimeters. As the evidence shows that the scars are nonsymptomatic with no features that would support the assignment of separate compensable ratings, the Diagnostic Codes for skin disorders are not contemplated. The Board also has considered the Veteran's and his spouse's lay statements that describe his bilateral knee pain and discomfort. The Veteran and his spouse are certainly competent to describe their observations and the Board finds their statements are credible. In this case, however, the Board finds the objective medical findings by skilled professionals are more persuasive which, as discussed above do not support a higher rating or any more separate ratings. In essence, the lay evidence, while accepted as credible, does not provide a basis for a higher evaluation or any additional separate ratings. The criteria for a separate rating of 20 percent for semilunar dislocated cartilage in the right knee is warranted for the current appeal period. As the criteria for a rating higher than 10 percent for the service connected right knee arthritis and left knee arthritis have not been demonstrated during the appeal period, the preponderance of the evidence is against the claims, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether the claim should be referred to the VA Director of the Compensation and Pension Service for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization so as to render the regular schedular standards impractical. The Board acknowledges that the service-connected low back disability and bilateral knee disability have impacted the Veteran's employment. However, the threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology pertaining to his service-connected chronic lumbosacral strain with degenerative disc disease, right knee arthritis with meniscus tear repair, and left knee arthritis. The Board finds that the Veteran's service-connected low back disability is manifested by pain and limitation of motion and the knees are manifested by symptoms such as pain, limitation of motion, locking, and effusion. For these reasons, the disability picture is contemplated by the Rating Schedule, and the assigned schedular ratings are, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). (The Order follows on the next page.) ORDER A rating higher than 40 percent for chronic lumbosacral strain with degenerative disc disease is denied. A rating higher than 10 percent for right knee arthritis with meniscus tear repair is denied. A rating higher than 10 percent for left knee arthritis is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs