Citation Nr: 1321735 Decision Date: 07/08/13 Archive Date: 07/18/13 DOCKET NO. 07-20 554 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to a rating in excess of 20 percent for the service-connected right knee disability, characterized as residuals of right knee meniscectomy with degenerative changes. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from January 1987 to March 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran testified before the undersigned Veterans Law Judge in a videoconference hearing from the RO in September 2011. A transcript of the hearing is of record. In February 2012 the Board remanded the case on appeal to the RO for further development, which has been accomplished. FINDING OF FACT The Veteran's right knee disability, diagnosed as degenerative joint disease, is generally manifested by painful motion, flexion to 45 degrees or better and extension to 10 degrees or better, without instability. CONCLUSION OF LAW The criteria for an evaluation higher than 20 percent for the right knee disability are not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to 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. The VA is required to notify a 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, the 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, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In this case, the Veteran was sent a letter in March 2005 advising him of the elements to establish entitlement to an increased rating, and he had ample opportunity to respond prior to the May 2005 rating decision on appeal. In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009 (reversing prior cases law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing harmful or prejudicial error normally falls on the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The record also reflects that service treatment records (STRs) and all available post-service medical evidence identified by the Veteran have been obtained. In February 2012 the Board determined a VA medical examination was warranted to establish the current severity of the Veteran's disability on appeal, and the examination was performed the same month. The Board has reviewed the examination report and finds the RO substantially complied with the requirements articulated in the Board's remand instructions. D'Aries v. Peake, 22 Vet. App. 97 (2008), citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and has not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of this appeal. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duties to notify and assist have been satisfied and will proceed to the merits of the issues on appeal. Legal Principles Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). 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. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.59 cited above are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Degenerative arthritis is rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003, which 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 the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) to DC 5003 provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Where medical evidence shows claimant has arthritis, and where the diagnostic code applicable to the disability is not based on limitation of motion, such as DC 5257 (knee subluxation or instability), a separate rating may be assigned if there is additional disability due to limitation of motion. VAOPGCPREC 23-97 (July 1, 1997); see also Hicks v. West, 8 Vet. App. 417 (1995). Painful motion of a major joint or groups caused by degenerative arthritis, where the arthritis is established by X-ray, is deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even though there is no actual limitation of motion. VAOPGCPREC 09-98 (August 14, 1998), citing Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Disabilities of the knee are rated under the provisions of 38 C.F.R. § 4.71a, DCs 5256 through 5263. The Veteran is not shown to have ankylosis (DC 5256), impairment of the tibia and fibula (DC 5262) or genu recurvatum (DC 5263), so those DCs are not applicable. Symptomatic removal of semilunar cartilage (DC 5259) has a maximum rating of 10 degrees, so rating under that DC would present no advantage to the Veteran. Those DCs that are potentially relevant in this case are set forth below. Recurrent subluxation and lateral instability of the knee is rated under DC 5257 (other impairment of the knee). The rating criteria are as follows. A rating of 10 percent is assigned for slight impairment; a rating of 20 percent is assigned for moderate impairment; and, a rating of 30 percent is assigned for severe impairment. Dislocation of semilunar cartilage with frequent episodes of "locking," pain and effusion into the joint is rated under DC 5258. The only rating under this DC is 20 percent. Limitation of flexion of a leg is rated under DC 5260. A rating of 0 percent is assigned for flexion is limited to 60 degrees; a rating of 10 percent is assigned for flexion limited to 45 degrees; a rating of 20 percent is assigned for flexion limited to 30 degrees; and, a rating of 30 percent is assigned for flexion is limited to 15 degrees. Limitation of extension of a leg is rated under DC 5261. A rating of 0 percent is assigned for extension limited to 5 degrees; a rating of 10 percent is assigned for limitation of extension to 10 degrees; a rating of 20 percent is assigned for extension limited to 15 degrees; a rating of 30 percent is assigned for extension limited to 20 degrees; a rating of 40 percent is assigned for extension limited to 30 degrees; and, a rating of 50 percent is assigned for extension limited to 45 degrees. Normal range of motion (ROM) of the knee is extension to 0 degrees and flexion to 140 degrees. 38 C.F.R. § 4.71a, Plate II. The VA General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 17, 2004). In any increased rating claim, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, id. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA 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). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2011) 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 the disability under review. The instant claim for increased rating was received in February 2005. Historically, the Veteran's right knee disability was assigned a noncompensable rating during the period March 1990 to August 2003 for what was then characterized as residuals of meniscectomy, right knee. The Veteran had had a VA examination in July 2004 in which he complained of constant sharp knee pain, with the knee thrusting outward when he walked. He complained of swelling as a result of walking or standing and limitation of ROM. He also complained of intermittent incapacitating episodes. Physical examination showed the Veteran's gait to be abnormal in that he was favoring the right knee. Both legs were of equal length and there was no indication of abnormal weight bearing. The Veteran required a cane for ambulation and a cane for support. ROM was flexion to 60 degrees with pain beginning at 60 degrees, and extension to 0 degrees without recorded pain. ROM was additionally limited by pain, fatigue, weakness, lack or endurance and incoordination, but there is no indication that repetitive motion caused additional limitation of motion. McMurray's test and Drawer test showed no indication of instability, although there was "locking" pain and crepitus. X-rays showed degenerative arthritic changes with osteochondritis dessicans at the medial condoyle. The examiner changed the established VA diagnosis from "meniscectomy of the right knee" to "meniscectomy of the right knee with degenerative changes." As a result of the medical examination cited above, the RO issued a rating decision in August 2004 that increased the disability evaluation from noncompensable to 20 percent, effective from August 2003. The 20 percent rating was based on application of DC 5003 (degenerative arthritis) with noncompensable range of motion but with incapacitating episodes. (The Board notes at this point that this provision requires x-ray evidence of 2 or more major joints, or 2 or more minor joint groups, but the propriety of the 20 percent rating is not a question before the Board.) Treatment notes from the Atlanta Center for Athletes (ACA) in January 2005 show the Veteran presented complaining of episodic pain, swelling, catching and weakness of the right knee. He had been previously diagnosed with degenerative joint disease (DJD). Examination showed the Veteran to ambulate with a mildly antalgic gait secondary to pain, swelling and spasm. The Veteran had 3+ effusion, 3+ tenderness, positive Apley grind and positive McMurray's for a medial meniscus tear. There was audible crepitus but the knee was stable to ligamentous stress testing. X-rays showed medial compartment degenerative arthritis, patellofemoral degenerative arthritis and osteochondritis dessicans of the medial femoral condoyle. Magnetic resonance imaging (MRI) showed a probable meniscus tear. The physician recommended the Veteran undergo arthroscopic surgery to remove the unstable fragments, treat the medial meniscus tear and debride the medical femoral condoyle and patellofemoral joint. The Veteran had a VA-contracted medical examination in March 2005 in which he described having had surgery the previous month (February 2005). He complained of constant swelling, weakness and pain associated with extending the knee. He described 26 episodes of incapacitation over the previous year for a total of 26 days. Examination showed the Veteran to walk with a limp and use a cane; he also wore a brace for post-surgical support. The right leg was 2 cm. shorter than the left leg, but examination of the feet did not show abnormal weight bearing. The knee joint showed swelling and effusion, with medial tenderness. Drawer test and McMurray's tests did not show instability. Overall, examination of the right knee showed joint effusion and decreased ROM with pain on movement. Measured ROM of the right knee was flexion to 70 degrees, with pain at 60 degrees, and normal extension (0 degrees) without demonstrated pain. Pain was the major functional impact on repetitive use. The examiner stated the Veteran had significant problems with the right knee, which should have been further along after surgery but the Veteran had only half the normal ROM due to swelling. The Veteran's co-worker submitted a letter dated in May 2005 stating that since the Veteran returned to work several nurses had noticed him to have difficulty standing long periods of time, as well as swelling around the joint areas. Similarly, a May 2005 letter from another co-worker, a Registered Nurse (RN), states the Veteran was observed to have right knee swelling and difficult ambulation. The file contains a May 2005 letter from the Veteran to his employer, a regional crisis center, stating that he was resigning his position because his right knee surgery rendered him unable to provide the requisite 27 hours of work per week. The May 2005 rating decision on appeal granted a temporary total evaluation for surgical treatment requiring convalescence during the period February-April 2005. The rating decision continued the previous 20 percent rating effective from April 1, 2005. The Veteran had a VA orthopedic consult in November 2006 during which he complained of continued anteriormedial knee pain radiating upward. X-rays taken in October 2006 were compared with previous studies in October 2003; the clinical impression was post-traumatic right knee joint disease. The treatment plan was to obtain an MRI and return to clinic thereafter. VA MRI of the right knee in December 2006 showed extensive degenerative-type tear involving the medial meniscus throughout its entirety, with medial compartment degenerative changes. There was central subchondral cyst formation within the medial femoral condoyle and lateral femoral condoyle. There was moderate-to-large joint effusion but no evidence of ligamentous injury, bone contusion or fracture. The Veteran had a VA-contracted medical examination in May 2007 in which he complained of weakness, stiffness, swelling, locking, popping, fatigability and lack of endurance. He described the pain as occurring four times per week and lasting two hours. The pain was described as 10/10 in intensity. The Veteran stated that the pain did not cause incapacitation when managed with medication. Functional limitations were characterized as limited ROM, constant pain and limited physical activity (limited climbing, walking, jogging, standing and driving). Examination showed a stable scar that was not tender or otherwise clinically significant. Both legs were equal in length, with no signs of abnormal weight bearing, but gait was abnormal for right lower extremity (RLE) limping. The Veteran was noted to use a cane for ambulation. The right knee showed tenderness and crepitus. ROM was flexion to 45 degrees with pain at 20 degrees; extension was normal at 0 degrees with no pain. Repetitive use caused increased pain, fatigue, weakness and lack of endurance but did not cause additional loss of motion. The medial and lateral collateral ligaments, lateral and medial meniscus and anterior and posterior cruciate ligaments of the right knee were within normal limits for stability. The examiner continued the current diagnosis of meniscectomy of the right knee with degenerative changes, with subjective pain, weakness and swelling and objective tenderness, limited ROM and scar. The examiner stated the effect of the condition on the Veteran's activities of daily living (ADLs) was to require help in bathing and dressing. In his substantive appeal, received in June 2007, the Veteran stated his right knee caused constant pain and would give out. The Veteran stated he was unable to stand, run, walk or long periods without losing strength, tripping, stumbling and sometimes falling. The Veteran asserted he avoided climbing stairs and that he was limited in ADLs that affected his job, such as driving, walking and standing. The Veteran testified before the Board in September 2011 that his knee had severe lateral instability when walking; he recently fell while descending stairs due to a misstep associated with instability. His instability had become progressively worse since surgery in 2005. The Veteran would occasionally wear a knee brace when the instability was especially pronounced. The Veteran described locking-up of the knee once every 2-3 weeks; also, in the morning or after resting his knee did not seem to be as ready to go as the rest of his body. The Veteran believed his ROM had decreased since the last VA examination in 2007. The Veteran stated he was currently employed in a sedentary occupation and had no issues in regard to his job performance during the day. The Veteran's most recent VA examination was performed in February 2012. The Veteran complained of severe pain on the inside of the knee, swelling and inability to straighten the leg. He described pain when standing with weightbearing and also with flexing all the way. He described difficulty climbing stairs and numbness in the RLE. He denied flare-ups. ROM was flexion to 95 degrees with pain beginning at 45 degrees; extension was to 10 degrees, and the examination report is silent in regard to pain on extension. Repetitive motion caused no additional limitation of movement, although there was additional pain and less movement than normal. The right knee had tenderness on palpation; stability testing was normal and muscle strength of the RLE was 5/5. No discrepancy was noted in leg length, right versus left. The examiner endorsed history of medial joint line pain post meniscectomy and pain post arthroscopy. The examiner noted a surgical scar that was not clinically significant. The Veteran was noted to use a cane regularly and a knee brace occasionally. The examiner stated there was no x-ray evidence of patellar subluxation. Functional impairment was described as difficulty with stairs, including at work; the Veteran was limited on exercising but other ADLs were okay (the Veteran could dress, feed and toilet). The examiner diagnosed DJD of the right knee. Review of the evidence shows the Veteran's flexion prior to onset of pain, as rated by DC 5260, was 60 degrees in July 2004 and March 2005 (noncompensable), 20 degrees in May 2007 (20 percent) and 45 degrees in February 2012 (10 percent). The Veteran's extension prior to onset of pain, as rated by DC 5261, was 0 degrees in July 2004, March 2005 and May 2007 (noncompensable) and 10 degrees in February 2012 (10 percent). Thus, even considering the application of separate ratings for limitation of extension and limitation of flexion, at no time were these limitations productive of ratings in excess of 20 percent individually or combined when flexion and extension were measured on the same occasions. The Veteran is diagnosed with arthritis of the knee and thus is entitled to minimum rating for loss of flexion of the joint. Burton, 25 Vet. App. 1; Schafrath, 1 Vet. App. 589, 592. The schedular minimum under DC 5260 is 0 percent (for limitation to 60 degrees), so the Veteran's current 20 percent rating satisfies the requirement. His current rating also satisfies the minimum 10 percent rating for painful arthritis specified in Lichtenfels, 1 Vet. App. 484. The Veteran has complained of subjective instability, but there has been no instability demonstrated on clinical examination. The Veteran has had four VA medical examinations during the course of the period under review (July 2004, March 2005, May 2007 and February 2012), all of which demonstrated that the knee was stable during appropriate diagnostic procedures. In addition to these examinations, there is no clinical evidence of instability in any VA or non-VA treatment note. Accordingly, rating under DC 5257 is not for consideration. In this case, DCs 5258 and 5259 are arguably available as alternatives to rating under the criteria for limitation of motion, but the highest available rating under those DCs is 20 percent. Thus, alternative rating under these DCs would present no potential benefit to this Veteran. The Veteran's representative submitted an Informal Hearing Presentation in May 2013 asserting the Veteran is entitled to a continued rating of 20 percent for torn meniscus plus separate ratings for limitation of extension and limitation of flexion. The Board disagrees. As described above, the facts here do not support the approach suggested. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence cited above the Board has carefully considered the lay evidence offered by the Veteran in the form of his testimony before the Board, his correspondence to VA, his statements to various medical examiners and providers and the lay statements that were submitted on his behalf. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). However, even affording the Veteran with full competence and credibility in reporting his right knee symptoms over time, the lay evidence of record simply does not show that the Veteran's right knee disability has met the criteria for a rating higher than the currently-assigned 20 percent. The Board has considered whether "staged ratings" are for application, per Hart, 21 Vet. App. 505. However, the Veteran is not shown to have satisfied the criteria for a rating higher than 20 percent during any discrete date range during the period under review, so "staged rating" is not appropriate. The Board has considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). 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. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations of the service-connected knee disability (limitation of motion due to pain and associated weakness, fatigability, lack of endurance and incoordination) are specifically contemplated by the schedular criteria as amplified by DeLuca and Burton. The Board has therefore determined that referral of this case for extra-schedular consideration under 38 C.F.R. § 3.321(b) is not in order. Finally, the United States Court of Appeals for Veterans Claims (Court) has held that a request for a total disability rating for individual unemployability due to service-connected disability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is part of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). In this case, the Veteran has not asserted, and the evidence of record does not suggest, that he is unemployable solely due to the right knee disability on appeal, and indeed he asserted during his most recent VA examination that he is currently employed. The Board accordingly finds that a claim for TDIU is not raised by this appeal. In sum, the Board has found the criteria for a rating higher than 20 percent for the service-connected right knee disability are not met. Accordingly, the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER A rating in excess of 20 percent for the right knee disability is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs