Citation Nr: 1322334 Decision Date: 07/12/13 Archive Date: 07/18/13 DOCKET NO. 09-50 270 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a rating in excess of 10 percent for irritable bowel syndrome. 2. Entitlement to a rating in excess of 10 percent for degenerative arthritis of the lumbar spine prior to June 20, 2011, and in excess of 40 percent thereafter. 3. Entitlement to a rating in excess of 10 percent for status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis. 4. Entitlement to a separate rating in excess of 20 percent for right knee instability as of June 20, 2011, associated with status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from May 1979 to July 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which denied ratings in excess of 10 percent for degenerative arthritis of the lumbar spine and status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis, and a compensable rating for irritable bowel syndrome. The Veteran appealed with respect to the propriety of the assigned ratings. During the course of the appeal, interim rating decisions increased the ratings for irritable bowel syndrome to 10 percent (effective from the date VA received the Veteran's claim for an increased rating, i.e., December 12, 2008) and degenerative arthritis of the lumbar spine to 40 percent (effective June 20, 2011). An interim rating decision also, in considering the claim for an increased rating for the status post anterior cruciate ligament tear of the right knee, granted service connection for associated instability of the right knee and assigned a separate 20 percent rating for such disability, effective June 20, 2011. The Veteran remains in disagreement with the ratings assigned for the disabilities at issue despite these interim decisions, and as the 40 percent rating for degenerative arthritis of the lumbar spine was not assigned effective from the date of the claim for increase but from June 20, 2011, there is for consideration, as the issue is listed on the title page, entitlement to a rating in excess of 10 percent for degenerative arthritis of the lumbar spine prior to June 20, 2011, and in excess of 40 percent thereafter. AB v. Brown, 6 Vet. App. 35 (1993). In his December 2009 substantive appeal (VA Form 9), the Veteran requested a Board hearing before a Veterans Law Judge in Washington, D.C. In a January 2013 letter, he was advised that his requested hearing had been scheduled for March 2013. Thereafter, in a February 2013 communication, the Veteran requested that his scheduled hearing be cancelled. He further indicated that he did not wish to reschedule his hearing. Therefore, the Board finds that the Veteran has withdrawn his request for a Board hearing. 38 C.F.R. § 20.702(e) (2012). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims reveals VA treatment records dated through March 2012, which were considered by the agency of original jurisdiction (AOJ) in the August 2012 supplemental statement of the case. FINDINGS OF FACT 1. For the entire appeal period, and resolving all doubt in favor of the Veteran, irritable bowel syndrome results in alternating diarrhea and constipation with more or less constant abdominal distress. 2. For the period prior to June 20, 2011, degenerative arthritis of the lumbar spine was manifested by forward flexion of the thoracolumbar spine greater than 60 degrees, and such did not result in the combined range of motion of the thoracolumbar spine being no greater than 120 degrees; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; ankylosis; incapacitating episodes of intervertebral disc syndrome (IDS) requiring bedrest prescribed by a physician having a total duration of at least two weeks during a 12 month period; or neurologic impairment. 3. As of June 20, 2011, degenerative arthritis of the lumbar spine is not manifested by unfavorable ankylosis; incapacitating episodes of IDS requiring bedrest prescribed by a physician having a total duration of at least six weeks or more during a 12 month period, or neurologic impairment. 4. For the entire appeal period, motion in the right knee is to full extension and, at worst, 70 degrees of flexion and, prior to June 20, 2011, no subluxation or instability was demonstrated in the right knee. 5. Moderate, but not severe, instability is shown in the right knee from June 20, 2011. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for a 30 percent rating for irritable bowel syndrome are met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code(DC) 7319 (2012). 2. The criteria for a rating in excess of 10 percent for degenerative arthritis of the lumbar spine prior to June 20, 2011, and in excess of 40 percent thereafter are not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010-5243 (2012). 3. The criteria for a rating in excess of 10 percent for status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis are not met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5257, 5260, 5261, (2012). 4. The criteria for a separate rating in excess of 20 percent for right knee instability as of June 20, 2011, associated with status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis, are not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Regarding claims for increased ratings such as those on appeal in the instant case, the VCAA requirement is generic notice, that is, 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, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). The Board finds that VA has satisfied its duty to notify under the VCAA with respect to the claims for increased ratings on appeal. Specifically, a May 2009 letter, sent prior to the initial unfavorable June 2009 rating decision on appeal, provided specific information, including relevant rating criteria, concerning the evidence and information necessary to substantiate the increased rating claims on appeal as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records and post-service treatment records. Moreover, the Veteran's statements in support of the claims are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. In this regard, the Walter Reed Medical Center in June 2012 replied to a request by VA for medical records indicating that there were no records of treatment for the Veteran at this facility. He was advised of such in a June 2012 letter. Additionally, while the Veteran reported treatment from Dr. Larkin for his back in June 2011, the authorization form was incomplete. As such, in an April 2012 letter, he was advised to resubmit a complete authorization form for Dr. Larkin's records; however, to date, he has not done so. Moreover, the Veteran himself in a June 2012 phone call and a September 2012 response to the August 2012 supplemental statement of the case indicated that he had no other information or evidence to submit. Additionally, the Veteran was afforded VA examinations in June 2009, November 2010, and June 2011 to evaluate the severity of the service-connected disabilities on appeal. Neither the Veteran nor his representative has alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected disabilities as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claims and no further examination is necessary. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Analysis Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. In this regard, the Board notes that it has reviewed all of the evidence of record, to include in the Veteran's paper claims file and the Virtual VA file, with an emphasis on the evidence relevant to this appeal. As noted in the Introduction, the Virtual VA file reveals VA outpatient treatment reports dated through March 2012, and the August 2012 supplemental statement of the case documents review of such reports. As such, a remand for consideration of any documents contained in the Virtual File that are not physically of record in another supplemental statement of the case pursuant to 38 C.F.R. § 20.1304(c) is not necessary. When describing a document contained in the Virtual VA file and not physically of record in the claims file, this fact will be so noted herein. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Ratings Schedule) found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Irritable Bowel Syndrome The Veteran's service connected irritable bowel syndrome is rated under DC 7319. Under DC 7319, ratings of 0, 10, and 30 percent are authorized for irritable colon syndrome. A 0 percent rating is warranted for mild irritable bowel syndrome with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is assigned for moderate irritable bowel syndrome with frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is assigned for severe irritable bowel syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. At the June 2009 VA examination, the Veteran reported having problems with irritable bowel syndrome for 20 years. He stated that the condition prevented him from maintaining weight and that he had lost ten pounds over the previous year. The Veteran also described having problems with nausea, vomiting, diarrhea, and diarrhea and alternating constipation on a weekly basis. He reported that he did not have chronic constipation, but did report abdominal pain that included distress and cramps that occurred two thirds of the year. The Veteran reported that the attacks of abdominal pain occurred intermittently, as often as one per week, with each occurrence lasting 3 days. He reported that he had "many" such attacks within the previous year. During such attacks, the Veteran reported that he is not able to perform daily functions because of having to make frequent trips to the restroom. The physical examination of the abdomen was normal. At a June 2011 VA examination, the Veteran reported that his irritable bowel syndrome did not affect his body weight but did result in chronic constipation, diarrhea, alternating diarrhea and constipation, and abdominal pain. He reported no nausea and vomiting. Symptoms of diarrhea were said to occur 2 to 3 times monthly. The Veteran reported having daily abdominal pain that occurred more than two thirds of the year manifested by symptoms of distress, cramps, pain, bloating, gas, and cramping. He stated that these symptoms occurred constantly and, with respect to functional impairment, he indicated that he cannot maintain focus during his bouts of diarrhea. The physical examination of the abdomen was normal. As set forth above, a 30 percent rating is assigned for severe irritable bowel syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. DC 7319. This is the highest assignable rating under DC 7319. Applying these criteria to the facts summarized above, at each examination and as noted by the Veteran's representative in her June 2013 presentation to the Board, the Veteran reported alternating diarrhea and constipation. Abdominal distress was described at each examination, with more frequent such episodes at the more recent VA examination, at which time the symptoms were described as occurring "constantly." While the Board recognizes that constant symptoms of abdominal distress were not described at the June 2009 VA examination, at which time the Veteran said the symptoms occurred intermittently, he did describe having "many" such attacks over the prior year and reported that he was not able to perform daily functions during such attacks. From the above, the Board finds a reasonable doubt as to whether irritable bowel syndrome resulted in alternating diarrhea and constipation with more or less constant abdominal distress for the entire appeal period. As set forth above, when there is a reasonable doubt as to the rating to be assigned, this doubt will be resolved in the Veteran's favor. See 38 C .F.R. § 5107(b); 38 C.F.R. § 3.102, 4.3, 4.7; Gilbert, 1 Vet. App. at 49. Accordingly, the Board resolves all reasonable doubt in favor of the Veteran and concludes that the criteria for a 30 percent rating for irritable bowel syndrome under DC 7319 for the entire appeal period are met. As indicated, the highest assignable rating under DC 7391 is 30 percent, and a review of the other potentially pertinent diagnostic codes pertaining to the rating of disabilities of the digestive system codified at 38 C.F.R. § 4.114 does not reveal a provision which would warrant the assignment of a rating in excess of 30 percent under the Ratings Schedule given the nature of the disability associated with the Veteran's irritable bowel syndrome. B. Lumbar Spine & Right Knee Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." 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. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application 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. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X- ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Traumatic arthritis is rated as for degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Lumbar Spine The Veteran's service-connected degenerative arthritis of the lumbar spine is currently evaluated pursuant to DC 5242 (degenerative arthritis of the spine). As indicated previously, arthritis is rated based on limitation of motion. Therefore, the lumbar spine disability at issue is rated under the General Rating Formula for Diseases and Injuries of the Spine, as such formula includes consideration of limitation of motion. The General Rating Formula for Diseases and Injuries of the Spine holds that for DCs 5235 to 5243, a rating of 100 percent is warranted when there is unfavorable ankylosis of the entire spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. A 20 percent rating is warranted for lumbar spine disabilities if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, if the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if the disability is manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 10 percent rating is warranted where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spine contour; or, vertebral body fracture with loss of 50 percent or more of the height. The criteria also include the following provisions: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is 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 neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. IDS (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome (IDS) Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating IDS Based on Incapacitating Episodes provides for a 60 percent rating when there are incapacitating episodes of IDS having a total duration of at least six weeks during the past 12 months. A 40 percent rating is warranted when there are incapacitating episodes of IDS having a total duration of at least four weeks, but less than six weeks during the past 12 months. A 20 percent rating is warranted when there are incapacitating episodes of IDS having a total duration of at least two weeks, but less than four weeks during the past 12 months. A 10 percent rating is warranted when there are incapacitating episodes of IDS having a total duration of at least one week but less than two weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IDS that required bed rest prescribed by a physician and treatment by a physician. An evaluation can be had either on the total duration of incapacitating episodes over the past 12 months or by combining separate evaluations of the chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities under 38 C.F.R. § 4.25, whichever method resulted in the higher evaluation. Summarizing the pertinent evidence with the above criteria in mind, reports from a June 2009 VA examination reflect complaints of stiffness and numbness associated with the Veteran's lumbar spine disability. He reported that the back "catches" at times in the lower regions and that he has severe back spasms at times. The Veteran described no loss of bladder or bowel control and reported having constant lower back pain, described as aching, sticking, and cramping, that traveled to the lower extremities. He described the pain to a level of 10 on a scale of one to 10, and reported that the pain at times prevents him from functioning. The Veteran described additional symptoms of pain causing numbness in the left shoulder region. He reported one episode of incapacitation, with physician-ordered bed rest, in the prior 12 months that lasted one and a half weekdays. He also reported one other such episode of incapacitation for one week in June 2008. With respect to functional impairment, the Veteran reported that he cannot lift heavy objects or work without the use of cane. The examination of the thoracolumbar spine in June 2009 revealed no evidence of radiating pain on movement, no muscle spasm, and no tenderness. The straight leg raising test was positive on each side and there was no ankylosis of the lumbar spine. The range of thoracolumbar motion was to 90 degrees of flexion and 30 degrees of extension backward and right and left lateral flexion and rotation. There was pain at the extremes of all motion, and the joint functioning of the spine was said to be limited by the following after repetitive use: fatigue, lack of endurance, and incoordination. Repetitive use was not said to result in any additional limitation of motion. The inspection of the spine revealed a normal head position with symmetry in appearance and there was symmetry of spinal motion with normal spinal curvature. There were no signs of IDS. The neurological examination of the lower extremities was negative. X-rays of the lumbosacral spine revealed disc disease. Following the examination, which also included an examination of the right knee as set forth below, the occupational effects were said to be that bending was not possible without pain. Pain on walking was listed as the only effect on daily activity. (The examiner was not specific as to the occupational effects or the effects on daily activates attributable to the service-connected back versus the service-connected right knee disability discussed below.) At a June 2011 VA examination, the Veteran reported that his lumbar spine disability limited his ability to walk, but had not resulted in any falls. He reported stiffness, spasms, decreased motion, numbness, bowel problems, erectile dysfunction, and leg weakness associated with the lumbar spine disability, but no fatigue, paresthesia, or bladder problems. He described constant severe pain that travels to his hips and legs that is exacerbated by physical activity. During flare-ups of pain, relived by rest and medication to include Percocet, he described functional impairment in the form of drowsiness, weakness, an unstable gait, and the inability to turn or bend at the waist. He reported incapacitating episodes of bed rest prescribed by a physician in the prior 12 months of one day in February 2011 and one day in March 2011. The physical examination of the spine in June 2011 revealed no evidence of radiating pain on movement and no muscle spasm or tenderness. There was no guarding of movement and the examination revealed no evidence of weakness. Muscle tone and musculature was normal, and there was a positive straight leg raising test on the right and left. The Lasegue's sign was negative and there was no atrophy in the limbs. There was no ankylosis of the thoracolumbar spine. The range of lumbar motion was to 30 degrees of flexion and 10 degrees of extension backward and right and left lateral flexion and rotation. There was pain at the extremes of all motion but repetitive motion did not result in any additional limitation of motion. The joint functioning of the spine was said to not be additionally limited by the following after repetitive use: pain, fatigue, weakness, or lack of endurance or incoordination. The inspection of the spine revealed a normal head position with symmetry in appearance and there was symmetry of spinal motion with normal spinal curvature. X-rays of the lumbar spine showed degenerative changes. The neurological examination was negative and there were no signs of IDS. Turning first to whether a higher rating may be assigned for the service-connected back disability for the period prior to June 20, 2011, which was the date of the June 2011 VA examination set forth above, a 20 percent rating would require there to be evidence during this period that this disability resulted in flexion of the thoracolumbar spine being to greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine was no greater than 120 degrees; or that the disability was manifested by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A higher rating would also be warranted if the Veteran had incapacitating episodes of IDS having a total duration of at least two weeks but less than four weeks during a 12 month period. As set forth above, forward flexion in the thoracolumbar spine at the June 2009 VA examination was to 90 degrees, well beyond that required for a 20 percent rating. The combined range of thoracolumbar spine at this examination was also well beyond that required for a 20 percent rating. Review of the other clinical evidence for the period at issue, to include the reports from VA outpatient treatment physically of record dated through December 2010, do not reveal the range of motion findings required for a 20 percent rating. In this regard, a September 22, 2010, VA outpatient treatment report reflects complaints of back pain, diffuse in the lumbar region, with radiating pain down his left leg when the Veteran twists his back. It was also noted that there was a decreased range of lumbar motion; however, the severity of such limitation of motion was not specified in degrees. January 27, 2011, and February 2, 2011, VA outpatient treatment reports contained in the Virtual VA file reflect acute low back pain after the Veteran shoveled snow; however, such do not contain findings, in degrees, from range of motion testing. Reports in the Virtual VA file from a VA outpatient visit on April 20, 2011, which appear to be the last such visit prior to the June 2011 VA examination, also do not reflect range of lumbar motion findings. As for the final basis for a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine; namely, the presence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, while the Veteran described lumbar spasms at the June 2009 VA examination, the examiner who conducted this examination specifically indicated that there were no muscle spasms and there was a normal spinal curvature. There is otherwise no clinical evidence for the period in question demonstrating that the service-connected lumbar spine disability resulted in muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. As such, a 20 percent for the service-connected lumbar spine disability prior to June 20, 2011, cannot be assigned under the General Rating Formula for Diseases and Injuries of the Spine. Finally, as the examiner who conducted the June 2009 VA examination specifically noted that IDS was not present, and there is otherwise no evidence that the Veteran had incapacitating episodes of IDS having a total duration of at least two weeks during a 12 month period prior to June 20, 2011, a 20 percent rating under the Formula for Rating IDS Based on Incapacitating Episodes prior to June 20, 2011, may not be assigned. As for a 40 percent rating for the service-connected lumbar spine disability for the period prior to June 20, 2011, under the General Rating Formula for Diseases and Injuries of the Spine (the General Rating Formula do not provide for a 30 percent rating for thoracolumbar disability), such a rating would have required limitation of lumbar flexion to 30 degrees or favorable ankylosis of the entire thoracolumbar spine. The limitation of lumbar flexion required for a 40 percent rating was not demonstrated by any clinical evidence prior to the June 20, 2011, VA examination range of motion finding of lumbar flexion being limited to 30 degrees. Moreover, the June 2009 VA examination specifically noted that there was no ankylosis and no other evidence during the period in question demonstrated ankylosis. As such, a 40 percent for the service connected lumbar spine disability prior to June 20, 2011, cannot be assigned under the General Rating Formula for Diseases and Injuries of the Spine. Again, as IDS was excluded by the examiner who conduced the June 2009 VA examination, and there is otherwise no evidence that there were incapacitating episodes of IDS having a total duration of at least four weeks but less than 6 weeks during a 12 month period prior to June 20, 2011, a 40 percent rating for the service connected lumbar disability prior to June 20, 2011, cannot be assigned under the Formula for Rating IDS Based on Incapacitating Episodes. As for whether a rating in excess of 40 percent may be assigned for the service connected lumbar spine disability for the period from June 20, 2011, such a rating would require unfavorable ankylosis of the entire thoracolumbar spine, or incapacitating episodes of IDS having a total duration of at least six weeks during a 12 month period. The June 20011 VA examination showed no, much less unfavorable, ankylosis of the thoracolumbar spine, and review of the other evidence of record dated from June 20, 2011, to include the VA outpatient treatment reports contained in the Virtual VA file dated through March 8, 2012, does not reflect lumbar ankylosis. The aforementioned records also do not demonstrate incapacitating episodes of IDS having a total duration of at least six weeks during a 12 month period. Thus, a rating in excess of 40 percent may not be assigned for the service connected lumbar spine disability for the period from June 20, 2011, under the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating IDS Based on Incapacitating Episodes. As for the assignment of an increased compensations on the basis of any associated neurologic impairment for either period of time in question, the Board has considered the Veteran's complaints of pain radiating to the lower extremities at both VA examination as well as on such VA outpatient visits as occurred on September 22, 2010, and on January 27, 2011, and February 2, 2011; the described associated bowel problems at the June 2011 VA examination and such outpatient visits as occurred on January 27, 2011, and February 2, 2011; and the associated erectile dysfunction described by the Veteran at the June 2011 VA examination. Also considered in this regard are the assertions of the Veteran's representative in her June 2013 presentation that increased compensation is warranted on the basis of radicular symptoms. These assertions notwithstanding, the neurological examinations conducted in conjunction with the June 2009 and June 2011 VA examinations were negative, and the Board otherwise finds the weight of the objective clinical evidence concerning the degree of neurologic involvement associated with the service-connected back disability, to include a December 10, 2011, (Virtual VA record) report from a visit to a VA emergency clinic for back pain that included a normal neurological examination, to be against a conclusion that increased compensation is warranted on the basis of neurologic impairment at any time during the appeal period. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 and the holdings in DeLuca and Mitchell, supra, the reports from the examinations conducted above document consideration of these principles, and there is no indication that increased compensation would be warranted under these principles. In short and based on the analysis above, the rating criteria for compensation in excess of 10 percent for degenerative arthritis of the lumbar spine prior to June 20, 2011, and in excess of 40 percent thereafter are not met. 38 C.F.R. § 4.71a, DC 5242. Right Knee Under DC 5260, a 10 percent rating is warranted for knee flexion limited to 45 degrees. A 20 percent rating under DC 5260 requires flexion to be limited to 30 degrees, and a 30 percent evaluation is warranted when flexion is limited to 15 degrees. Under DC 5261, a 10 percent rating is warranted for limitation of extension to 10 degrees. A 20 percent rating requires extension to be limited to 15 degrees, and a 30 percent evaluation is warranted when extension is limited to 20 degrees. The normal range of motion of the knee is from 140 degrees flexion to 0 degrees extension. 38 C.F.R. § 4.71, Plate II. In the event of a disability manifesting both limitation of flexion and limitation of extension, VA is to provide two separate ratings under DCs 5260 and 5261. See VAOPGCPREC 9-04, 69 Fed. Reg. 59990 (2004). Slight recurrent subluxation or lateral instability of a knee warrants a 10 percent rating under DC 5257. A 20 percent rating requires moderate recurrent subluxation or lateral instability, and a 30 percent evaluation is warranted for severe recurrent subluxation or lateral instability. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003/5010 and 5257, respectively. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604(1997). In VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998), the VA General Counsel further explained that, to warrant a separate rating, the limitation of motion need not be compensable under DC 5260 or 5261; rather, such limited motion must at least meet the criteria for a zero (0) percent rating. The service-connected status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis is rated under DCs 5010-5260, which reflects the fact, as set forth above, that disability due to arthritis is to be rated on the basis of limitation of motion. (Hyphenated Diagnostic Code numbers reflects the assignment of a rating under the first Diagnostic Code number using the criteria of the second Diagnostic Code. See 38 C.F.R. § 4.20.) The evidence pertinent to the compensation to be assigned for the service-connected right knee disability includes reports from the aforementioned June 2009 VA examination. At this examination, the Veteran reported constant pain in his right knee descried as crushing, sharp, sticking, and popping/slipping. On a scale from 1 to 10, the pain was described as being to the level of "10." The pain was said to be elicited by physical activity, and the Veteran stated even when taking pain mediation he finds it difficult to function. He descried the pain as being constant and reported the following symptoms: stiffness, giving way, lack of endurance, locking, and dislocation. He stated that he did not have weakness, swelling, heat, redness, redness, or fatigability. The Veteran reported functional impairment of not being able to walk any distance without resting, not being able to bend the leg at the knee when sitting at times, and not being able to lift due to pressure on the leg which resulted in severe pain. He reported that he must use a brace and cane. The physical examination of the right knee in June 2009 showed weakness, tenderness, and guarding of movement. There was no subluxation. Motion in the right knee was from full extension to 100 degrees of flexion with pain at 70 degrees of flexion and full extension. Functioning of the right knee was said to be additionally limited by the following after repetitive use: pain, fatigue, weakness, lack of endurance, and incoordination. Incoordination was said to have been the major functional deficit resulting from repetitive use but there was no additional limitation of motion with repetitive use. Testing showed all ligaments in the right knee and the meniscus to be stable. The examination of the right knee at a November 2010 VA examination showed tenderness and no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, misalignment, subluxation, or drainage. Motion in the right knee was from 70 degrees of flexion to full extension with pain at the end of flexion. Repetitive motion resulted in no additional limitation of motion, pain, fatigue, weakness, lack of endurance, or incoordination. Testing showed all ligaments in the right knee and the meniscus to be stable. At the June 2011 VA examination, the examination of the right knee showed instability, weakness, and tenderness. There were no signs of edema, abnormal movement, effusion, redness, heat, deformity, guarding of movement, misalignment, subluxation, or drainage. The right knee revealed an acquired Genu recurvatum with weakness and insecurity on weight bearing, locking pain, and crepitus. Examination of the "knee," (without specification as to which knee) was said to reveal no ankylosis. Motion in the right knee was to full extension and 80 degrees of flexion with pain at the extremes of each motion. Repetitive motion resulted in no additional limitation of motion, pain, fatigue, weakness, lack of endurance, or incoordination. The anterior and posterior ligaments were stable and the medial and lateral collateral ligaments demonstrated moderate instability. Knee instability (instability was shown in both knees at the examination) was said to result in occupational and daily activity effects of pain with walking and bending VA outpatient treatment reports reflect treatment for right knee pain, to include one dated May 19, 2010, which noted that the Veteran wore a knee brace when he did a lot of walking. Motion in the right knee at that time was to full extension and 122 degrees of flexion. The collateral and cruciate ligaments appeared to be intact. A September 10, 2010, report signed by a VA orthopedic surgeon recommended a hinge support brace for the right knee. A January 2012 VA outpatient treatment report contained in the Virtual VA file showed pain in the right knee with no significant swelling. The Board finds that a rating in excess of 10 percent is not warranted for the Veteran's service-connected status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis rated under DCs 5010-5260 at any time during the appeal period. In this regard, flexion in the right knee was shown by the clinical evidence above be to, at worst, 70 degrees. Therefore (as indicated, any disability due to traumatic arthritis is to be rated on the basis of limitation of motion under DC 5010), because a rating in excess of 10 percent under DC 5260 requires flexion to be limited to 30 degrees, a rating in excess of 10 percent cannot be assigned under DC 5260. The clinical evidence has also shown full extension in the right knee; therefore, a rating in excess of 10 percent for the right knee disability cannot be assigned under DC 5261. The examination reports also document consideration of the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 and the holdings in DeLuca and Mitchell, supra, and there is no indication that increased compensation would be warranted under these principles as such factors do not result in functional loss that more nearly approximates flexion or extension limited to a compensable degree. While the Veteran does not meet the criteria for even a zero percent rating based on limitation of flexion or extension, since there has been at least some limited and painful flexion, a 10 percent rating is warranted for the right knee under 38 C.F.R. § 4.59. As for increased compensation on the basis of instability under DC 5257, prior to the June 20, 2011, VA examination, the effective date for the grant of service connection for instability in the right knee granted by an August 2012 rating decision, no instability was shown in the right knee, thereby precluding a separate rating for instability prior to June 20, 2011 under DC 5257 and VAOPGCPREC 23-97. With respect to entitlement to a separate rating in excess of 20 percent for instability in the right knee from June 20, 2011, such a rating would require "severe" recurrent subluxation or lateral instability under DC 5257. The degree of instability described at the June 2011 VA examination was only moderate, and there is otherwise no clinical evidence indicating that the Veterans suffers from severe recurrent subluxation or lateral instability in the right knee so as to warrant a rating in excess of 20 percent under DC 5257 from June 20, 2011. The only other remaining DCs pertinent to the knee that would provide for a rating in excess of 10 percent are inapplicable. In this regard, as the medical records show no findings of ankylosis in the knee, a rating in excess of 10 percent cannot be assigned under DC 5256. There is also no evidence of dislocated cartilage with frequent episodes of locking, pain and effusion into the joint or malunion or non-union of the tibia or fibula, thereby precluding increased compensation under DCs 5258 or 5262, respectively. With respect to the finding at the June 2011 VA examination of acquired Genu recurvatum with weakness and insecurity on weight bearing, the maximum rating for such disability under DC 5263 is 10 percent, thus precluding increased compensation for this manifestation given the ratings for the right knee already in effect. Moreover, to the degree that the Genu recurvatum results in symptoms such as limitation of motion or instability, such symptomatology is already compensated by the ratings currently assigned; as such, a separate 10 percent rating for the Veteran's Genu recurvatum cannot be assigned as it would violate the principle against pyramiding, or compensating a claimant twice for the same symptomatology. Esteban, supra; Brady v. Brown, 4 Vet. App. 203, 206 (1993); 38 C.F.R. § 4.14. In short, from the above, the Board finds that the criteria for schedular ratings in excess of 10 percent for status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis or in excess of 20 percent for associated right knee instability from June 20, 2011, are not met. In making these determinations, the Board has considered the contentions of the Veteran's representative in her June 2013 presentation to the Board that increased compensation is warranted due to the fact that the Veteran wears a knee brace and utilizes a cane to ambulate and has symptoms to include severe pain with "additional tenderness and weakness." However, the objective findings in the right knee simply weigh against the assignment of compensation beyond that already assigned. C. Other Considerations The Board further finds that staged ratings for the Veteran's disabilities beyond those already assigned are not warranted as his symptomatology has remained stable throughout each time period during the appeal. See Hart, supra. In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and have been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. The Board has also contemplated whether the case should be referred for extra-schedular consideration for the disabilities at issue. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected disabilities at issue with the established criteria found in the rating schedule. The Board finds that the disabilities at issue are fully addressed by the rating criteria under which each such disability is rated. In this regard, the specific diagnostic criteria adequately address the whole of the Veteran's symptoms referable to his service-connected irritable bowel syndrome and lumbar spine and right knee disabilities. There are no additional symptoms of the service-connected disabilities at issue. In this regard, a wide range of signs and symptoms are contemplated in the applicable rating criteria for the Veteran's irritable bowel syndrome and lumbar spine and right knee disabilities. The service-connected lumbar spine and right knee disabilities require application of the holding in Deluca, supra, and Mitchell, supra, which, in turn, requires consideration of 38 C.F.R. §§ 4.40 and 4.45. 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation as well as any painful arthritic motion. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected disabilities addressed above. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating for either of the service-connected disabilities addressed above is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). "Because the VA disability rating schedule is designed to consider the disabling effect of disabilities separately, no single DC provision will adequately assess the variety of symptoms involved with multiple service-connected disabilities." Johnson v. Shinseki, No. 10-1785, slip op. at 10 (Vet. App. Mar. 27, 2013) (en banc). Thus, as to the question of "whether [38 C.F.R.] § 3.321(b)(1) requires VA to consider multiple service-connected disabilities on a collective basis" the Court held that it did not. Johnson v. Shinseki, No. 10-1785, slip op. at 4 (Vet. App. Mar. 27, 2013) (en banc) (noting that a concurring opinion in Brambley v. Principi, 17 Vet. App. 20, 27 (2003) that there should have been a determination of "whether the appellant's service-connected disabilities as a whole [sic] entitled [a Veteran] to [an extraschedular rating] under § 3.321(b)(1)" had never been adopted by the Court and concurring opinions are not binding on the Court" (citing Maryland v. Wilson, 519 U.S. 408, 412-13). Stated in other terms, an extraschedular rating may not be assigned for the cumulative impact of the service-connected disabilities herein at issue. Finally, the Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009) that a total rating based on individual unemployability due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Board observes that the Court has noted that VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to special monthly compensation (SMC) under 38 U.S.C.A § 1114. See Bradley, 22 Vet. App. 280, 294 (2008) (finding that SMC "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim"). Subsection 1114(s) requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under the law, subsection 1114(s) benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. The record reflects that the Veteran is currently in receipt of a TDIU based on his service-connected posttraumatic stress disorder, major depressive disorder, and panic disorder as of September 29, 2010, and SMC pursuant to 38 U.S.C.A § 1114(s) based on such 100 percent rating and additional disabilities independently ratable at 60 percent or more as of October 13, 2010. Therefore, the Board has considered whether the Veteran the issue of entitlement to a TDIU prior to September 29, 2010, has been raised. In this regard, while the Veteran has reported that he has been unemployed since December 2008, the evidence fails to show that the disabilities on appeal have rendered him unemployable. In this regard, the June 2009 VA examiner noted that, as relevant to the Veteran's lumbar spine, right knee, and irritable bowel syndrome disorders, the sole effect on his usual occupation is that he cannot bend without pain. Moreover, the award of the TDIU as of September 2010 was based solely on the Veteran's psychiatric disorders. There is no indication that his lumbar spine, right knee, and irritable bowel syndrome disorders rendered him unemployable prior to such date. Therefore, the issue of entitlement to a TDIU is not raised in the instant appeal and further consideration of such is not necessary. In sum, while entitlement to a 30 percent rating for irritable bowel for the entire appeal period is warranted, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for degenerative arthritis of the lumbar spine prior to June 20, 2011, and in excess of 40 percent thereafter; a rating in excess of 10 percent for status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis; and a separate rating in excess of 20 percent for right knee instability from June 20, 2011. Therefore, the benefit of the doubt doctrine is not applicable, and the increased rating claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert, supra. ORDER For the entire appeal period, a 30 percent rating for irritable bowel syndrome is granted, subject to regulations governing the payment of monetary awards. A rating in excess of 10 percent for degenerative arthritis of the lumbar spine prior to June 20, 2011, and in excess of 40 percent thereafter is denied. A rating in excess of 10 percent for status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis is denied. A separate rating in excess of 20 percent for right knee instability as of June 20, 2011, associated with status post anterior cruciate ligament tear of the right knee with degenerative arthritis and patellar tendonitis, is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs