Citation Nr: 1322701 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 09-22 977A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for a left knee disability, to include as secondary to the service connected right knee disability. 2. Whether new and material evidence has been received to reopen a claim for service connection for a back disability, to include as secondary to the service connected right knee disability. 3. Entitlement to service connection a left knee disability, to include as secondary to the service connected right knee disability. 4. Entitlement to service connection for a back disability, to include as secondary to the service connected right knee disability. 5. Entitlement to service connection for tendonitis of the bilateral feet and ankles, to include as secondary to the service connected right knee disability. 6. Entitlement to an increased rating greater than 30 percent for a right knee disability, status post total right knee replacement. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD H.J. Baucom, Associate Counsel INTRODUCTION The Veteran had active service from May 1967 to September 1967 These matters come to the Board of Veterans' Appeals (Board) from multiple rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. A December 2006 decision reopened and denied the claims for service connection for a back disability and left knee disability. A February 2008 rating decision denied an increased rating continuing the 30 percent rating for right knee disability, status post right knee replacement. A June 2011 decision denied service connection for tendonitis of the left and right ankles and feet. Irrespective of the RO's action, the Board must decide whether the Veteran has submitted new and material evidence to reopen the claims of service connection for a left knee disability and back disability. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In May 2013, a videoconference Board hearing was held at the RO before the undersigned; the transcript is of record. At the conclusion of the hearing, the Board left the record open for 30 days to allow the appellant to submit additional evidence. No additional evidence was received. FINDINGS OF FACT 1. In a May 1993 decision the Board denied service connection for a left knee disability. The decision is final. 2. Evidence submitted since the Board's May 1993 decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for left knee disability. 3. In a November 1991 rating decision, the RO denied service connection for a back disability. The Veteran did not appeal the decision. No new evidence was received within one year of the decision and no additional relevant service treatment records were received. The decision is now final. 4. Evidence submitted since the RO's November 1991 decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for a back disability. 5. The competent, credible evidence of record does not show that a left knee disability incurred in service or is related to any injury or disease in service. 6. The competent, credible evidence of record does not show that a back disability incurred in service or is related to any injury or disease in service. 7. The competent, credible evidence of record does not show that tendonitis of the bilateral feet and ankles was incurred in service or is related to any injury or disease in service. 8. Residuals of post right knee total arthroplasty are manifested by neither intermediate degrees of weakness, pain, or limitation of motion nor severe painful motion or weakness. CONCLUSIONS OF LAW 1. The May 1993 Board decision that denied entitlement to service connection for a left knee disability is final. 38 U.S.C.A. § 7104(a) (West 2002); 38 C.F.R. §§ 20.1100(a), 20.1104 (2012). 2. The criteria for reopening the claim for service connection for a left knee disability are met. 38 U.S.C.A. §§ 5108, 7104(b) (West 2002); 38 C.F.R. § 3.156 (2012). 3. The November 1991 rating decision denied service connection for a back disability. No evidence was received within one year of the rating decision and no additional relevant service records have been received. The decision is final. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.160(d) (2012). 4. The criteria for reopening the claim for service connection for a back disability are met. 38 U.S.C.A. §§ 5108, 7104(b) (West 2002); 38 C.F.R. § 3.156 (2012). 5. The criteria for service connection for a left knee disability, to include as secondary to the service connected right knee disability, have not been met. 38 U.S.C.A. 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 6. The criteria for service connection for a back disability, to include as secondary to the service connected right knee disability, have not been met. 38 U.S.C.A. 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 7. The criteria for service connection for tendonitis of the bilateral feet and ankles, to include as secondary to the service connected right knee disability, have not been met. 38 U.S.C.A. 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 8. The criteria for a rating higher than 30 percent for status post right knee total arthroplasty have not been met from November 1, 2007. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5055 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Letters dated April 2006, May 2006 and August 2010 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The notification also informed the Veteran of the evidence and information necessary to reopen the claim for service connection, including the basis on which the prior claim was denied in compliance with Kent v. Nicholson, 20 Vet. App. 1 (2006). The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained; he did not identify any additional private or VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). VA examinations were conducted in September 2006, November 2007 with clarification in January 2008, August 2010 and March 2011 with an addendum in June 2012; the Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examinations were adequate as the examiners reviewed the record, evaluated the Veteran and provided an opinion with supporting rationale as to the cause of the Veteran's current disabilities; the examiners also evaluated the Veteran's current disability level and provided findings to allow for proper application of the rating criteria. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). New and Material Evidence A November 1991 rating decision denied service connection for a back disability finding that a back disability was not secondary to the service connected right knee disability. No evidence was received within one year of the rating decision and no additional relevant service records have been received. The decision is final. 38 C.F.R. §§ 3.160(d) (2012). In a March 1993 decision the Board denied service connection for a left knee disability finding that there was no left knee disability. The decision is final. 38 C.F.R. §§ 20.1100(a), 20.1104 (2012). Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. Id. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108 . The regulations define 'new' evidence as existing evidence not previously submitted to agency decisionmakers. 'Material' evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273 (1996). Since the last final decisions an October 2009 medical opinion from Dr. SM was received who opined that there was a high likelihood that the original [right] knee injury in service caused the Veteran to develop arthritis in his knees and degenerative joint disease of the spine. This evidence is new and material as it was not of record at the time of the last decisions and it relates to a material element of each of the claims, specifically evidence that the left knee disability and back disability maybe secondary to the service connected right knee disability. As the information submitted since the last final decisions constitutes new and material evidence within the meaning of 38 C.F.R. § 3.156(a); reopening the claims is warranted. 38 U.S.C.A. § 5108. Service Connection Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. Arthritis is listed as a chronic diseases for purposes of presumptive service connection. 38 U.S.C.A. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). The applicable presumptive period is one year following separation from service. 38 C.F.R. § 3.307(a)(3). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Left knee disability The Veteran contends that his left knee disability is caused by his service connected right knee disability as he has altered his gait to accommodate his right knee, causing his left knee disability. The left knee was diagnosed with arthritis based upon x-rays. In September 2008 the Veteran had surgery to replace his left knee. The Veteran has a current left knee disability. The question is whether the right knee disability causes or aggravates the left knee disability. In September 2006, after evaluating the Veteran and the evidence of record, the VA examiner opined that the left knee arthritis is not at least as likely as not related to the right knee arthritis. Stating that he was not aware of any medical literature that confirms that arthritis of one knee caused arthritis in the other knee. In an October 2009 letter Dr. SM, a VA staff physician, opined that in view of the time course of events there is a high likelihood that the original knee injury in service lead over time to changes in posture and weight bearing and caused the Veteran to develop arthritis in his knees. In March 2011 a VA examination was conducted. The examiner evaluated the Veteran, reviewed the record and provided an opinion. The examiner noted that the Veteran underwent left total knee arthroplasty for degenerative arthritis, and the degenerative arthritis at this age group is ubiquitous in the general population. He reported that under certain conditions a right knee condition may cause degenerative arthritis of the contralateral knee, namely, as a result of a significant antalgic gait over a protracted period of time. He was unable to find documentation of such a limp in the medical record. Accordingly, it would be very difficult to attribute the degenerative condition of the left knee to the service connected right knee. Should evidence of a documented significant limp (not "alteration of biomechanics") be provided this opinion would have to be revisited. In response to Dr. SM's favorable opinion, the VA examiner opined that there was little medical science to support the conclusions made. The weight of the competent medical evidence is against the claim. The March 2011 VA examiner's opinion has greater probative value as the opinion is supported by a sound rationale with explanation that while a significant limp over a period of time may cause degenerative arthritis of the contralateral knee, in this case there is no evidence that the Veteran had a significant limp. Without a limp there is no means to connect one disability to the other. Dr. SM's opinion has less probative value as it is not supported by a rationale. In sum, the weight of the probative evidence does not show that the left knee disability is caused by or aggravated by the service-connected right knee disability. As such, service connection on a secondary basis is not warranted. The Veteran is competent to report what he experiences through his five senses, such as left knee pain. See, Layno v. Brown, 6 Vet. App. 465 (1994). Here, however, while the Board has carefully considered his lay contentions, the Board finds that the competent medical opinion evidence discussed above is more probative in resolving the issue of the relationship between the right and left knee disabilities. Service connection on a direct basis is also not warranted. There is no evidence of a left knee injury, or symptoms of a left knee disability, in service or within one year of service. There is no medical evidence to suggest that a left knee disability began in service or resulted in arthritis within one year of service; nor does the Veteran contend as much. The preponderance of the evidence is against the claim; there is no doubt to be resolved; and service connection for a left knee disability is not warranted. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Back disability The Veteran contends that his back disability is caused by his service connected right knee disability as he has altered his gait to accommodate his right knee, causing his back disability. A September 1991orthopedic evaluation determined that the Veteran's low back pain was in fact referred pain coming from the right knee joint with no history of injury to the back. In a November 2002 letter Dr. JK, one of the Veteran's treating physicians, reported on the extent of the Veteran's disabilities. Dr. JK reported that the Veteran was working as a bus driver when he was involved in a bus accident, in October 1996 which caused back neck and knee pain. In January 1997 it was determined that the Veteran had radiculopathy of the cervical spine and lumbosacral spine due to the bus accident. In July 1999 the Veteran was involved in another bus accident when his bus was rear-ended by a car which reaggravated his previous injuries. A MRI was taken in 1999 which showed degenerative disc disease in both spinal areas. Dr. JK reported that the Veteran had not been able to work since February 2001. In June 2006 Dr. JM noted that due to the altered gait from the service related knee injury the Veteran had developed right sciatica. At a September 2006 VA examination the Veteran reported that his low back pain had been present for the last ten years with a gradual onset and that he originally noticed low back pain when rehabilitating his knee. The examiner noted that a January 2003 MRI showed herniations at L5-S1 and L4-L5. The examiner opined that the degenerative disc disease of the low back and cervical spine were unrelated to the right knee problem as there is no evidence that these problems had been affected by the Veteran's right knee arthritis. In an October 2009 letter Dr. SM opined that in view of the time course of events there is a high likelihood that the original knee injury in service lead over time to changes in posture and weight bearing and caused the Veteran to develop degenerative joint disease of the spine. In March 2011 a VA examination was conducted. The examiner reviewed the record, noting that the Veteran was involved in a motor vehicle accident (MVA) in 1997 and that multiple progress notes and physical reports note the abrupt onset of low back pain following the MVA. The examiner opined that there is no relationship between the Veteran's service connected right knee condition and the Veteran's lumbosacral spine condition and disc protrusion with radiculopathy as both are caused by the MVA. The examiner noted that electrodiagnostic studies of the right lower extremity have been ordered but not completed as of yet but it was unlikely that those results would change the conclusion of the report unless an isolated peroneal nerve condition was diagnosed. A June 2012 addendum noted that the electrodiagnostic studies did not change the conclusion of the March 2011 report. The weight of the competent medical evidence is against the claim. The March 2011 VA examiner's opinion that the Veteran's back disability was due to the MVA and not the right knee disability, has greater weight as the VA examiner was aware of the Veteran's entire medical history as he had reviewed the claims folder. Although Doctors JM and SM provided opinions that the Veteran's back disability was due to the right knee, no rationale was provided and their opinions have less probative value. More importantly neither addressed the two bus accidents in 1997 and 1999 which caused back and neck injuries of such significance they prevented the Veteran from working for at least one 18 month stretch, February 2001 to November 2002. It is unclear whether either was even aware of the bus accidents, as the Veteran failed to report them at the September 2006 VA examination, instead reporting that his back disability had a gradual onset. Service connection on a secondary basis is not warranted. The Veteran is competent to report what he experiences through his five senses, such as back pain. See, Layno v. Brown, 6 Vet. App. 465 (1994). While his lay contentions have been considered, the Board finds that the March 2011 VA medical opinion is more persuasive in addressing the issue of the relationship between the service-connected knee disability and the low back disability. Service connection on a direct basis is also not warranted. There is no evidence of a back injury, or symptoms of a back disability, in service or x-ray evidence of arthritis within one year of service. In fact the Veteran affirmatively denies any back injury in service. The preponderance of the evidence is against the claim; there is no doubt to be resolved; and service connection for a back disability is not warranted. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Tendonitis of the bilateral feet and ankles The Veteran contends that he has bilateral tendonitis of the feet and ankles, secondary to his service connected right knee disability. As discussed above, although competent to report symptomatology and things he experiences through his five senses, the Veteran is not competent to render an opinion that his right knee disability caused bilateral tendonitis of the feet and ankles as this is outside the realm of common knowledge and would require medical knowledge or training. In an October 2009 letter Dr. SM opined that in view of the time course of events there is a high likelihood that the original knee injury in service lead over time to changes in posture and weight bearing and caused the Veteran to develop tendinitis in his feet and ankles. In August 2010 a joint examination diagnosed right and left foot arthritis based upon x-rays. The examiner opined that it is not at least as likely as not that the Veteran's feet and ankle complaints are related to the right knee condition with the rationale that a right knee replacement does not cause arthritis in the feet and it is more likely due to the normal aging process. In March 2011 a VA examination evaluated the Veteran and diagnosed insertional tendinitis peroneus brevis, right. The examiner noted prior treatment for multiple bilateral tendonopathies but the left sided symptoms have essentially resolved. The examiner explained that peroneal tendonopathy of the right is caused by peroneal muscle weakness which is caused by the Veteran's low back radiculopathy and is accordingly secondarily related to the MVA and not the service connected right knee condition. The examiner also opined that tendinopathy of the foot and ankle following total knee arthroplasty is distinctly uncommon. The examiner also addressed Dr. SM's opinion, stating that there was no medical science to support the conclusion. A June 2012 addendum concluded that the electrodiagnostic studies do not change the medical opinion of the March 2011 report and again opined that it was less likely as not that the peroneus brevis insertional tendinitis is caused by the Veteran's service connected total knee arthroplasty. The weight of the medical evidence is against the claim. The March 2011 VA examiner's opinion has greater weight then Dr. SM's opinion as it contains a convincing rationale. Service connection on a direct basis is also not warranted. There is no evidence of a back injury, or symptoms of a foot disability, in service or within one year of service nor does the Veteran contend as much. The preponderance of the evidence is against the claim; there is no doubt to be resolved; and service connection for tendonitis of the bilateral feet and ankles is not warranted. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Rating In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. 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, premature or excess fatigability, or incoordination is demonstrated, assuming these factors are not already 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). Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or reasonably by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). It is important to note that although pain may cause functional loss, pain itself does not constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (emphasis added). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided, as this would violate VA's anti-pyramiding regulation. 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). 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). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). While the Veteran is competent to offer evidence as to the visible symptoms or manifestations of a disease or disability, his belief as to its current severity under pertinent rating criteria is not probative evidence. Layno v. Brown, 6 Vet. App. at 470 (1994); Grottveit v. Brown, 5 Vet. App. at 92-93 (1993). The Veteran's right knee disability is rated under Diagnostic Code (DC) 5055, applicable to knee replacement (prosthesis). Under DC 5055, a 100 percent rating is warranted for one year following replacement implantation. Thereafter, where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is warranted. Where there are intermediate degrees of residual weakness, pain or limitation of motion, the disability is rated by analogy to DCs 5256, 5261 or 5262. The minimum rating is 30 percent. In November 2007 a VA examination of the right knee was conducted. The examiner noted the Veteran's subjective complaints of looseness and pain with marked improvement. He reported still needing a cane for some stability. Physical examination found no true rotatory instability to be present. Range of motion was from 0 to 100 degrees with pain at 100. There were no additional functional impairments due to pain, weakness, fatigability, incoordination or flare-ups. The range of motion was the same after three repetitions. A January 2008 file review explained that when the range of motion is written as 0 to 100 this means that extension is 0 degrees and flexion is 100 degrees. An October 2008 private treatment note found the range of motion of the right knee to be 0 degrees extension and 60 degrees flexion. At an August 2010 VA examination the Veteran reported a tendency for the right leg to give out. Range of motion findings were from 0 degrees extension to 115 degrees flexion with stiffness at 115. There was no additional functional impairment due to pain, weakness, fatigability, incoordination, or flare ups. No assisted devises were in place but the Veteran reported using a cane for stability primarily by history of his radiculopathy. In March 2011 a VA examination was conducted. The Veteran was noted to ambulate with a cane. Range of motion testing was from 0 to 95 degrees with no pain noted. No appreciable AP instability and 1+ medial instability at 30 degrees flexion. Slight medial instability of the right knee was noted but no subluxation. The examination findings did not indicate intermediate degrees of residual weakness, pain, or limitation of motion, or severe painful motion or weakness warranting a rating higher than 30 percent under DC 5055. Even if there were findings of intermediate degrees of weakness, pain or limitation of motion, a rating by analogy under DC 5256, 5260 or 5261 would result in a noncompensable rating. The minimal rating under DC 5055 is 30 percent. A rating higher than 30 percent for right knee replacement is not warranted. Extraschedular Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, a determination must be made as to whether the schedular criteria reasonably describe a veteran's disability level and symptomatology. Id. At 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, referral for extraschedular consideration is not required and the analysis stops. Id. If the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other related factors, such as marked interference with employment and frequent periods of hospitalization. Id. At 116. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The schedular evaluation in this case is adequate. Ratings in excess of that assigned are provided for certain manifestations of the service-connected right shoulder disability but the competent evidence reflects that those symptoms are not present in this case. The symptoms associated with the Veteran's right knee disability, status post knee replacement (i.e., slight instability) are not shown to cause any impairment that is not already contemplated by the relevant diagnostic code, as cited above, and the Board finds that the rating criteria reasonably contemplates this disability. ORDER New and material evidence has been received, the petition to reopen a claim for service connection for a left knee disability, to include as secondary to the service connected right knee disability, is granted. New and material evidence has been received, the petition to reopen a claim for service connection for a back disability, to include as secondary to the service connected right knee disability, is granted. Service connection a left knee disability, to include as secondary to the service connected right knee disability is denied. Service connection for a back disability, to include as secondary to the service connected right knee disability is denied. Service connection for tendonitis of the bilateral feet and ankles, to include as secondary to the service connected right knee disability is denied. An increased rating greater than 30 percent for a right knee disability, status post total right knee replacement, is denied. ____________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs