Citation Nr: 1322831 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 06-13 186 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an initial compensable rating prior to August 25, 2009, and a rating in excess of 10 percent since August 25, 2009, for a right knee disability. 2. Entitlement to an initial compensable rating prior to August 25, 2009, and a rating in excess of 10 percent since August 25, 2009, for a left knee disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran served on active duty from August 1978 to July 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2009. In July 2009 and April 2011, the Board remanded the appeal to the RO via the Appeals Management Center (AMC) for additional development. In a July 2012 decision, the Board denied an increased rating for the right knee disability and remanded the issue regarding the left knee disability. The Veteran appealed that Board decision to the United States Court of Appeals for Veterans Claims. Pursuant to a Joint Motion for Partial Remand, in an April 2013 Order, the Court remanded that part of the Board decision that denied an increased rating for the right knee disability for readjudication in accordance with the Joint Motion. In the remand portion of the July 2012 decision, the Board requested that the Appeals Management Center associate with the claims file any VA treatment reports dated after September 2010. A review of the claims file shows substantial compliance with the remand. FINDINGS OF FACT 1. Prior to August 25, 2009, the Veteran's right knee disability was not manifested by compensable limitation of motion, recurrent subluxation or lateral instability, and there was no x-ray evidence of arthritis. 2. Since August 25, 2009, there has been x-ray evidence of arthritis of the right knee joint and extension limited by 10 degrees. 3. Prior to August 25, 2009, the Veteran's left knee disability was not manifested by compensable limitation of motion, recurrent subluxation or lateral instability, and there was no x-ray evidence of arthritis. 4. Since August 25, 2009, there has been x-ray evidence of arthritis of the left knee joint and extension limited by 10 degrees. CONCLUSIONS OF LAW 1. Prior to August 25, 2009, a compensable rating was not warranted for the Veteran's right knee disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.71, 4.71a, Diagnostic Code 5003, 5010, 5014, 5257, 5260, 5261 (2012). 2. Since August 25, 2009, a rating in excess of 10 percent is not warranted for the Veteran's right knee disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.71, 4.71a, Diagnostic Code 5003, 5010, 5014, 5257, 5260, 5261 (2012). 3. Prior to August 25, 2009, a compensable rating was not warranted for the Veteran's left knee disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.71, 4.71a, Diagnostic Code 5003, 5010, 5014, 5257, 5260, 5261 (2012). 4. Since August 25, 2009, a rating in excess of 10 percent is not warranted for the Veteran's left knee disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.71, 4.71a, Diagnostic Code 5003, 5010, 5014, 5257, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and his or her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice requirements apply to all five elements of a service-connection claim, to include Veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's claims arise from an appeal of the initial evaluations following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, no further notice is needed. 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 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). In this case, all necessary development has been accomplished and therefore appellate review may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service medical records, and post-service reports of VA and private treatment and examination. The Veteran's statements in support of the claims are of record. The Board has carefully reviewed the statements and concludes that 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 claims. VA provided the Veteran with an examination in September 2004, September 2006, August 2009 and July 2011 to determine the nature and severity of his disabilities. 38 C.F.R. § 3.159(c)(4) (2012). When VA provides an examination or obtains an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the findings of the September 2006 and August 2009 examinations are inadequate. However, the Board finds the September 2004 and July 2011 examination reports to be thorough and adequate upon which to base decision on the claims. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information needed to evaluate the disabilities under the applicable rating criteria. Therefore, no further notice or assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). A veteran's entire history is to be considered when making disability ratings. 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When the veteran has disagreed with the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of staged ratings, the assignment of different ratings for distinct periods of time, is required. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings have been assigned in this case, and the Board will consider the possibility of whether further staged ratings are warranted. When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14 (2012); Esteban v. Brown, 6 Vet. App. 259 (1995). In this case, the Veteran contends that his knee disabilities warrant ratings higher than those assigned during the appeal period. At an April 2004 service retirement examination, the Veteran reported recurring pain in both knees and was found to have mild tenderness on the inferior patella areas of both knees. At a September 2004 VA joints examination, the Veteran reported recurrent bilateral knee pain aggravated by sudden weather changes, excessive bending, kneeling, squatting and climbing but not with ordinary standing or walking and denied additional limitation on repetitive use. He indicated no interference with his usual occupation. Range of motion testing revealed extension to 0 degrees and flexion to 140 degrees, bilaterally without tenderness, effusion, or instability. There was no additional limitation of motion on repetitive testing. X-rays revealed accessory ossification centers off the anterior patella bilaterally. The examiner assessed the Veteran with recurrent bilateral patellofemoral pain syndrome. A June 2006 VA treatment note shows complaints of bilateral knee pain and that examination revealed limited range of motion of the right shoulder but no knee effusion or inflammation. Gait was noted as being "ok." At a September 2006 VA joints examination, the Veteran reported bilateral knee pain relieved by Motrin and ice packs. The examiner indicated that there were no constitutional symptoms of arthritis and no incapacitating episodes of arthritis. The Veteran reported that he was able to stand for three to eight hours with only short rest periods and able to walk more than a quarter of a mile but less than one mile. Gait was noted as being antalgic which the examiner attributed to foot pain due to service-connected bilateral Achilles tendonitis. There was evidence of pain, stiffness, weakness, and flare-ups but not of deformity, giving way, instability, episodes of dislocation or subluxation, locking, or effusion. When asked about the extent of the effects of the flare-ups on limitation of motion or other functional impairment, the Veteran reported an increase in pain lasting for hours. Range of motion testing of the right knee revealed extension from 0 to -30 degrees and flexion from -30 to 120 degrees. Repetitive testing revealed extension from 0 to -20 degrees with no change in flexion. The left knee showed extension from -20 to 0 degrees and flexion from -20 to 120 degrees. Repetitive testing revealed extension from -10 to 0 degrees with no change in flexion. The examiner indicated that there was additional loss of motion on repetitive use. The examiner commented that the Veteran was reluctant to move his legs and would not allow passive or manual extension and flexion, the Veteran's legs were straighter while lying down, there was no flexion contraction, and most ranges of motion were decreased due to subjective pain beyond examination findings. The examiner assessed the Veteran with bilateral patellofemoral pain syndrome. The examiner indicated that the disabilities had significant effects on the Veteran's occupation, resulting in problems with lifting and carrying and decreased strength. A February 2008 VA treatment note shows complaints of bilateral knee pain but no objective findings. A note dated later that day shows that the Veteran exercised with weights three days per week and walked on a treadmill four days per week 30 minutes at a time. At the March 2009 Board hearing, the Veteran testified that his knee disabilities had worsened since the September 2006 VA examination. He indicated that at the time of that examination he had been able to run, play basketball, and ride his motorcycle, but that he had become unable to do those things due to his knee disabilities. At an August 2009 VA joints examination, the Veteran reported bilateral knee pain and that he could not kneel, squat, climb, or stand or walk for a prolonged time. He stated that he can walk less than one block, lift 20 pounds, and had pain on standing or walking more than 30 minutes. The examiner indicated that the Veteran limped due to heel pain. There was evidence of giving way, stiffness, weakness, and flare-ups, but no deformity, instability, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking, or effusion. When asked about the extent of the effects of the flare-ups on limitation of motion or other functional impairment, the Veteran indicated a loss of 20 degrees of flexion due to pain on repeated use. The examiner indicated that there were no constitutional symptoms of arthritis and no incapacitating episodes of arthritis. Range of motion testing revealed extension limited to -40 degrees and flexion to 90 degrees. The examiner noted that there was objective evidence of pain following repetitive motion but no additional limitations after repetitive testing. The examiner also indicated that there was guarding of movement. X-rays of the right knee revealed mild to moderate degenerative joint disease involving the medial and lateral joint compartments and those of the left revealed mild degenerative joint disease involving the medial joint compartment. The examiner assessed the Veteran with bilateral patellofemoral pain syndrome with degenerative joint disease. The examiner noted that the Veteran was not employed but indicated that his disabilities would result in decreased manual dexterity, problems with lifting and carrying, difficulty reaching, decreased strength, increased tardiness, and increased absenteeism. The August 2009 VA examiner submitted an addendum opinion in September 2010. The examiner indicated that the bilateral knee degenerative joint disease was part of the bilateral patellofemoral pain syndrome. The rationale was that patellofemoral syndrome was a progressive condition of the patella that affected the femur and the entire joint with degenerative joint disease as the eventual condition. At a July 2011 VA joints examination, the Veteran reported worsening knee pain. There was evidence of pain, deformity, giving way, stiffness, weakness, decreased speed of joint motion, swelling, locking, and flare-ups, but no evidence of instability, incoordination, or episodes of dislocation or subluxation. When asked about the extent of the effects of the flare-ups on limitation of motion or other functional impairment, the Veteran indicated a loss of 10 degrees of flexion and extension due to pain. The examiner indicated that there were no constitutional symptoms of arthritis and no incapacitating episodes of arthritis. The Veteran reported that he was unable to stand for more than a few minutes or walk more than a few yards. He was noted to ambulate with a cane with an antalgic gait and right knee stiffness. The examiner noted that the Veteran guarded to prevent movement of the right knee on range of motion testing. Range of motion testing found flexion to 130 degrees and extension limited by 10 degrees bilaterally. The examiner indicated there was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions. The examiner diagnosed the Veteran with bilateral degenerative joint disease of the knee with patellofemoral pain syndrome. The examiner noted that the Veteran had been working full-time for less than one year and had lost no time from work during that time. The examiner indicated that the disabilities had significant effects on the Veteran's occupation as a supply technician, resulting in decreased mobility, problems with lifting and carrying, difficulty reaching, lack of stamina, weakness or fatigue, pain, and disfigurement. Prior to August 25, 2009, the Veteran's right knee disability was rated 0 percent disabling under Diagnostic Code 5099-5014 by analogy to osteomalacia. 38 C.F.R. § 4.71a (2012). Since August 25, 2009, the Veteran's right knee disability has been rated as 10 percent disabling under Diagnostic Code 5010-5014 for traumatic arthritis and osteomalacia. 38 C.F.R. § 4.71a (2012). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 5014 provides that osteomalacia is to be rated based on limitation of motion of the affected body part, as degenerative arthritis, except gout which will be rated under Diagnostic Code 5002. 38 C.F.R. § 4.71a (2012). Diagnostic Code 5010 pertains to arthritis due to trauma and indicates that the disability should be rated under Diagnostic Code 5003 (degenerative arthritis), which provides that degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. When the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. A 20 percent rating is warranted for x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Ratings for arthritis are not to be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Normal knee joint motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2012). The words slight, moderate, and severe are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2012). Use of descriptive terminology such as mild by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. Separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee. Where a veteran has both compensable limitation of flexion and compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (2004), 69 Fed. Reg. 59990 (2005). Separate ratings may also be assigned for arthritis or limitation of motion and instability of the knee. However, a separate rating must be based on additional compensable disability. VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). The Board finds that neither the Veteran's right nor left knee disability warrants a compensable rating prior to August 25, 2009, or a rating in excess of 10 percent since August 25, 2009. Initially, the Board notes that the x-rays taken during the August 25, 2009 VA examination provide the first evidence of arthritis in either knee. Thus, the earliest date the 10 percent rating based on x-ray evidence of arthritis can be assigned is August 25, 2009. Moreover, as each knee, a major joint, has been assigned a 10 percent rating, Diagnostic Code 5010 does not provide for an even higher rating. To the extent that the arthritis of the medial and lateral joint compartments in the right knee shows arthritis of two minor joint groups, there is no evidence that the right knee disability has resulted in incapacitating exacerbations. The September 2006, August 2009, and July 2011 VA examiners specified that there were no incapacitating episodes. Thus, a higher 20 percent rating is not warranted. The Board will now turn to the diagnostic codes pertaining specifically to the knees. Initially, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5258 (dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint), 5259 (removal of symptomatic semilunar cartilage), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable because the Veteran's knee disabilities are not manifested by any of the disabilities or symptoms associated with those diagnostic codes. Diagnostic Code 5257 pertains to other impairment of the knee caused by recurrent subluxation or lateral instability. A 10 percent rating is warranted when slight. A 20 percent rating is warranted when moderate. A 30 percent rating is warranted when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The examinations of record do not show findings consistent with recurrent subluxation or lateral instability of either knee. While the August 2009 and July 2011 VA examiners noted complaints of giving way, on examination the examiners specifically indicated that there was no instability. Thus, the Board finds that an increased rating is not warranted for either knee disability under Diagnostic Code 5257 at any time during the pendency of the appeal because the objective medical evidence does not show recurrent instability or subluxation. Diagnostic Code 5260 pertains to limitation of flexion. Flexion limited to 60 degrees warrants a 0 percent rating. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). The examinations of record reveal flexion limited to no worse than 90 degrees for either knee, which does not warrant a compensable rating for either knee disability under Diagnostic Code 5260 at any time during the appeal period. Diagnostic Code 5261 pertains to limitation of extension. Limitation of extension of the leg to 5 degrees warrants a 0 percent rating. A 10 percent rating requires that extension be limited to 10 degrees. A 20 percent rating requires that extension be limited to 15 degrees. A 30 percent rating requires that extension be limited to 20 degrees. A 40 percent rating requires that extension be limited to 30 degrees. A 50 percent rating requires that extension be limited to 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Before proceeding with the analysis under Diagnostic Code 5261, the Board finds it necessary to discuss the findings contained in the September 2006 and August 2009 VA examination reports. The Board observes that the September 2006 VA examination found right knee extension limited to 30 degrees, 20 degrees after repetitive testing, and left knee extension limited to 20 degrees, 10 degrees after repetitive testing. However, the Board finds those figures to be unreliable and thus inadequate for rating purposes. In support of that finding, the Board notes the examiner's comments that the Veteran was reluctant to move his knee joints, that the Veteran would not allow passive or manual extension, that the Veteran's legs were straighter while lying down, that there was no flexion contraction, and that range of motion was decreased due to subjective pain beyond examination findings. The above comments indicate that the examination was not indicative of the Veteran's true disability picture with respect to limitation of extension. The Board also notes that the Veteran's ability to extend the knees actually improved after repetitive testing, contrary to expectation and further indicating the Veteran's attempt to prevent movement of his knees, perhaps subconsciously due to anticipated pain. Although the Veteran's gait was noted as being antalgic, the examiner attributed that to foot pain. Considering the Veteran's functional abilities as reported at that examination, being able to stand for three to eight hours with only short rest periods and walk more than a quarter of a mile, the Board observes that the above would be difficult with his right and left knees unable to straighten by 30 and 20 degrees, respectively. Therefore, the Board finds that those findings are not adequate for rating purposes. Other evidence of record also supports the Board's finding on the unreliability and inadequacy of the extension figures of the September 2006 examination. The June 2006 VA treatment note showing the Veteran's gait as adequate does not indicate an inability to extend the leg. The February 2008 VA treatment note shows that he regularly exercised with weights and walked on a treadmill. At the March 2009 Board hearing, he testified that at the time of the September 2006 examination he had been able to run, play basketball, and ride his motorcycle. The Board observes that engaging in the above would be difficult with his knees unable to straighten by 30 and 20 degrees. Lastly, although the Veteran has been treated at a VA medical center since September 2004, there is not one mention of an inability to extend or straighten his legs, a finding that the Board observes would be obvious to and be noted by any healthcare provider. With respect to the August 2009 VA examination findings, the Board observes that right knee extension was limited to 40 degrees and left knee extension was limited to 30 degrees. However, the Board also finds those figures to be unreliable and thus inadequate for rating purposes. The Board notes the examiner's comment that the Veteran was guarding his movements, which indicates that the examination was not indicative of his true disability picture. The Board again notes that the Veteran may have been guarding subconsciously due to anticipated pain. However, the resultant findings are not indicative of his actual disability picture. When asked about the effects of his flare-ups, the Veteran only indicated a loss of 20 degrees of flexion, with no mention of any loss of extension. If the Veteran had a loss of 40 and 30 degrees of extension, one would assume that he would have mentioned that in describing the effect of flare-ups. Although the Veteran's gait was noted as being antalgic, the examiner indicated that was due to heel pain and not due to the Veteran's inability to straighten his legs. The Board observes that, on a practical level, someone whose knees are unable to straighten by 40 degrees would have an extremely difficult time walking. The Board reiterates that, although the Veteran has been treated at a VA medical center since shortly after discharge from service, there is no mention of his inability to fully extend or straighten his legs, a finding that the Board observes would be noted in his treatment records. Lastly, although the Veteran indicated at the subsequent July 2011 VA examination that his knee disabilities had progressively worsened, extension was only limited to 10 degrees at that time, and there was no mention during either the September 2006 or August 2009 examination that he was having a flare-up at either time that would have accounted for the findings. Therefore, the Board concludes that the extension findings in the September 2006 and August 2009 VA examination reports are inadequate for rating purposes and will not be used. The Board acknowledges that the Veteran's disabilities cause him pain. However, due to his failure to provide full effort during the examinations, VA has been unable to obtain the needed range of motion findings. The Board observes that VA's duty to assist is not a one-way street; the veteran has an obligation to assist in the adjudication of his claims. Wood v. Derwinski, 1 Vet. App. 190 (1991). Due to the Veteran's failure to cooperate, the above examination findings with respect to extension are inadequate and his claims will be adjudicated based on the other evidence of record. Returning to the analysis of the Veteran's knee disabilities under Diagnostic Code 5261, the findings of the September 2004 VA examination are consistent with a noncompensable limitation of extension for each knee, but the findings of the July 2011 VA examination are consistent with a 10 percent rating as extension was limited to 10 degrees in each knee at that time. However, the Veteran is already in receipt of a 10 percent rating for arthritis in each knee. Ratings for arthritis cannot be combined with ratings based on limitation of motion. Thus, the Board finds that a rating in excess of 10 percent is not warranted under Diagnostic Code 5261. In conclusion, the Board finds that higher initial ratings are not warranted for the Veteran's right and left knee disabilities at any time during the appeal period. As the preponderance of the evidence is against each claim, the claims must be denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The Board must also determine whether the schedular ratings are inadequate, thus requiring a referral of the claim to the Under Secretary for Benefits or Director of Compensation and Pension Service for consideration of an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disabilities. 38 C.F.R. § 3.321(b)(1) (2012). An extraschedular rating is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111 (2008). When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular rating is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the Board finds that the schedular ratings are adequate. Ratings in excess of those assigned are provided for certain manifestations of the Veteran's service-connected knee disabilities, but the medical evidence shows that those manifestations are not present in this case. Additionally, the diagnostic criteria reasonably describe the severity and symptomatology of the disabilities. As the rating schedule is adequate to rate the disabilities, referral for extra-schedular consideration is not warranted. Moreover, the evidence of record does not show that the Veteran's service-connected knee disabilities markedly interfere with employment, beyond that contemplated in the assigned ratings. The Veteran indicated no interference with employment at the September 2004 examination. Although the September 2006 VA examiner indicated that the disabilities had significant effects on occupation, the resulting impairments were only noted as problems lifting and carrying and decreased strength, which are reasonably contemplated by the diagnostic criteria. Although the August 2009 VA examiner indicated that the disabilities would result in increased tardiness and absenteeism, those effects are also contemplated in the schedular rating. Moreover, the Veteran was not working at that time and so there is no documentation of any actual tardiness or absenteeism. Although the record indicates that the Veteran's employer changed his duty station, the Veteran testified that that change was due to his service-connected right shoulder disability. Finally, although the July 2011 VA examiner indicated that the disabilities had a significant impact on employment, the resulting impairments were only noted as decreased mobility, problems with lifting and carrying, difficulty reaching, lack of stamina, weakness or fatigue, pain, and disfigurement, all of which are reasonably contemplated in the schedular ratings. Moreover, that the Veteran returned to work full-time and lost no time from work indicates that his disabilities have not resulted in marked interference with employment. The evidence also does not show that his knee disabilities warrant frequent periods of hospitalization. Lastly, although the Veteran has submitted evidence of a medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable. At the August 2009 examination, he reported that he had retired due to age or duration of work. At the July 2011 examination, he reported that he had returned to work full-time. Thus, the question of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities has not been raised. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER An initial compensable rating prior to August 25, 2009, and a rating in excess of 10 percent since August 25, 2009, for a right knee disability is denied. An initial compensable rating prior to August 25, 2009, and a rating in excess of 10 percent since August 25, 2009, for a left knee disability is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs