Citation Nr: 1323318 Decision Date: 07/22/13 Archive Date: 08/01/13 DOCKET NO. 09-46 700A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an increased disability rating for lumbar spinal spondylolisthesis, currently evaluated as 10 percent disabling. 2. Entitlement to an increased disability rating for status post partial medial meniscectomy with anterior cruciate ligament (ACL) reconstruction of the right knee, currently evaluated as 10 percent disabling. 3. Entitlement to an increased disability rating for degenerative arthritis of the right knee, currently evaluated as 30 percent disabling. 4. Entitlement to an increased disability rating for status post partial medical meniscectomy of the left knee, currently evaluated as 10 percent disabling. 5. Entitlement to a total disability rating, based on individual unemployability, due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from March 1984 to March 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. By that rating action, the RO continued 20 and 10 percent disability ratings assigned to the service-connected postoperative residuals, medial meniscectomy and anterior cruciate ligament reconstruction of the right knee and degenerative arthritis of the right knee, respectively; continued a 10 percent disability rating for status post partial medical meniscectomy of the left knee; awarded service connection for a low back disability and assigned an initial evaluation of 10 percent, effective January 20, 2006; and, denied service connection for bilateral plantar fasciitis, to include as secondary to the service-connected right and left knee disabilities. The Veteran appealed this rating action to the RO. By an October 2009 rating action, the RO assigned a 30 percent disability rating to the service-connected degenerative arthritis of the right knee and 10 percent rating to the service-connected status-post medial meniscectomy with ACL reconstruction of the right knee; a total combined 40 percent disability rating was assigned to the right knee. In view of these actions, the increased rating issues with respect to the right knee have been framed as those listed on the title page. In April 2012, the Veteran testified before the undersigned at the Chicago, Illinois RO. A copy of the hearing transcript has been associated with the claims files. In September 2012, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. In an April 2013 rating decision, the RO granted service connection for bilateral plantar fasciitis, secondary to the service-connected postoperative residuals, medial meniscectomy and anterior cruciate ligament reconstruction of the right knee. A 10 percent evaluation was assigned, effective March 18, 2013. This was a full grant of the benefit sought with regard to that issue. Grantham v. Brown, 114 F .3d 1156 (Fed. Cir. 1997). The issue of entitlement to a disability rating in excess of 10 percent for bilateral plantar fasciitis has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See May 2013 statement from the Veteran. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's lumbar spondylolisthesis is manifested by forward flexion of the lumbar spine limited to 50 degrees, with consideration of functional impairment and symptoms of pain; the Veteran has had no periods of physician prescribed bed rest; there is no favorable or unfavorable ankylosis of the entire thoracolumbar spine; and there are no separately ratable neurological abnormalities. 2. The Veteran's right knee degenerative arthritis is manifested by limitation of flexion and extension; flexion is not limited to less than 60 degrees, and extension is not limited to more than 20 degrees. 3. The status post partial medial meniscectomy with ACL reconstruction of the right knee is manifested by no more than slight lateral instability; there is no recurrent subluxation. 4. For the period prior to February 23, 2009, the Veteran's status post partial medical meniscectomy of the left knee was manifested by subjective complaints related to symptomatic removal of the semilunar cartilage, including pain, popping, swelling, effusion, and giving out; limitation of flexion, which was not limited to less than 60 degrees; and limitation of extension, which was not limited to more than 5 degrees. 5. For the period beginning February 23, 2009, the Veteran's status post partial medical meniscectomy of the left knee was manifested by subjective complaints related to symptomatic removal of the semilunar cartilage, including pain, popping, swelling, effusion, and giving out; limitation of flexion, which was not limited to less than 60 degrees; and limitation of extension to 10 degrees, with consideration of functional impairment and symptoms of pain. 6. For the period beginning March 18, 2013, the Veteran's status post partial medical meniscectomy of the left knee is manifested by frequent episodes of "locking," pain, and effusion into the joint; no more than slight lateral instability; there is no recurrent subluxation; limitation of flexion, which was not limited to less than 60 degrees; and limitation of extension to 10 degrees, with consideration of functional impairment and symptoms of pain. CONCLUSIONS OF LAW 1. The criteria for a 20 percent rating, but no higher, for lumbar spinal spondylolisthesis, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R §§ 4.7, 4.71a, Diagnostic Code 5237, 5242, 5243 (2012). 2. The criteria for a disability rating in excess of 30 percent for right knee degenerative arthritis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256, 5257, 5858, 5259, 5260, 5261, 5262, 5263 (2012). 3. The criteria for a disability rating in excess of 10 percent for status post partial medial meniscectomy with ACL reconstruction of the right knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, , 4.71a, Diagnostic Codes 5256, 5257, 5858, 5259, 5260, 5263 (2012). 4. For the period prior to February 23, 2009, the criteria for a disability rating in excess of 10 percent for the status post partial medical meniscectomy of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, , 4.71a, Diagnostic Codes 5257, 5258, 5259, 5260, 5261 (2012). 5. For the period beginning February 23, 2009, the criteria for a separate 10 percent rating, but no higher, for limitation of motion of the left knee, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, , 4.71a, Diagnostic Codes 5260, 5261 (2012). 6. For the period beginning March 18, 2013, the criteria for a 20 percent rating, but no higher, for the status post partial medical meniscectomy of the left knee, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, , 4.71a, Diagnostic Codes 5257, 5258, 5259, 5260, 5261 (2012). 7. For the period beginning March 18, 2013, the criteria for a separate 10 percent rating, but no higher, for slight instability of the left knee, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, , 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA 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. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court had held that at a minimum, adequate VCAA notice in an increased rating claim required that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazques-Flores v. Peake, 22 Vet. App. 37 (2008). The Federal Circuit has overturned the requirement that VA provide notice that the claim could be substantiated by evidence of a disability's impact on daily life and that VA provide notice with regard to potential diagnostic code criteria (element 2). Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1280 (Fed. Cir. 2009). In a January 2006 letter, issued prior to the initial adjudication of the claims, the RO or AMC notified the Veteran of the evidence needed to substantiate his claims for increased ratings. The letter told the Veteran that he could substantiate the claims with evidence that the disability had worsened. It satisfied the second and third elements of the duty to notify by informing the Veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The Veteran has substantiated his status as a Veteran. He was notified of all elements of the Dingess notice, and the surviving elements of Vazquez-Flores notice, including the disability-rating and effective-date elements of the claims, in a March 2006 letter and a February 2009 letter. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, VA's notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. There was a timing deficiency in that the March 2006 and February 2009 letters were sent after the initial adjudication of the claims. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The timing deficiency was cured by readjudication of the claims in supplemental statements of the case issued in October 2009 and April 2013, as well as a rating decision in October 2009. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c), (d) (2012). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4) (2012). VA has obtained records of treatment reported by the Veteran, including service treatment records, and VA and private treatment records. Additionally, the Veteran was provided VA examinations in June 2006, August 2006, February 2009 and March 2013, for his right and left knee disabilities and his low back disability, and there is no evidence or contention that there has been a change in the Veteran's symptoms since the last examination in March 2013. The duty to assist does not require that a claim be remanded solely because of the passage of time since otherwise adequate VA examinations were conducted. See VAOPGCPREC 11-95 (April 7, 1995). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2011); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) . The Board remanded the case in September 2012 to obtain relevant VA treatment records dated since 2004, as well as any available records from the Social Security Administration (SSA), and to afford the Veteran additional examinations to evaluate the severity of his right and left knee disabilities and his low back disability. The available additional VA treatment records were obtained and the SSA indicated that the Veteran's records were destroyed. The Veteran was afforded VA examinations in March 2013. The remand instructions were thereby complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Furthermore, as noted above, the Veteran presented testimony before the undersigned. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. General Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5010. Pursuant to DC 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each 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, the disability is to be rated as follows: with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59 (2012). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The Veteran's entire history is to be considered when making a disability determination. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). This includes consideration of the evidence pertaining to the level of disability from the time period one year before the claim was filed. 38 U.S.C. § 5110. In addition, the Court has determined that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). Low Back Disability Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area of the spine affected by the residuals of injury or disease, a 10 percent evaluation is warranted for disability of the thoracolumbar spine when 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 spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, 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 40 percent evaluation is warranted for disability of the thoracolumbar spine when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling, and unfavorable ankylosis of the entire spine is evaluated as 100 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5237 (2012). Note (1) permits the evaluation of any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 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 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. Each range of motion measurement should be rounded to the nearest five degrees. See Plate V, 38 C.F.R. § 4.71 and 38 C.F.R. § 4.71a, Notes (2) and (4). 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. 38 C.F.R. § 4.71a, Note (3). 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 dysphasia; 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. 38 C.F.R. § 4.71a, Note (5). Intervertebral disc syndrome is to be evaluated either under the general rating formula for diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. For intervertebral disc syndrome manifested by incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent evaluation is warranted; with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent evaluation is warranted; and with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent evaluation is warranted. Note one states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Analysis In an October 2006 rating decision, the RO granted service connection for degenerative spondylolisthesis, L5-S1, secondary to the service-connected bilateral knee disabilities, with an evaluation of 10 percent, effective January 10, 2006. The Veteran was afforded a VA examination of his spine in June 2006, in response to his claim for an increased rating. The Veteran complained of intermittent low back pain and denied lower extremity weakness or radiating pain, erectile dysfunction or incontinence. He reported that he was receiving regular chiropractic services, which helped, and that he was not taking any prescribed medication for his back. He complained of flare-ups of back pain once a month, which lasted for 1-2 days, and caused his movements and activities to be slowed down. The Veteran also reported that his back disability caused him to move slower when performing activities of daily living, including working, but that he was still able to perform them. He also reported that he walked unaided, and his walking was not limited by his back disability, but he also noted that he wore a back brace as needed. On physical examination, the examiner noted that the Veteran was able to flex to 80 degrees, rotate to 30 degrees on the left and right, and perform lateral flexion to 30 degrees on the left and right. However, the examiner stated the extent (if any) to which range of motion was additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups, was unknown. Furthermore, he failed to note at which point the Veteran experienced pain during range of motion testing. 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). Painful motion can equate to limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Accordingly, the Board finds that the June 2006 examination results are inadequate for rating purposes. The Veteran was afforded another VA examination of the spine in February 2009. The Veteran complained of knife-like pain across the lower back, and popping in the back. He also indicated that his back pain made it hard to bend over and that he was unable to walk more than a few yards. He also complained of numbness down the sides of his hips and hotness and numbness down the thighs into the knees, and pins and needles feelings in the back. He reported that chiropractic care and heat helped alleviate the pain, and that he occasionally wore a supportive back brace if his back hurt very badly, and that at times, he would sleep with it on. He denied any incontinence, erectile dysfunction, leg or foot weakness, falls, or unsteadiness, but complained of numbness, as noted above, and paresthesias. He also denied any fatigue or weakness, but complained of decreased motion, stiffness, spasms, and pain. On physical examination, the Veteran's pelvis was tilted, but his head position was normal and there was symmetry in appearance. The examiner also noted that he had an antalgic gait favoring the right knee. With regard to abnormal spinal curvatures, the examiner noted that there was lumbar flattening, but no lordosis, scoliosis or ankylosis. He also noted that there was guarding and pain with motion on the left and right of the thoracic spine. Range of motion testing showed that the Veteran was able to flex to 75 degrees, extend to 20 degrees, demonstrate left lateral flexion to 25 degrees and right lateral flexion to 20 degrees, and demonstrate left lateral rotation to 30 degrees and right lateral rotation to 30 degrees. He noted that there was objective evidence of pain on active range of motion, but failed to note at which point the Veteran actually experienced pain. Furthermore, although the examiner noted that there were no additional limitations after three repetitions of range of motion, he did not specifically note whether range of motion was additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. Accordingly, the Board finds that the February 2009 VA examination results are also inadequate for rating purposes. See DeLuca and Lichtenfels. The Veteran was afforded his most recent VA examination of the spine in March 2013. The Veteran complained of low back pain, which radiated to both legs. He denied any incontinence, or any physical therapy or injections for his back, incapacitating episodes , ordered bedrest, or hospitalizations. He also complained of flare-ups of back pain. On physical examination, there was no deformity of the spine. The Veteran's gait was slightly antalgic on weightbearing on the right side, and tandem walk heel to toe and walking on toes and heels was difficult, but due to knee pains. The examiner also noted that the Veteran was not distressed during the examination, and the Veteran was able to sit, bend over to reach his shoes and dress and undress without significant problems other than the above-noted antalgic gait. There was no localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine, no guarding, muscle spasm or muscle atrophy, and muscle strength testing was normal. Reflex and sensory examinations were normal; straight leg raising test was negative on the left and right, and there was no evidence of radiculopathy or any other neurological abnormalities. The examiner also noted that the Veteran did have intervertebral disc syndrome, but he had not had any incapacitating episodes over the past 12 months, due to the intervertebral disc syndrome, and he did not use any assistive devices as a normal mode of locomotion. During range of motion testing, the Veteran was able to forward flex to 70 degrees, with pain noted at 50 degrees. Extension, lateral flexion on the left and right, and lateral rotation on the left and right were all normal, with no evidence of painful motion. The examiner noted that there was no additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing, however there was functional loss and/or functional impairment of the thoracolumbar spine, in that he had less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing and/or weight-bearing. As noted above, during range of motion testing during the March 2013 VA examination, the only examination of record with adequate test results for the low back disability, the Veteran was able to forward flex to 70 degrees, but pain was noted at 50 degrees. Painful motion can equate to limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Furthermore, the Veteran has reported functional impairment as a result of his low back disability, and the examiner found that there was functional loss and/or functional impairment of the thoracolumbar spine following repetitive-use testing. Resolving reasonable doubt in the Veteran's favor the Board finds that his range of forward flexion most closely approximates 50 degrees, and meets the criteria for a 20 percent rating under the general rating formula for diseases and injuries of the spine. 38 C.F.R. §§ 4.7, 4.21. back disabilities. 38 C.F.R. §§ 4.7, 4.21. However, even with consideration of all pertinent disability factors, none of the evidence supports a finding that the Veteran's functional impairment more nearly approximates an evaluation of 40 percent under the general rating formula. In this regard, the Board notes that during his examination in March 2013, the Veteran was able to flex significantly more than 30 degrees, even with consideration of pain, which the examiner noted limited his range of motion. Furthermore, there was no evidence of ankylosis of the spine, in that the Veteran still maintained significant motion of the lumbar spine. The private treatment records do not show that the Veteran had limitation of motion commensurate with a 40 percent rating during this period either. The Board also notes that although the Veteran complained of numbness down the sides of his hips and hotness and numbness down the thighs into the knees, and pins and needles feelings in the back on examination in February 2009, and back pain that radiated to his legs on examination in March 2013, there is no objective evidence of any neurological abnormalities. See February 2009 and March 2013 VA examination reports. The Veteran has complained of functional impairment, in that he has trouble bending over and walking for an extended period of time. He has also reported that his ability to perform activities of daily living, including working, is affected by his back disability because it causes him to move slower. He also reported that he wore a back brace to support his back. However, during examination, he has also reported that chiropractic care and heat helped alleviate the pain, as well as over-the-counter pain medications, such as Ibuprofen. He also reported that he was not taking any prescribed medication for his back. Furthermore, the March 2013 VA examiner noted that the Veteran was not distressed during the examination, and the Veteran was able to sit, bend over to reach his shoes and dress and undress without significant problems other than the noted antalgic gait, which was due to his right knee disability. The Board also notes that although he reported using a back brace, the Veteran did not require the use of an assistive device for walking, due to his low back disability. The Board also finds that a higher rating is not available under the formula for rating intervertebral disc syndrome based on incapacitating episodes, as there is no evidence of record of any incapacitating episodes with physician-prescribed bed rest due to the Veteran's lumbar spine disability. In fact, as noted above, the Veteran denied experiencing any incapacitating episodes during his VA examination in March 2013. See 38 C.F.R. § 4.71a, Diagnostic Code 5243. Based on this evidence, the Board cannot conclude that the criteria for the assignment of a 40 percent disability evaluation at any time during the pendency of this appeal has been demonstrated. Extraschedular Consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation 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 as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The Veteran's low back disability, as discussed above, is manifested by symptomatology contemplated by the rating criteria which have been applied in this case. These rating criteria also take into account the pain and limitation of function reported in the record. The Veteran has not reported any symptoms outside of those contemplated by the rating schedule. Hence, referral for consideration of an extraschedular rating is not warranted. In reaching this conclusion the Board has resolved reasonable doubt in the Veteran's favor, where applicable. 38 U.S.C.A. § 5107(b) (West 2002). Left and Right Knee Disabilities Limitation of flexion of a leg warrants a noncompensable evaluation if flexion is limited to 60 degrees, a 10 percent evaluation if flexion is limited to 45 degrees, a 20 percent evaluation if flexion is limited to 30 degrees, or a maximum 30 percent evaluation if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of a leg warrants a noncompensable evaluation if extension is limited to 5 degrees, a 10 percent evaluation if extension is limited to 10 degrees, a 20 percent evaluation if extension is limited to 15 degrees, a 30 percent evaluation if extension is limited to 20 degrees, a 40 percent evaluation if extension is limited to 30 degrees, or a maximum 50 percent evaluation if extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Ankylosis of a knee warrants a 30 percent evaluation if it is at a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Knee impairment with recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight, a 20 percent evaluation if it is moderate, or a maximum 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint will be rated maximum 20 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Removal of the semilunar cartilage, if symptomatic, will be rated a maximum 10 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5259. The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (July 1, 1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (Aug. 14, 1998). The VA General Counsel also held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (Sept. 17, 2004). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Evidentiary Background In a December 1988 rating decision, the RO granted service connection for status post, right medial meniscectomy of the right knee, with a 10 percent evaluation, effective March 26, 1988, under Diagnostic Code 5257, for instability of the right knee. In a July 1997 rating decision, the RO granted a temporary total evaluation (TTE) based on treatment requiring convalescence for the service-connected status post, right medial meniscectomy of the right knee from May 30, 1997 to July 31, 1997, 1997. A 10 percent evaluation was continued from August 1, 1997. In a September 1997 rating decision, the RO granted a TTE for the service-connected status post, right medial meniscectomy of the right knee from May 30, 1997 to October 1, 1997. In an August 1998 rating decision, the RO granted an increased rating of 20 percent for the post-operative residuals, medial meniscectomy and anterior cruciate ligament reconstruction of the right knee, effective from October 1, 1997. A TTE was also granted from June 30, 1998 to October 31, 1998, and the 20 percent evaluation was continued from November 1, 1998. In a February 1999 rating decision, the RO extended the TTE for the service-connected post-operative residuals, medial meniscectomy and anterior cruciate ligament reconstruction of the right knee from November 1, 1998 to April 30, 1999. The 20 percent evaluation was continued from March 1, 1999. In a July 1999 rating decision, the RO granted service connection for status post, partial medial meniscectomy of the left knee, secondary to the service-connected right knee disability, with a 10 percent evaluation, effective from January 30, 1996. In a December 1999 rating decision, the RO granted a TTE for the service-connected left knee disability, effective from September 27, 1999 to November 31, 1999. The 10 percent evaluation was continued from December 1, 1999. In a June 2000 rating decision, the RO granted a TTE for the service-connected left knee disability, effective from January 14, 2000 to May 31, 2000. The 10 percent evaluation was continued from June 1, 2000. In an April 2001 rating decision, the RO granted service connection for degenerative arthritis of the right knee, with a 10 percent evaluation, based on limitation of motion of the knee, effective October 1, 1997. This gave the Veteran a combined evaluation of 30 percent for the right knee. In January 2006, the Veteran filed a claim for increased ratings for his left and right knee disabilities, and a claim for service connection for a low back disability, secondary to the service-connected right knee disability. In an October 2009 rating decision, the RO granted an increased rating of 30 percent for the service-connected degenerative arthritis of the right knee, effective from January 10, 2006. In the same rating decision, the rating for the service-connected postoperative residuals, medial meniscectomy and anterior cruciate ligament reconstruction of the right knee, was reduced to 10 percent, under Diagnostic Code 5257. This gave the Veteran a new combined evaluation for the right knee of 40 percent, effective January 1, 2006. The Veteran was afforded a VA examination in August 2006 in response to his claim for increased ratings. The Veteran complained of constant, daily pain in both knees, weakness and stiffness. He denied heat or redness, fatigability or lack of endurance. He also complained of giving out, swelling and occasional locking in the right knee. He reported treating the knees with Ibuprofen, ice and elevation. He complained of flare-ups during damp or raining weather that lasted for a few days. He denied limitation of motion with flare-ups. He reported that he was wearing knee braces, but not using crutches or a cane. He denied any effects from his knee disabilities on his activities of daily living. On physical examination of the right knee, there was tenderness to palpation on the lateral aspect of the knee. There was no crepitation, effusion, increased warmth, or erythema. He was able to flex from 0-140 degrees, with pain from 0-140, but no functional impairment. The examiner noted that there was no fatigue, weakness, lack of endurance or incoordination, and no instability of the joint. He also noted that on repetitive motion, there was a decrease in range of motion, but no limitation due to fatigue, weakness, lack of endurance or incoordination. However, he did not state how much range of motion was decreased on repetitive motion, and furthermore, he did not report findings for extension. Accordingly, the Board finds that the August 2006 VA examination did not contain enough information to adequately rate the Veteran's right knee based on limitation of motion under Diagnostic Codes 5261 and 5262. On physical examination of the left knee, there was slight tenderness to palpation on the inferior aspect of the knee, but no crepitation, effusion, increased swelling or edema. The Veteran was able to flex from 0-140 degrees, with pain beginning at 110 degrees, but no functional limitation. Extension was normal, with pain, but no functional limitation. There was no instability of the joint. The examiner noted that on repetitive motion, there was no decrease in range of motion and no limitation due to fatigue, weakness, lack of endurance, or incoordination. The Veteran was able to walk on his heels, with pain, and was able to squat 90 degrees holding on to an object. He was also able to stand on alternate legs, and his gait was normal, although he did limp, due to the right knee. Motor strength of the lower extremity was normal, and sensation and deep tendon reflexes were intact. The examiner diagnosed right knee with degenerative arthritis, status post residual medial meniscectomy and anterior cruciate ligament repair, and status post partial medial meniscectomy of the left knee, with a normal x-ray. The Veteran was afforded another VA examination in February 2009. He complained of pain and stiffness in both knees, and reported that he was unable to cross his legs and that his knees were painful to use. He also reported that he was taking Ibuprofen and Alleve for pain, with minimal effects, and supportive knee braces, and that he had also received steroid injections in the knees. With regard to the right knee, he reported symptoms of deformity, giving way, instability, pain, stiffness, decreased speed of joint motion, dislocation or subluxation once or twice a year, repeated effusions, warmth, swelling, tenderness, and severe, weekly flare-ups that lasted 1-2 days. As for the left knee, he reported symptoms of deformity, giving way, instability, pain, stiffness, incoordination, decreased speed of joint motion, dislocation or subluxation once or twice a year, repeated effusions, warmth, swelling, tenderness, and severe weekly flare-ups that lasted 1-2 days. The Veteran also reported that he had experienced incapacitating episodes that year due to pain and stiffness in the knees that was not alleviated as usual. The Veteran also reported that he was unable to stand for more than a few minutes or walk more than a few yards due to knee symptoms. On physical examination, the Veteran's gait was antalgic, with poor propulsion, and there was evidence of abnormal weight bearing on the right (callus formation on the right foot). There was also abnormal shoe wear pattern on the left and right. For the right knee, there was bony joint enlargement, crepitus, deformity, effusion, tenderness, pain at rest, and guarding of movement. Furthermore, anterior drawer test showed 0.5 cm laxity anterior and the same posterior, with mild pain and stress on the collateral ligaments. There was also evidence of crepitation, clicks/snaps, grinding, patellar abnormality (subpatellar tenderness) and meniscus abnormality (effusion, and meniscus surgically absent). McMurray's test was also positive. There was no evidence of instability or locking. On the left side, there was evidence of tenderness, guarding of movement, and crepitation. There was no evidence of clicks/snaps, grinding, instability, or patellar or meniscus abnormality. During range of motion testing, the Veteran was able to flex the left knee to 135 degrees, and extension was normal. The examiner noted that there was evidence of pain with active motion, but he did not state at what point pain was experienced. The Veteran was able to flex the right knee to 100 degrees, and extension was normal. Again, however, the examiner noted that there was evidence of pain with active motion, but he did not state at what point pain was experienced. However, he did note that there were additional limitations on range of motion after repetitive motion, due primarily to pain. Specifically, he noted that flexion on the left side was limited to 130 degrees, and on the right to 90 degrees. Extension was limited on the left to 10 degrees and on the right to 20 degrees. The examiner diagnosed grade 4 osteoarthritis of the right knee, and moderate patellar tendonitis in the left knee, based on x-ray results. In response to the Board's September 2012 remand, the Veteran was afforded his most recent VA examination in March 2013. He complained of constant, throbbing/aching severe pain in the left knee. He reported a history of falls and buckling of the left knee, like the right knee, and feelings of giving out in the knee while walking, with pain. The Veteran also reported difficulty walking, and difficulty trying to get out of a chair or bed, due to his knee disabilities. He also reported that he had been prescribed and was wearing knee braces, and taking Ibuprofen, 800 mg, as needed, for pain. He also reported that he had received injections in the left knee, which did not help much, and that the left knee was worse than the right knee. The Veteran complained of flare-ups of knee pain during cold weather, occasional locking and buckling under of the right knee, and constant pain and giving out of the left knee after walking a few feet. During range of motion testing of the right knee, the Veteran was able to flex to 130 degrees, with pain beginning at 100 degrees. Extension was normal, with no evidence of pain on motion. With regard to the left knee, the Veteran was able to flex to 110 degrees, with pain beginning at 70 degrees. Extension again was normal, with no evidence of pain on motion. The examiner noted that after repetitive-use testing, range of motion in the right knee was reduced to 120 degrees, and in the left knee to 100 degrees. He also noted that the Veteran did have functional loss/and or functional impairment of both knees and lower legs after repetitive-use testing, including less movement than normal, weakened movement, excess fatigability, pain on movement, instability of station, and interference with sitting, standing and weight-bearing. The examiner also noted that the Veteran had tenderness or pain to palpation for joint line or soft tissues of both knees. Muscle strength testing was normal for both knees, as was anterior instability (Lachman) and posterior instability (Posterior drawer) tests for both knees. Medial-lateral instability (valgus/varus) testing was normal for the right knee, but indicated that there was mild instability of 0-5 millimeters (1+) in the left knee. There was no evidence of recurrent patellar subluxation/dislocation in either knee, and no evidence of shin splints (medial tibial stress syndrome) in either knee. The examiner also noted that there was evidence of a meniscal tear in both knees (as previously diagnosed) and frequent episodes of joint locking in the left knee. The examiner also noted that the Veteran had chronic pain in both knees as a result of prior meniscectomies, and scars from the knee surgeries, which were not painful or unstable. Finally, the examiner noted that the Veteran used knee braces on a constant basis, due to his knee disabilities. Right Knee Arthritis The Veteran is currently in receipt of a 30 percent rating under Diagnostic Code 5261 for his right knee arthritis, based on evidence of extension limited to 20 degrees on VA examination in February 2009. The Board finds that as there is no evidence of flexion limited to 15 degrees or extension limited to 30 degrees during the appeal period, a rating in excess of 30 percent under Diagnostic Code 5260 or 5261 is not warranted. There is also no evidence of recurrent subluxation or lateral instability during the appeal period and therefore, a separate rating under Diagnostic Code 5257 is not warranted. Similarly, during the appeal, there is no evidence of ankylosis, of impairment of the tibia and fibula, or of genu recurvatum of the right knee so as to warrant higher or separate ratings under Diagnostic Codes 5256, 5259, 5262, or 5263. The Board also finds that a rating in excess of 30 percent is not warranted for any period on appeal under DeLuca. In this regard, the Veteran reported painful motion of the left knee on physical examination in August 2006, February 2009 and March 2013. In August 2006, he experienced pain on flexion from 0-140, but the examiner noted that there was no functional impairment. Painful motion can equate to limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). However, pain alone does not constitute a functional loss under VA regulations that evaluate disability based upon range-of-motion loss. Mitchell v. Shinseki, No. 09-2169 (U.S. Vet. App. Aug. 23, 2011). The examiner also noted that there was no fatigue, weakness, lack of endurance or incoordination. He also noted that on repetitive motion, there was a decrease in range of motion, but no limitation due to fatigue, weakness, lack of endurance or incoordination. In February 2009, the examiner noted that there were additional limitations on range of motion after repetitive-use testing, due primarily to pain. Specifically, he noted that flexion on the right side was limited, but only to 90 degrees, and extension was limited to 20 degrees. There is no evidence that flexion was limited to any more than 90 degrees or that extension was limited to any more than 20 degrees, with consideration of pain and functional limitations, and the reduction in extension was considered in the increased rating of 20 percent the RO assigned following the examination. See October 2009 rating decision. The March 2013 examiner noted that after repetitive-use testing, range of motion (flexion) in the right knee was reduced. He also noted that the Veteran did have functional loss/and or functional impairment of both knees and lower legs after repetitive-use testing, including less movement than normal, weakened movement, excess fatigability, pain on movement, instability of station, and interference with sitting, standing and weight-bearing. However, with consideration of all those factors, the Veteran was still able to flex to 120 degrees, well beyond the 60 degrees required for a compensable rating under Diagnostic Code 5260, and extension was normal, with no evidence of pain on motion. The Board also notes that in August 2006, the Veteran complained of flare-ups during damp or raining weather that lasted for a few days. However, he also reported that he was able to treat his knees with just Ibuprofen, ice and elevation. He also denied limitation of motion with flare-ups, and reported that he was wearing knee braces, but not using crutches or a cane. He also denied any effects from his knee disabilities on his activities of daily living. In February 2009, the Veteran reported that he was unable to cross his legs and that his knees were painful to use. He also indicated that he was using supportive knee braces, and that he had also received steroid injections in the knees. The Veteran also reported that he was unable to stand for more than a few minutes or walk more than a few yards due to knee symptoms, and that he had experienced incapacitating episodes that year due to pain and stiffness in the knees that was not alleviated as usual. However, the Veteran also reported that he was still just taking Ibuprofen and Alleve for pain, and the Board notes that there is no documentary evidence of any incapacitating episodes or physician-prescribed bedrest due the right knee disability at that time, and there was no evidence of problems with ambulation on examination, and no indication that the Veteran was using assistive devices for walking. In March 2013, he reported a history of falls and buckling of the knees, and feelings of giving out in the knee while walking, with pain. The Veteran also reported difficulty walking, and difficulty trying to get out of a chair or bed, due to his knee disabilities. He also reported that he had received injections in the left knee, which did not help much. The Veteran complained of flare-ups of knee pain during cold weather, occasional locking and buckling under of the right knee, and constant pain and giving out of the left knee after walking a few feet. However, the Veteran reported that he was only treating the knee with a brace and over-the-counter medications such as Ibuprofen, 800 mg, as needed, for pain. Furthermore, his reports of giving way, instability and difficulty ambulating and walking were not confirmed on objective examination. Furthermore, the evidence shows that the Veteran was still independent in his activities of daily living and was still employed and working full-time. Based on this evidence, the Board cannot conclude that the criteria for the assignment of a disability rating in excess of 30 percent for limitation of motion of the right knee has been demonstrated at any time during the pendency of this appeal. Postoperative Residuals, Medial Meniscectomy And Anterior Cruciate Ligament Reconstruction, Right Knee The Veteran was initially rated as 10 percent disabling under Diagnostic Code 5259 for symptomatic removal of the semilunar cartilage. Effective December 1, 1999, he was evaluated as 20 percent disabling under Diagnostic Code 5258, for the dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint. However, in an October 2009 rating decision, the RO found that the Veteran's disability was more appropriately rated as 10 percent disabling under Diagnostic Code 5257, based on mild subluxation and instability. On VA examination in August 2006, the Veteran complained of giving out, swelling (effusion) and occasional locking in the right knee. On objective examination, there was no crepitation, effusion, increased warmth or erythema. On VA examination in February 2009, he reported that the right knee caused symptoms of deformity, giving way, instability, pain, stiffness, decreased speed of joint motion, dislocation or subluxation once or twice a year, repeated effusions, warmth, swelling, and tenderness. On objective examination, there was bony joint enlargement, crepitus, deformity, effusion, tenderness, pain at rest, and guarding of movement. Furthermore, anterior drawer test showed 0.5 cm laxity anterior and the same posterior, with mild pain and stress on the collateral ligaments. There was also evidence of crepitation, clicks/snaps, grinding, patellar abnormality (subpatellar tenderness) and meniscus abnormality (effusion, and meniscus surgically absent). McMurray's test was also positive. There was no evidence of instability or locking. On VA examination in March 2013, the Veteran complained of flare-ups of knee pain during cold weather, and occasional locking and buckling under of the right knee. On objective examination, the examiner noted that the Veteran had tenderness or pain to palpation for joint line or soft tissues of both knees. Muscle strength testing, anterior instability (Lachman), posterior instability (Posterior drawer), and medial-lateral instability (valgus/varus) testing was also normal for the right knee. There was no evidence of recurrent patellar subluxation/dislocation in either knee. The examiner also noted that there was evidence of a meniscal tear in both knees (as previously diagnosed) and frequent episodes of joint locking in the left knee. Although the Veteran has reported occasional locking of the right knee, as well as pain and effusion, and there has been evidence of pain and effusion in the right knee on objective examination, however; there has never been evidence of frequent episodes of "locking," pain, and effusion into the right knee joint on objective examination. Therefore, a rating in excess of 10 percent under Diagnostic Code 5258 is not warranted during the period on appeal. The Board also notes that as there is no evidence of anything more than slight instability of the right knee during the appeal period, a rating in excess of 10 percent under Diagnostic Code 5257 is not warranted. In this regard, there was no instability of the right knee noted on examination in August 2006; in February 2009, anterior drawer test showed 0.5 cm laxity anterior and the same posterior, with mild pain and stress on the collateral ligaments, and in March 2013, instability tests for the right knee were normal. Status Post, Partial Medial Meniscectomy, Left Knee The Veteran's left knee disability is currently rated as 10 percent disabling under Diagnostic Code 5259, for symptomatic removal of the semilunar cartilage. Prior to February 23, 2009, there is no evidence in the record, including in private or VA treatment records, or during VA examinations in August 2006 or February 2009, of frequent episodes of "locking," pain, and effusion into the joint of the left knee, nor is there any evidence of recurrent subluxation or lateral instability or limitation of flexion limited to at least 60 degrees or limitation of extension limited to at least 5 degrees. Therefore, a increased or separate rating under Diagnostic Codes 5257-5261 is not warranted. However, resolving reasonable doubt in the Veteran's favor, the Board finds that as of the February 23, 2009 VA examination, the Veteran's left knee disability meets the criteria for a separate 10 percent rating under Diagnostic Code 5261, based on the evidence of limitation of extension of the left knee limited to 10 degrees. See February 2009 VA examination report. The Board also finds that resolving reasonable doubt in the Veteran's favor, as of March 18, 2013, the date of the most recent VA examination, the Veteran's left knee disability meets the criteria for a 20 percent rating under Diagnostic Code 5258, and a separate 10 percent rating under Diagnostic Code 5257. In this regard, during the March 2013 VA examination, the examiner noted that there was objective evidence on physical examination of mild instability of 0-5 millimeters (1+) in the left knee during medial-lateral instability (valgus/varus) testing, as well as chronic pain and frequent episodes of joint locking in the left knee. The Board also notes that the Veteran has consistently reported symptoms of effusion in the knees. As there is no evidence during any period on appeal of ankylosis, impairment of the tibia and fibula, or of genu recurvatum of the left knee, a higher or separate ratings under Diagnostic Codes 5256, 5262, or 5263 are not warranted. However, even with consideration of all pertinent disability factors, none of the evidence supports a finding that an evaluation in excess of 10 percent under Diagnostic Code 5261, or an evaluation in excess of 10 percent under Diagnostic Code 5257 is warranted for any period on appeal under DeLuca. In this regard, the Veteran reported painful motion of the left knee on physical examination in August 2006, February 2009 and March 2013. In August 2006, he experienced pain on flexion from 0-140, but the examiner noted that there was no functional impairment. Painful motion can equate to limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). However, pain alone does not constitute a functional loss under VA regulations that evaluate disability based upon range-of-motion loss. Mitchell v. Shinseki, No. 09-2169 (U.S. Vet. App. Aug. 23, 2011). The Veteran complained of pain, stiffness, weakness, giving out, swelling and occasional locking in the knee in August 2006. However, he also denied, heat, redness or fatigability, and denied any effects from the knee on his activities of daily living. He also reported that he was only treating the knee with ice and over-the-counter pain medications, such as Ibuprofen. Furthermore, although there was pain on motion, the examiner noted that there was no functional impairment. The examiner also noted that there was no instability of the joint on examination and on repetitive motion, there was no decrease in range of motion and no limitation due to fatigue, weakness, lack of endurance, or incoordination. The Veteran also reported functional impairment due to the left knee disability on examination in February 2009 and March 2013. However, there was no evidence of instability on objective examination in February 2009, and the findings of decreased extension were considered and reflected in the above-noted grant of a separate rating under Diagnostic Code 5261. There is no evidence that the Veteran's extension was limited to more than 10 degrees in February 2009 or March 2013, even with consideration of pain and functional limitations. Furthermore, the Veteran was noted during both examinations to still be able to independently complete activities of daily living, including work. Extraschedular Consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation 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 as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The Veteran's knee disabilities, as discussed above, are manifested by symptomatology contemplated by the rating criteria which have been applied in this case. These rating criteria also take into account the pain and limitation of function reported in the record. The Veteran has not reported any symptoms outside of those contemplated by the rating schedule. Hence, referral for consideration of extraschedular ratings is not warranted. In reaching these conclusions the Board has resolved reasonable doubt in the Veteran's favor, where applicable. 38 U.S.C.A. § 5107(b) (West 2002). ORDER An increased rating for degenerative spondylolisthesis, L5-S1 is granted, subject to the criteria applicable to the payment of monetary benefits. An increased rating for degenerative arthritis of the right knee is denied. An increased rating for the postoperative residuals, medial meniscectomy and anterior cruciate ligament reconstruction, right knee is denied. For the period prior to February 23, 2009, an increased rating for status post, partial medial meniscectomy, left knee is denied. For the period beginning February 23, 2009, a separate 10 percent rating for limitation of motion of the left knee is granted, subject to the criteria applicable to the payment of monetary benefits. For the period beginning March 18, 2013, an increased rating of 20 percent for status post, partial medial meniscectomy, left knee is granted, subject to the criteria applicable to the payment of monetary benefits. For the period beginning March 18, 2013, a separate 10 percent rating for instability of the left knee is granted, subject to the criteria applicable to the payment of monetary benefits. REMAND TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2011). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2011) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). As noted in the September 2012 remand, during an April 2012 hearing before the undersigned, the Veteran testified that his service-connected bilateral knee and low back disabilities had hindered or prevented him from obtaining substantially gainful employment. The Court has held that in the case of a claim for TDIU, the duty to assist requires that VA obtain an examination which includes an opinion on what effect the appellant's service-connected disability has on his ability to work. Friscia v. Brown, 7 Vet. App. 294, 297 (1994). In the September 2012 remand, the Board directed that the VA examiner provide a medical opinion concerning the extent of functional and industrial impairment resulting from each of the Veteran's service-connected disabilities. The Board specifically stated that the medical opinion needed to address whether his service-connected disabilities alone are so disabling as to render him unemployable. The March 2013 examiners recorded the Veteran's reports and noted that the Veteran's disabilities affected his employment, but they did not provide an opinion as to whether his service-connected disabilities specifically precluded gainful employment or rendered him unemployable. A remand by the Board confers on an appellant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In Stegall, the Court held that "where . . . the remand orders of the Board . . . are not complied with, the Board itself errs in failing to insure compliance." Id. Furthermore, the Board notes that the Veteran was not service-connected for his bilateral plantar fasciitis at the time of the March 2013 VA examinations. There is no opinion of record that discusses the impact of all of the Veteran's service-connected disabilities on his ability to work. Accordingly, the Board finds that another VA examination is necessary in order to provide a current assessment of the Veteran's employability. The Veteran is advised that it is his responsibility to report for the examination and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran a VA examination to determine whether his service connected disabilities (right and left knee disabilities, low back disability, and now service-connected bilateral plantar fasciitis) together preclude him from obtaining or maintaining gainful employment for which he would otherwise be qualified with consideration of his education and occupational experience. The Veteran's claims file should be made available and the examination report should indicate that the claims file was reviewed by the examiner. Specifically, the VA examiner is directed to provide a medical opinion concerning the extent of functional and industrial impairment resulting from each of the Veteran's service-connected disabilities. The medical opinion must address whether his service-connected disabilities alone are so disabling as to render him unemployable. A complete medical, education, and employment history should be taken. The VA examiner should also consider the fact that the Veteran is in receipt of SSA disability benefits. The Veteran's age and the effects of non-service-connected disabilities cannot be factors for consideration in making the determination. However, the effects of treatments and medications used to treat the service-connected disabilities must be considered in the opinion. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. All necessary studies and tests shall be conducted. If the examiner determines that a decision cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge. In other words, simply stating that an opinion cannot be provided without resort to mere speculation is not acceptable without a detailed reason as to why this is so. Id. 2. Then, readjudicate the claims on appeal. If any benefit sought on appeal is not granted, the Veteran and his representative should be furnished a supplemental statement of the case before the case is returned to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs