Citation Nr: 1323436 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 07-28 856 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to increases in the "staged" ratings (10 percent prior to January 23, 2006; a combined 20 percent from January 23, 2006 to August 18, 2010; and 30 percent from October 1, 2011) assigned for right knee disability (now status post (s/p) total knee replacement (TKR)). 2. Entitlement to a rating in excess of 10 percent for a left knee disability. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1973 to September 1985. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision of the Roanoke RO that granted service connection for right knee degenerative joint disease (DJD), rated 10 percent, effective May 13, 2002, and a June 2, 2006 rating decision of the Columbia, South Carolina RO that granted service connection for left knee DJD, rated 10 percent, effective March 2, 2006, (and continued the 10 percent rating for right knee DJD). An August 2007 rating decision increased the rating for right knee disability to 20 percent (by assigning a separate 10 percent rating for instability), effective January 23, 2006. In May 2010, a Travel Board hearing was held before the undersigned; a transcript of the hearing is associated with the claims file. In July 2010 the Board remanded the case for additional development. An interim (October 2010) rating decision assigned a 100 percent schedular rating for the one year period following right total knee replacement, and a 30 percent rating thereafter, effective October 1, 2011. [Consequently, the matter of the rating from August 18, 2010 to October 1, 2011 is not for consideration.] In July 2012 the Board again remanded the case for additional development. The Veteran's claims file has been returned to the jurisdiction of the Roanoke RO. FINDINGS OF FACT 1. Prior to January 23, 2006, the Veteran's right knee disability is reasonably shown to have been manifested by arthritis with painful motion and mild instability; compensable limitations of flexion or extension were not shown. 2. From January 23, 2006 to August 18, 2010, the Veteran's right knee disability was not shown to be manifested by any more than slight subluxation or instability, compensable limitations of flexion or extension were not shown; additional limitations due to pain, weakened movement, excessive fatigability with use, or incoordination were not shown. 3. At no time since October 1, 2011 is the Veteran's service connected right knee disability shown to have been manifested by chronic residuals of TKR consisting of severe weakness or severe painful motion or impairment approximating such level of severity; impairment reflecting an intermediate level of weakness, pain, and/or limitation of motion is not shown. 4. From January 31, 2011 until August 3, 2012, the Veteran's left knee disability is reasonably shown to have been manifested by limitation of extension to 15 degrees; compensable limitations of flexion or extension are not shown prior to that period or since; subluxation or instability is not shown. CONCLUSIONS OF LAW 1. An increased (to 20 percent) rating is warranted for the Veteran's right knee disability for throughout prior to January 23, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.71a; Codes 5010, 5257 (2012). 2. A combined rating in excess of 20 percent is not warranted for the Veteran's right knee disability for the period from January 23, 2006 to August 18, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.71a; Codes 5010, 5256-5263 (2012). 3. A rating in excess of 30 percent is not warranted for the Veteran's post-TKR right knee disability for any period of time since October 1, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.71a; Codes 5055, 5256-5263 (2012). 4. The Veteran's left knee disability warrants staged ratings of 10 percent prior to January 31, 2011;20 percent from January 31, 2011 until August 3, 2012; and 10 percent from August 3, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.71a; Codes 5003, 5256-5263 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). As the rating decisions on appeal granted service connection for right and left knee DJD and assigned disability ratings and effective dates for each award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). An August 2007 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased rating; while a November 2008 supplemental SOC (SSOC) readjudicated the matter after the appellant and his representative responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has had ample opportunity to respond/supplement the record. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). The Veteran's pertinent (private and VA) treatment records have been secured. The RO arranged for VA examinations in March 2006, April 2008, February 2009, and August 2012. The Board notes that the VA examination reports (cumulatively) include findings describing, and history of, the disabilities adequate for rating purposes. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide this matter, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earnings capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran's service-connected right knee disability has been rated by the RO under multiple Codes in 38 C.F.R. § 4.71a. Prior to January 23, 2006, a 10 percent rating was assigned under Code 5010 for DJD. From January 23, 2006 to August 18, 2010, a 20 percent combined rating (based on a formulation of 10 percent rating under Code 5010 and a 10 percent rating under Code 5257 for instability) was assigned. From October 1, 2011, a 30 percent rating under Code 5055 has been assigned for right knee disability after a year following implementation of a prosthesis. The Veteran's service-connected left knee disability has been rated under Codes 5003 and 5260 (for DJD based on limitation of motion). Traumatic arthritis (established by X-ray findings) is rated as degenerative arthritis, and is rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When the limitation of motion is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each major joint affected by limitation of motion, to be combined, not added under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Codes 5010-5003. 38 C.F.R. § 4.71a includes multiple diagnostic codes for evaluating knee impairment, including Code 5256 (ankylosis), Code 5257 (other impairment, including recurrent subluxation or lateral instability), Code 5258 (dislocated semilunar cartilage), Code 5259 (symptomatic removal of semilunar cartilage), Code 5260 (limitation of flexion), Code 5261 (limitation of extension), Code 5262 (impairment of the tibia and fibula), and Code 5263 (genu recurvatum). Under Code 5256, a 30 percent rating may be assigned for ankylosis of a knee at a favorable angle (in full extension), or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 50 percent rating may be assigned for ankylosis of a knee between 20 degrees and 45 degrees. A 60 percent rating may be assigned for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a; Code 5256. Code 5257 provides for a 10 percent rating for slight recurrent subluxation or lateral instability of a knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Code 5258, a 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under Code 5259, removal of semilunar cartilage that is symptomatic warrants a 10 percent rating. 38 C.F.R. § 4.71a. Flexion of the leg 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, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Code 5260. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Code 5261. [Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. 38 C.F.R. § 4.71, Plate II.] Under Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating when there is malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating for malunion of the tibia and fibula with marked knee or ankle disability; and a maximum rating of 40 percent for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a. Under Code 5263, a 10 percent rating is warranted for genu recurvatum. 38 C.F.R. § 4.71a. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pain, in and of itself, that does not result in additional functional loss does not warrant a higher rating; the Court held that pain alone does not constitute function loss, but is just one fact to be considered when evaluating functional impairment. Id. Separate ratings may be assigned for knee disability under Codes 5257 and 5003 where there is x-ray evidence of arthritis in addition to recurrent subluxation or lateral instability. See generally VAOPGCPREC 23- 97 and VAOPGCREC 9-98. A precedent opinion by VA's General Counsel holds that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Code 5260 and a compensable limitation of extension under Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). Post TKR knee disability is rated under Code 5055. A 100 percent rating is to be assigned for 1 year following implantation of the prosthesis. With chronic residuals consisting of severe painful motion or severe weakness in the affected extremity a 60 percent rating is warranted. 30 percent is the minimum rating assigned for knee disability following TKR. Intermediate degrees of residual weakness, pain or limitation of motion, are to be rated (40 or 50 percent) by analogy to Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a. Private treatment records show the Veteran underwent a meniscal debridement of the right knee in March 2004. On April 2004 post-surgical examination, full range of motion was measured for both flexion and extension. The Veteran reported his knee felt great. On January 2005 VA examination, the Veteran complained of constant pain that interfered with his ability to ambulate, swelling, and instability. He stated that he had limitations on climbing steps, climbing ladders, and prolonged walking. The examiner noted the Veteran's gait was abnormal due to a limp favoring the right knee, and that he used a cane for support. On examination, the right knee was tender throughout. Range of motion studies revealed flexion to 140 degrees, with no pain; extension was normal, without pain. There was no additional limitation of motion reported on repetitive use. There was no ankylosis of the knee joint. The drawer's sign was normal. The McMurray's sign was slightly positive. There was no evidence of recurrent subluxation or locking pain, joint effusion, or crepitus. DJD of moderate severity was diagnosed by x-ray. Private treatment records from November 2005 showed the Veteran's right leg gave out. On March 2006 VA examination, the Veteran reported right knee weakness, swelling, stiffness, and pain at a 9 (on a scale 1 to 10, 10 being the worst). He reported that his right knee gave way after walking short distances or climbing stairs. He also stated that because of his knee he experienced incapacitating episodes, each lasting 2 days; 100 days of incapacitation were related. However, it was noted that the knee condition did not result in any time lost from work, and no functional impairment was reported. On examination, the right knee showed signs of effusion, weakness, and tenderness. There was evidence of locking, joint effusion, and crepitus. Right knee range of motion revealed flexion measured to 100 degree, with pain at 100 degrees; and normal extension. It was noted that the right knee was additionally limited following repetitive use by pain, fatigue, weakness, lack of endurance, incoordination and pain. The anterior and posterior cruciate ligaments, and medial and lateral collateral ligaments stability tests of the right knee were abnormal and showed slight instability. Left knee range of motion studies revealed flexion to 140 degrees, with pain at 140 degrees, and full extension. There was no additional limitation of motion on repetitive use. No instability of the left knee was shown. Degenerative joint disease of the left knee was diagnosed by March 2006 x-ray. A March 2006 private pain management treatment report notes the Veteran's right knee gave out constantly, causing numerous falls. In May 2006, pain management treatment records noted the Veteran fell because both knees gave out. Treatment records continued to show he used a cane to ambulate. His treatment consisted of pain medications. VA treatment records from 2006 through 2007 show the Veteran continued to complain of bilateral knee pain. In an August 2007 statement, the Veteran reported swelling, pain at level 9, and weakness of his right knee, which pops out and is unsteady. He reported being unable to sit or stand for prolonged times, and unable to walk in a straight line. As to the left knee, the Veteran reported weakness, numbness, swelling, and pain at a 9 (on a scale of 10). He also reported that bending was painful. On April 2008 VA examination, the Veteran complained of constant pain in both knees at a level 8. When in pain, he could function with medication. He reported weakness, stiffness, swelling, and giving away of both knees. The Veteran stated he walked with a cane and was unable to sit, stand or walk for prolonged periods. [The examiner incorrectly noted that the Veteran had prosthetic implants of both knees.] On examination, there was right knee weakness, tenderness, and guarding of movement; no signs of edema, effusion, redness or heat were shown. On the left, there was weakness, tenderness and guarding of movement; no signs of edema, effusion, redness or heat were noted. There was evidence of crepitus of both knees, but no genu recurvatum or locking pain. On the right knee, flexion was to 100 degrees (pain was not reported); extension was normal. Joint function was additionally limited on repetitive use by pain, fatigue, weakness, lack of endurance, incoordination and pain, but joint motion was not additionally limited. The anterior and posterior cruciate ligament, and medial and lateral collateral ligament stability tests of the right knee were within normal limits. The medial and lateral meniscus test of the right knee was abnormal. On the left knee, flexion was to 110 degrees (pain was not reported); extension was normal. The anterior and posterior cruciate ligaments; medial and lateral collateral ligaments; and medial and lateral meniscus stability tests were all within normal limits. VA treatment records from 2007 through 2009 show the Veteran continued receiving treatment with medication for multiple joint pain. On February 2009 VA examination, the Veteran reported constant pain in the right knee at level 10. He reported pain was elicited on physical activity and relieved by rest and medications. He stated that at times of pain he could not function at all. He reported he experienced weakness, stiffness, swelling, heat, giving away, lack of endurance, locking, fatigability and dislocation of the right knee. He walked with a cane and had pain with any activity. On examination, there was no evidence of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement. There was evidence of crepitus; there was no evidence of genu recurvatum or locking pain. Flexion was to 95 degrees, with pain at 95 degrees. Extension was normal. Joint function was additionally limited by pain; but there was no additional limitation of motion. The anterior and posterior cruciate ligament, medial and lateral collateral ligament, and medial and lateral meniscus stability tests were all within normal limits. As to the left knee, the Veteran reported constant pain at a level 10. He also reported numbness. Pain was elicited on activity and relieved by medication. When in pain, the Veteran could not function, except to dress and for hygiene. He reported weakness, stiffness, swelling, giving away, locking, and numbness of the left knee. He did not report heat, redness, lack of endurance, fatigability or dislocation. On examination, there were no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement. Crepitus was present, but there was no evidence of genu recurvatum or locking pain. Flexion was to 110 degrees, without pain. Extension was normal. Joint function was not additionally limited. The anterior and posterior cruciate ligament, medial and lateral collateral ligament, and medial and lateral meniscus stability tests were all within normal limits. At the May 2010 hearing, the Veteran testified that his right knee popped out 2 to 3 times a day, and that he could not stand for more than 5 to 10 minutes at a time. He testified that he used a knee brace. As to the left knee, the Veteran testified that he was in constant pain, and that his knee was starting to give way like the right knee. He testified that used a knee band for support. Additionally, the Veteran testified that he was on pain medications and received pain management treatment. On June 2010 orthopedic consultation, bilateral genu varum (right greater than left), bilateral medial facet tenderness, and right effusion were shown. The right knee showed complete loss of medial joint space, with tricompartmental DJD. The left knee showed mild degenerative changes. Range of motion studies showed flexion to 95 degrees for the right knee, and to 120 degrees for the left knee. Both knees were negative for McMurray's; all ligaments were stable. Right TKR was proposed. The Veteran underwent a right TKR on August 18, 2010. Following the surgery, physical therapy was prescribed. Postsurgical private treatment records from August 2010 showed the right knee appeared normal. There was no effusion, no tenderness to palpation, normal movement, and medial or lateral instability. There were no anterior or posterior drawer signs. Results of the McMurray and apprehension tests were negative. Flexion was to 90 degrees, and there was full extension. He was instructed to continue physical therapy. On January 31, 2011, the Veteran was seen at a VA emergency room after falling and injuring his left knee. A left knee sprain was diagnosed, and he was given a knee brace and crutches. In February 2011, pain continued, with tenderness at the patella. Range of motion was normal. In March 2011, VA treatment records noted the Veteran was post- right TKR, and his right knee was in good condition. His left knee remained painful; steroids and Vicodin were prescribed. On April 2011 orthopedic consult, the Veteran's left knee remained swollen, it locks/catches, buckles backwards. A large effusion was noted, with tender medial joints. Flexion was measured to 90 degrees; extension was measured to 15 degrees. An MRI of the left knee was conducted in April 2011, and showed a complex tear in the posterior horn of the medical meniscus. Arthroscopic surgery was discussed. There is no evidence in the record that surgery occurred. A note in the VA treatment records indicates that the last orthopedic note was in 2011, and that surgery was waiting until the Veteran's weight and diabetes were in better control. On August 3, 2012 VA examination, the Veteran reported he experienced flare-ups from cold rainy weather, which made his knee stiff and pain worse. Range of motion studies were conducted and showed right knee flexion measured to 100 degrees, with pain at 100 degrees. Extension was normal. Left knee flexion was measured to 85 degrees, with pain at 85 degrees. Extension was normal. Repetitive testing was conducted; there was no additional loss of motion of the right knee. However, flexion of the left knee decreased to 80 degrees. Functional impairment of both knees was found to result in less movement than normal, pain on movement, disturbance of locomotion, and interference with sitting, standing and weight-bearing. Tenderness of the left knee was exhibited. Neither knee showed evidence of instability (considering the Lachman, posterior drawer, and valgus/varus tests). There was no evidence of recurrent subluxation or dislocation. An x-ray of the right knee showed satisfactory alignment of the TKR. The examiner noted the Veteran had a left meniscal tear. The examiner also noted the Veteran experienced intermediate degrees of residual weakness, pain or limitation of motion following his August 2010 surgery. The examiner noted the Veteran used a cane for ambulation. Additionally, the examiner stated that the Veteran's knee disabilities did not interfere with his ability to work, because the Veteran was unemployed due to his back condition and fusion. On examination, a scar measuring 25 centimeters by 1 centimeter was identified on the Veteran right knee. The scar was not painful, unstable, or measured greater than 39 square centimeters. The scar was also not keloid. Restriction of movement was limited to 100 degrees. Right Knee At the outset the Board notes that although the Veteran did not file an NOD with the March 2005 rating decision, under 38 C.F.R. § 3.156(b), if any new and material evidence is received prior to the expiration of the appeal period (i.e., March 9, 2006), such evidence will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. In this regard, the Board has examined the additional evidence received in conjunction with the Veteran's January 2006 claim for an increased rating for right knee DJD, to determine whether such evidence would constitute "new and material evidence" under 38 C.F.R. § 3.156(b), so as to warrant review from May 13, 2002 (on the basis that the March 2005 rating decision was not final). The additional evidence received (on March 7, 2006) consists mainly of private treatment records. Such records are "new" as they were not previously associated with the record or considered; and are "material" as they show additional symptomatology (namely instability of the right knee) that was not considered in the March 2005 rating decision. Therefore, the Board finds the March 2005 rating decision did not become final, and the Board will consider the appeal for an increased rating for right knee DJD to encompass the appeal period beginning May 13, 2002 (or the original date of claim). Prior to January 23, 2006 Prior to January 23, 2006, the Veteran's right knee disability has been rated 10 percent under Code 5003/5010 (for arthritis with less than compensable limitation of knee motion, but with motion limited by pain). As no examination or treatment record showed right knee flexion limited to 45 degrees or extension by 10 degrees (even with consideration of such factors as pain/use) there is no basis in the record for assigning a rating in excess of 10 percent by application of Codes 5260 and 5261. And as 10 percent is the maximum rating for one joint under Code 5003, a rating in excess of 10 percent for arthritis with limitation of motion/painful motion is not warranted. A close review of the record also found that during this period there was evidence of right knee instability. On January 2005 examination the Veteran complained of instability; more significantly the McMurray test (for instability) was noted to be positive. Furthermore, private records show that the Veteran was seen because his right knee "gave out." Such evidence reflects a finding of slight instability (warranting a 10 percent rating under Code 5257). The Board has considered whether any other diagnostic codes apply, and would afford the Veteran a further increase in the rating for the disability at issue. As pathology required for ratings under Codes 5256 (ankylosis), 5258, 5259 (involvement of semilunar cartilage), and 5262 (impairment of the tibia and fibula) is not shown, ratings under those codes are not warranted. Consequently, a combined 20 percent rating is warranted for the right knee disability for throughout prior to January 23, 2006. From January 23, 2006 to August 18, 2010 Between January 23, 2006 and August 18, 2010, the Veteran's right knee disability was rated 10 percent under Code 5003/5010 (for arthritis with less than compensable limitation of knee motion, but with motion limited by pain), and 10 percent under Code 5257 for instability. As no examination or treatment record during this portion of the appeal showed right knee flexion limited to 45 degrees or extension by 10 degrees (even with consideration of such factors as pain/use) there is no basis in the record for assigning a rating in excess of 10 percent by application of Codes 5260 and 5261. Again as 10 percent is the maximum rating for one joint under Code 5003, a rating in excess of 10 percent is not warranted. The analysis turns to the rating assigned for the instability aspect of the service connected right knee disability. March 2006 examination showed the anterior and posterior cruciate ligaments and medical and lateral collateral ligaments stability tests were abnormal and showed slight instability of the right knee. The next higher (20 percent) rating requires moderate subluxation or instability of the knee. No examinations or treatment records reflect more than slight instability. While the Veteran reported that his right knee will give way, examinations did not find objective evidence of more than slight instability. Examinations in April 2008 and February 2009 show all right knee ligaments within normal limits. Consequently, a rating in excess of 10 percent for subluxation or instability was not warranted. The Board has considered whether any other diagnostic codes apply, and would afford the Veteran a further increase in the rating for the disability at issue. As pathology required for ratings under Codes 5256 (ankylosis), 5258, 5259 (involvement of semilunar cartilage), and 5262 (impairment of the tibia and fibula) is not shown, ratings under those codes are not warranted. Accordingly, a combined rating in excess of 20 percent for the period between January 23, 2006 and August 18, 2010 is not warranted. From October 1, 2011 As stated above, the Veteran underwent right TKR in August 2010 and was assigned a 30 percent rating. A 60 percent rating under Code 5055 requires chronic residuals of severe painful motion or weakness. See 38 C.F.R. § 4.71a, Code 5055. Neither severe painful motion nor severe weakness is shown at any time from October 1, 2011. Next for consideration is whether or not the disability warrants an intermediate (i.e., between 30 and 60 percent) rating based on an intermediate degree of weakness, pain, or limitation of motion under Codes 5256, 5260, 5261, 5262. No evaluation or treatment received since October 1, 2011 has found impairment equivalent to ankylosis, or compensable limitation of flexion or extension. Post TKR, extension has been shown to be full; flexion has not been limited to less than 100 degrees. There was no evidence of instability or subluxation on August 2012 examination, and it cannot be found that he has functional impairment equivalent to tibia/fibula non-union with loose motion, requiring a brace (so as to warrant a 40 percent rating by analogy to code 5262). In summary, all manifestations and impairment shown are encompassed by the criteria for the 30 percent rating currently assigned, and neither the next higher (60 percent) schedular rating under Code 5055, nor an intermediate rating in excess of 30 percent by analogy to Codes 5256, 5261, 5262, is warranted. Left Knee The Veteran's left knee has been rated 10 percent throughout on the basis of x-ray-confirmed arthritis with motion limited by pain (but to a degree less than compensable under the criteria for rating limitations of flexion/extension). That is the maximum rating under Code 5003. As to a rating based on limitation of range of motion, at no time during the appeal period was the Veteran's left knee flexion limited to 45 (or less) degrees. On March 2006 examination, flexion measured 140 degrees. On April 2008 and February 2009 examination, flexion measured 110 degrees. On June 2010 consultation, flexion measured 120 degrees. Following the January 2011 injury, flexion was limited to 90 degrees and on most recent (August 2012) examination, flexion was limited to 85 degrees. At no time during the appeal period was flexion limited to a compensable degree. Therefore, Code 5260 is not for application. Prior to January 31, 2011, extension of the left knee was not limited to 10 degrees or more. March 2006, April 2008 and February 2009 examinations found full extension. Following the Veteran's fall injury on January 31, 2011, as reported on April 2011 examination, extension was limited to 15 degrees. Such limitation warrants a 20 percent rating under Code 5261. As August 3, 2012 examination once again found extension full, a 20 percent rating was no longer warranted from that date. Instead from the August 3, 2012 date of examination, a 10 percent rating under Code 5003 is once again warranted. The evidence does not show dislocated semilunar cartilage. Treatment records following, the January 2011 injury show arthroscopic surgery was discussed to repair a complex tear of the posterior horn of the medial meniscus; however, surgery was not performed. Treatment records clearly establish the Veteran has not had any operation to remove semilunar cartilage (nor does he contend otherwise); therefore, Codes 5258 and 5259 are not for application. The Board has considered whether any other diagnostic codes apply, and would afford the Veteran a further increase in the rating for his left knee disability. During the appeal period, the left knee has never been found to be ankylosed; therefore, Code 5256 is not for application. Additionally, at no time during the appeal period does the evidence reflect impairment of the tibia or fibula or genu recurvatum; therefore, Codes 5262 and 5263 are not for application. The Board has considered whether referral of these claims for extraschedular consideration is indicated. The evidentiary record does not show any manifestations of, or functional impairment due to, the left knee disability not encompassed by the schedular criteria. The Veteran's complaints of pain, instability, limitation of motion, and weakness are directly contemplated by the applicable schedular criteria (Codes 5003/5010, 5055, 5256-5263). Therefore, the schedular criteria are not inadequate, and referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Additionally, the Board notes the Veteran stopped working in December 2004 due to his back surgery. Social Security Disability records show he is disabled for full-time employment due to his discogenic/degenerative back disorder and affective disorders. He has not alleged unemployability due to his service-connected knee disabilities. Therefore, the matter of entitlement to a total rating based on individual unemployability is not raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A 20 percent combined rating is granted for the Veteran's right knee disability for the period prior to January 23, 2006, subject to the regulations as governing the payment of monetary awards. A combined rating for right knee disability in excess of 20 percent for the period from January 23, 2006 to August 18, 2010 is denied. A rating for post-TKR right knee disability in excess of 30 percent from October 1, 2011 is denied. A staged increased rating of 20 percent is granted for the Veteran's left knee disability from January 31, 2011 until August 3, 2012, subject to the regulations governing payment of monetary awards. Ratings for left knee disability in excess of 10 percent prior to January 31, 2001, and from August 3, 2012 are denied. ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs