Citation Nr: 1323624 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 09-18 364 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for the right knee patellofemoral syndrome, with degenerative joint disease and chondromalacia. 2. Entitlement to an evaluation in excess of 10 percent for right knee patellar subluxation. 3. Entitlement to an evaluation in excess of 10 percent for the left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia. 4. Entitlement to an evaluation in excess of 10 percent for left knee patellar subluxation. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The appellant served on active duty from June 1992 to July 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision issued by the above Department of Veterans Affairs (VA) Regional Office (RO). FINDINGS OF FACT 1. The evidence does not show right knee ankylosis or knee replacement surgery. Flexion of the right knee is not limited to 30 degrees and extension is not limited to 15 degrees. 2. Right knee arthritis, with crepitation, grinding, and tenderness, as well as complaints of pain and pain on use is shown. 3. Slight patellar subluxation has been clinically demonstrated in the right knee. 4. The appellant has a history of frequent episodes of locking, pain, and effusions into the right knee joint; magnetic resonance imaging (MRI) revealed a meniscal tear and trace effusion in the right knee joint in February 2013. 5. The evidence does not show left knee ankylosis, knee replacement surgery, or any dislocated semilunar cartilage. Flexion of the left knee is not limited to 30 degrees and extension is not limited to 15 degrees. 6. Left knee arthritis, with crepitation, grinding, and tenderness, as well as with complaints of pain and pain on use is shown. 7. Slight patellar subluxation has been clinically demonstrated in the left knee. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for right knee patellofemoral syndrome, with degenerative joint disease and chondromalacia, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260 (2012). 2. The criteria for an evaluation in excess of 10 percent for right knee patellar subluxation have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). 3. The criteria for a separate evaluation of 20 percent, but no more, for right knee meniscal tear have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2012). 4. The criteria for an evaluation in excess of 10 percent for left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260 (2012). 5. The criteria for an evaluation in excess of 10 percent for left knee patellar subluxation have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the appellant's bilateral knee increased rating claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 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. An October 2008 letter provided the notice requirement for an increased rating. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). This letter also provided the appellant with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Accordingly, this letter satisfied the notice requirements with respect to the issues on appeal. The duty to assist the appellant has also been satisfied in this case. The RO has obtained relevant treatment reports. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The appellant was afforded VA examinations in November 2008, June 2011, a June 2012 addendum, and February 2013. The Board finds the VA examinations adequate, as they were based on a complete review of the appellant's claims file and physical examination of the appellant, and they provide sufficient findings to evaluate the appellant's service-connected right and left knee disabilities. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). This case was remanded by the Board in May 2011 to the RO to allow the appellant to submit additional evidence, obtain recent VA treatment reports, and provide a current evaluation of the right and left knees. Additional VA medical records were added to the claims file and the appellant has submitted a private evaluation report, as well as lay statements. The appellant was afforded a VA medical examination in June 2011, and a supplemental report was added in June 2012. Consequently, there has been substantial compliance with the May 2011 remand instructions and the March 2012 remand instructions. This case was also remanded by the Board in January 2013 to the RO to allow the appellant to submit additional evidence and to obtain a current evaluation of the right and left knees. The appellant was afforded a VA medical examination in February 2013. The appellant has also submitted lay statements. Consequently, there has been substantial compliance with the January 2013 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999). There is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). The evidence of record includes lay statements from the appellant, his spouse, and a friend. The appellant has stated that he uses a sleeve on each knee for stability; that he has been issued a cane for support; that he is in pain due to his knee disabilities each day and all day; that he is unable to kneel, squat, bend, stand, or run; that he walks more slowly than others and with a limp; that his knees are red and swollen on a daily basis; that his knees sublux and drop him to the floor on a daily basis; that the range of motion of his knees are limited due to pain; and that pain medications do not alleviate the pain. The appellant's wife has stated that his knee caps slip out of place frequently and that he falls to the floor in agony. She has also said that the appellant is unable to get up from the floor or a kneeling position, and that he has missed work due to his knees. She further stated that he missed work due to his shoulder and back problems, as well. The appellant's wife described his knee pain as severe. A co-worker wrote that he had observed the appellant's knees buckle to the point of the appellant falling to the ground on multiple occasions. The colleague further stated that the appellant walked with a limp and that he was apparently in constant pain. The appellant underwent a VA medical examination in November 2008. He reported knee symptoms of weakness, stiffness, swelling, heat, giving way, locking, and subluxation. The appellant did not report redness, lack of endurance, fatigability, or dislocation. He stated he had constant pain in each knee and described it as burning, aching, sharp, stabbing and grinding. He also said that the pain could be elicited by physical activity and that it was relieved by rest and medication. The appellant further stated that he had difficulty with bending, kneeling, squatting, walking, running, standing, driving, sitting, falling asleep, and climbing and descending stairs. On physical examination, the doctor noted that the appellant limped to avoid weight on the right. The appellant used a cane to ambulate. Each knee exhibited tenderness and the appellant had guarding of movement. There was slight subluxation, bilaterally. There were no signs of effusion, edema, weakness, redness, or heat in either knee. There was no locking pain or crepitus in either knee. Range of motion from zero degrees to 140 degrees in each knee was shown. The joint function in each knee was additionally limited after repetitive use by pain but not by fatigue, weakness, lack of endurance, or incoordination. However, there was no additional limitation in range of motion after repetitive use. The anterior and posterior ligament stability test was within normal limits in each knee, as was the medial and lateral collateral ligaments test and the medial and lateral meniscus test. The examiner rendered a diagnosis of patellofemoral syndrome, with degenerative joint disease in each knee. The right knee also showed Grade 2 chondromalacia. The examiner stated that the appellant could not participate in sports and that he was limited in walking distances. Review of the appellant's VA treatment records dated between October 2007 and July 2011 reveals that he underwent magnetic resonance imaging of the right knee in August 2007; this demonstrated the presence of mild Grade II chondromalacia of the patellofemoral joint. The ligaments and tendons were normal. An October 2007 orthopedic surgery note found full range of motion in his right knee, without effusion. Tenderness was observed. The clinical assessment was chondromalacia. In November 2007, the appellant sought treatment for complaints of bilateral knee pain, with the right being more severe. He reported that his knees would swell up, intermittently, and that he had episodes of his right knee going out. The appellant stated that his right knee pain was 5-6/10 and that the left was 2/10. On physical examination, the appellant ambulated without an assistive device, albeit with minimal limping on the right lower extremity. There was positive patellar grinding on the right. Drawer and McMurray testing were negative. There was lateral tracking of each patella. A January 2008 nursing assessment indicates that the appellant complained of painful knees. He did not have a history of falling. His gait was described as weak. A December 2008 nursing note indicates that the appellant was encouraged to walk briskly for an hour for exercise at least three to four times per week. A March 2009 primary care note indicates that the appellant was exercising by walking, but that this was limited by knee pain. A March 2009 nursing note stated that the appellant did not have a history of falling. The appellant's knee pain was worse in a July 2011 primary care note. On physical examination, each knee was severely tender to palpation. A July 2011 nursing note indicates that the appellant was again encouraged to walk for one hour three to four times per week. He reported that his current pain was 4/10 and chronic. The appellant was afforded another VA medical examination in June 2011; the examining physician reviewed the claims file and noted that the appellant had not undergone any knee surgery and that his medical records did not document extensive treatment for the knees. The appellant reported that his knees were symptomatic on a daily basis and that the right knee was worse than the left knee. He reported experiencing constant stabbing and shooting pain, that was moderate to severe. He said that he could walk about two blocks before pain made him stop and rest. The appellant stated that he would have swelling in his knees after standing, that he used a cane and braces on both knees, and that he had episodes of falling. The appellant reported having flare-ups weekly; these lasted one day and led to swelling of the knees, which in turn reduced the appellant's capacity to walk, stand, or sit. He said that he could engage in activities such as lifting and carrying, as long as no squatting or kneeling was involved. On physical examination, the appellant exhibited a gait that was slow and wide based. He also exhibited stooping and stiff-leggedness. He had facial expressions of pain. The examiner stated that informal observation of the appellant's lower extremity range of motion yielded an observation of flexion to 110 degrees, without objective evidence of pain. On formal testing, the each knee demonstrated zero to 140 degrees of motion on passive testing in each knee. Active range of motion was to 90 degrees. After five repetitions, the appellant exhibited a passive range of motion of zero to 130 degrees. The knee joints were stable to varus and valgus stress and to anterior/posterior stress. There was no joint effusion. Mild crepitation was present. There was no muscle atrophy. The examiner stated that there was no evidence of any physical findings to indicate disuse due to the knee disabilities. There was evidence of mild lateral tracking of the patella, bilaterally. The examiner rendered a diagnosis of chondromalacia, with degenerative joint disease, bilaterally. The examiner commented that the appellant's displays of pain were out of proportion to objective findings. The examiner also noted that patellar subluxation, lateral tracking of the patella, could cause pain in the knee but did not cause ligamentous instability of the knee and therefore, would not cause the knee to give out due to instability of the ligaments. The evidence of record includes a private physical therapy evaluation report dated in September 2011. The appellant reported that his knees buckled, primarily on the left. On physical examination, each patella had a mild lateral tilt and there was moderate tenderness to palpation. The appellant's active range of motion in the right knee was from 5 to 110 degrees; it was from 5 to 95 degrees on the left. Crepitus was present. The varus/valgus stress tests were within normal limits, as was the anterior drawer test. The appellant's gait was described as slow and with a wide base of support. The VA physician who conducted the June 2011 examination issued an addendum in June 2012. The examiner reviewed the evidence of record, including the documents that had been added to the claims file since that time. The doctor indicated that the appellant provided a history of frequent episodes of locking, pain, and effusion, but these had not been documented in the medical records. The physician also stated that the appellant's muscle strength was 5/5 in his lower extremities and that there was no muscle atrophy; any strength reduction was "likely" due to pain. The examiner stated that the appellant had patellar subluxation/dislocation that was slight in severity. The examiner noted that severe pain could cause the type of buckling described by the appellant and that the appellant's knee pain was moderate to severe. The appellant underwent a VA medical examination in February 2013; the examiner reviewed the appellant's claims file. The appellant complained of daily knee pain, the left greater than the right. He said that the pain was moderate to severe and that it was increased by movement. He reported that he could walk about two blocks before stopping due to pain. The appellant stated that he was employed by the United States Postal Service. He complained of swelling and stiffness in his knees after standing. He said that he used a cane because of problems falling while standing or walking and that he had been using knee braces for three or four years. He stated that his knees would buckle approximately three to four times per day. The appellant denied experiencing any flare-ups. On physical examination, each knee had a range of motion from zero to 140 degrees; this was accomplished with pain. After repetitive testing, the right knee demonstrated zero to 130 degrees of motion, and zero to 125 degrees in the left knee. The examiner noted that the appellant had less movement than normal, excess fatigability, pain on movement and interference with sitting, standing, and weight bearing, bilaterally. There was pain on palpation of the knee joints. Strength testing was 5/5 in each knee. The knee joints were stable to varus and valgus stress and to anterior/posterior stress. There was evidence of chondromalacia and slight patellar subluxation, bilaterally. MRI examination revealed the presence of a trace effusion and a radial tear of the medial meniscus on the right, as well as trace effusion in the left knee joint, but no meniscal tear. The appellant's service-connected right and left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia, are currently evaluated at 10 percent for each knee under the provisions of Diagnostic Codes 5010-5260. 38 C.F.R. § 4.71a. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that a traumatic arthritis under Diagnostic Code 5010, is the service-connected disorder, and limitation of flexion of the knee, under Diagnostic Code 5260, is a residual condition. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2012). Degenerative arthritis established by radiographic imaging/x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. Limitation of motion must be objectively confirmed by clinical findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Where there is x-ray evidence of arthritis and limitation of motion, but not to a compensable degree under the diagnostic code, a 10 percent rating is for assignment for each major joint affected. Id. Limitation of motion of the knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Under Diagnostic Code 5260, flexion that is limited to 60 degrees is noncompensable, flexion that is limited to 45 degrees warrants a 10 percent evaluation, and flexion that is limited to 30 degrees warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, extension that is limited to 5 degrees is noncompensable, extension that is limited to 10 degrees warrants a 10 percent evaluation, and extension that is limited to 15 degrees warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2012). The medical evidence shows normal extension in his right and left knees, with one finding of a five degree loss of extension shown in each knee in September 2011. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. Limitation of flexion, as reflected in the clinical evidence, was limited at worst to 90 degrees with pain, bilaterally. In this case, chronic pain was reported in the right knee and in the left knee. However, the evidence of record does not support a rating in excess of 10 percent for the either knee disability as the requisite limitation of flexion or extension has not been shown, even when taking pain into consideration. Additional limitation of joint function was shown after repetition due to pain, fatigability, and weakness, however, the additional degree of function did not meet the criteria for a compensable evaluation based on limitation of motion. Id.; see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The findings for extension and flexion fail to meet the criteria for a compensable evaluation based on limitation of motion for both the right and left knee. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. However, as degenerative arthritis for both knees have been shown by radiographic evidence, and motion of the knees based on painful motion has been shown, a 10 percent is for assignment. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Ankylosis of either knee has not been show, nor has a right or left knee replacement. Accordingly, ratings under these provision are not for application. Therefore Diagnostic Code 5256 is not for application. 38 C.F.R. § 4.71a, Diagnostic Codes 5055, 5256 (2012). Moreover, removal of the semilunar cartilage has not been shown in either knee and therefore, Diagnostic Code 5259 is not for application. 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2012). A 20 percent evaluation may be assigned where there is evidence of dislocated cartilage, with frequent episodes of "locking," pain, and effusion of the knee joint. This is the maximum evaluation available. 38 C.F.R. § 4.71a, Diagnostic Code 5258. There is objective clinical evidence of dislocated cartilage in the right knee, and, as noted in the 2013 VA examination report and MRI, the appellant provided a history of frequent episodes of locking, pain, and effusion into the joint of the right knee. However, there was no objective clinical evidence of a current meniscal tear in the left knee at any time during the appeal period. Thus, a separate rating of 20 percent for right knee meniscal tear, with frequent episodes of locking and effusion in the joint is warranted under Diagnostic Code 5258. A separate rating is not warranted for the left knee under Diagnostic Code 5258, as the requisite medical findings have not been made. A separate evaluation of 10 percent has been assigned to each knee based on subluxation. 38 C.F.R. § 4.71a, Diagnostic Code5257. This rating contemplates slight patellar subluxation of the knee. Id. A 20 percent evaluation is for assignment for moderate patellar subluxation, and a 30 percent evaluation is for assignment for severe patellar subluxation. The November 2008 VA examiner reported that the patellar subluxation was slight in degree. The June 2011 VA examiner found lateral tracking of the patella in both knees. This same VA examiner stated that bilateral patellar subluxation was present to a slight degree in the June 2012 addendum report. The February 2013 VA examiner also found slight patellar subluxation, bilaterally. The Board has also considered the appellant's and other lay statements regarding the symptoms of his knee disorders and that each knee disability is worse. The Veteran's statements are competent evidence as to the symptoms of his bilateral knee disorders as this comes to him through his senses. Moreover, his statements are credible as they are consistent with the medical evidence of the record. However, his statements are not competent evidence as to a specific level of disability of this disorder according to the appropriate diagnostic codes. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Evidence concerning the nature and extent of each one of the appellant's knee disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings as provided in the examination reports directly address the criteria under which this type of disability is evaluated. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual appellant's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the appellant's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the appellant's disability level and symptomatology, then the appellant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the evaluations for the appellant's right and left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia are not so unusual or exceptional in nature as to render the ratings for these disorders inadequate. The appellant's right and left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia are evaluated based for limitation of motion and arthritis of both knees, the criteria of which are found by the Board to specifically contemplate the appellant's level of disability and symptomatology. 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260. As demonstrated by the evidence of record, the appellant's bilateral knee arthritis was manifested by extension limited to 0 degrees, with pain, and on one occasion 5 degrees, with pain. The appellant's bilateral knee arthritis, at worst, was manifested by flexion limited to 90 degrees, with pain. When comparing the appellant's symptoms with the symptoms contemplated in the Rating Schedule, the Board finds that the schedular evaluations regarding the appellant's right and left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia are not inadequate. Ratings in excess of the currently assigned ratings are provided for certain manifestations of the right and left knee disorder, but the medical evidence reflects that those manifestations are not present in this case. The criteria for the assigned ratings more than reasonably describe the appellant's disability level and symptomatology and, therefore, the currently assigned schedular evaluations for right and left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia are adequate and no referral is required. The Board finds that the evaluations for the appellant's patellar subluxation of both knees are not so unusual or exceptional in nature as to render the ratings for these disorders inadequate. Subluxation of both knees are evaluated under impairment to the knee, the criteria of which are found by the Board to specifically contemplate the appellant's level of disability and symptomatology. 38 C.F.R. § 4.71a, Diagnostic Code 5257. As demonstrated by the evidence of record, the appellant's bilateral patellar subluxation was slight. When comparing the appellant's symptoms with the symptoms contemplated in the Rating Schedule, the Board finds that the schedular evaluations regarding the appellant's patellar subluxation of both knees are not inadequate. Ratings in excess of the currently assigned ratings are provided for certain manifestations of these disorders, but the medical evidence reflects that those manifestations are not present in this case. The criteria for the assigned ratings more than reasonably describe the appellant's disability level and symptomatology and, therefore, the currently assigned schedular evaluations for patellar subluxation of both knees are adequate and no referral is required. A separate 20 percent evaluation for a right knee meniscal tear has been assigned herein. The Board finds that the evaluation for the appellant's right knee meniscal tear is not so unusual or exceptional in nature as to render the rating for this disorder inadequate. The appellant's right knee meniscal tear is evaluated under impairment to the knee, the criteria of which are found by the Board to specifically contemplate the appellant's level of disability and symptomatology. 38 C.F.R. § 4.71a, Diagnostic Code 5258. As demonstrated by the evidence of record, the appellant's right knee meniscal tear is manifested by frequent episodes of "locking" and effusion of the knee joint. When comparing the appellant's symptoms with the symptoms contemplated in the Rating Schedule, the Board finds that the schedular evaluation regarding the appellant's right meniscal tear is not inadequate. The criteria for the assigned rating more than reasonably describe the appellant's disability level and symptomatology and, therefore, the currently assigned schedular evaluations for right meniscal tear are adequate and no referral is required. After review of the evidence of record, there is no evidence of record that would warrant a rating in excess of those assigned at any time during the period pertinent to this appeal. 38 U.S.C.A. 5110 (West 2002); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected bilateral knee disorders, the evidence shows no distinct periods of time during which the Veteran's left knee disorder has varied to such an extent that a rating greater or less than those assigned would be warranted. Cf. 38 C.F.R. § 3.344 (2012) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). In reaching these decisions, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for increased ratings in excess of those assigned, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An evaluation in excess of 10 percent for the right knee patellofemoral syndrome, with degenerative joint disease and chondromalacia, is denied. An evaluation in excess of 10 percent for the right knee patellar subluxation is denied. A separate evaluation of 20 percent for right knee meniscal tear is granted, subject to the controlling regulations applicable to the payment of monetary benefits. An evaluation in excess of 10 percent for the left knee patellofemoral syndrome, with degenerative joint disease and chondromalacia, is denied. An evaluation in excess of 10 percent for the left knee patellar subluxation is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs