Citation Nr: 1323872 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 13-00 532 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased (compensable) rating for retropatellar pain syndrome of the right knee. 2. Entitlement to service connection for a left knee disorder, including as secondary to service-connected right knee disability. ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, served on active duty from August 2001 to August 2003. These matters come to the Board of Veterans' Appeals (Board) from a September 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the claims. In March 2013, the Veteran submitted additional pertinent evidence to the Board in support of his claims with a waiver of agency of original jurisdiction consideration pursuant to 38 C.F.R. § 20.1304 (2012). The Board has considered this additional evidence in this decision. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. For the entire appeal period, the service-connected right knee retropatellar pain syndrome has been manifested by pain, full range of motion, and normal gait, with no instability, fatigability, incoordination, or weakness of the knee joint, arthritis, or functional loss or impairment. 2. For the entire appeal period, the Veteran did not have instability of the right knee. 3. The Veteran does not have a current left knee disability. CONCLUSIONS OF LAW 1. For the entire appeal period, the criteria for a compensable disability rating for the service-connected retropatellar pain syndrome of the right knee have not been met or more nearly approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40. 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5020, 5257, 5260, 5261 (2012). 2. The criteria for service connection for a left knee disorder, including as secondary to service-connected right knee disability, have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of the VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). This notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), as was done in this case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO provided a VCAA notice letter to the Veteran in August 2011, prior to the initial adjudication of the claims for an increased rating and service connection. The letter notified the Veteran of what information and evidence must be submitted to substantiate a claim for an increased rating and service connection, as well as what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of his claims to the RO. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). In September 2011, the Veteran informed VA that he had no additional evidence or information to submit in support of his claims. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting a claimant in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Service treatment records are associated with the claims folder. VA treatment records dated from 2001 to 2012 are associated with the claims file. The Veteran underwent VA examinations in September 2011 and September 2012 to obtain medical evidence as to the nature and severity of the service-connected right knee disability and as to the nature and etiology of the claimed left knee disability. The Board finds that the VA examinations were adequate for rating purposes. Each examination was performed by a medical professional based on either a review of claims file or solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The VA examiners carefully examined each knee, measured the range of motion of the knees, and considered whether there was evidence of range of motion limited by pain or by repetitive motion. The examination reports are accurate and fully descriptive. An opinion as to whether the right knee disability caused any functional loss and as to the effects of the right knee disability on the Veteran's ordinary activity and occupational impairment were provided. The VA examiners provide an opinion as to whether there was a current left knee disability. For these reasons, the Veteran has been afforded adequate examinations of the knees. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor representative has challenged the adequacy of the VA examinations. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). 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). For these reasons, the Board finds that the duties to notify and assist the Veteran in the claims have been met, so that no further VCAA notice or assistance to the Veteran is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Increased Rating for Right Knee Disability Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of a veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). The factors involved in evaluating, and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. In DeLuca, 8 Vet. App. 202, the Court held that, for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40, and 4.45, pertaining to functional impairment. The Court 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, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. The Court has also noted that, when rating spine disabilities, the Board must discuss any additional limitation of motion that a Veteran has due to pain, weakness, or fatigue. See Cullen v. Shinseki, 24 Vet. App. 74, 85 (2010). Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. Functional loss due to pain is to be rated at the same level as the functional loss where motion is impeded. Schafrath, 1 Vet. App. at 592. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); VAOPGCPREC 9-98 (motion of a joint effectively ends where pain begins). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (the Board had failed to address painful motion and the applicability of 38 C.F.R. § 4.59 to an initial disability rating for residuals of a left shoulder injury with surgical repair). Degenerative arthritis established by x-ray findings is rated according to limitation of motion for the joint or joints involved. Where limitation of motion is noncompensable, a rating of 10 percent is assigned for each 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 a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. The knee is considered a major joint. 38 C.F.R. § 4.45(f). 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 at 592. Instead, the Mitchell Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Under Diagnostic Code 5257 (other impairment of the knee), a 10 percent disability evaluation requires slight recurrent subluxation or lateral instability. A 20 percent evaluation requires moderate recurrent subluxation or lateral instability. A 30 percent evaluation requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. VA's General Counsel has interpreted that a veteran who has arthritis and instability of the knee could receive separate ratings under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for noncompensable rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, the VA General Counsel further explained that, when a veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. In the alternative, a compensable rating may be granted by virtue of 38 C.F.R. § 4.59. Diagnostic Code 5258 provides for a maximum 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion in the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a maximum 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. Diagnostic Codes 5260 and 5261 are utilized to rate limitation of flexion and extension of the knee joint. 38 C.F.R. § 4.71a. The Schedule provides that the normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, limitation of flexion of the knee to 60 degrees warrants a noncompensable evaluation, limitation of flexion to 45 degrees warrants a 10 percent rating, limitation of flexion to 30 degrees warrants a 20 percent evaluation and limitation of flexion to 15 degrees warrants a 30 percent evaluation, the highest schedular evaluation under this diagnostic code. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of extension of the knee to 5 degrees warrants a noncompensable evaluation, limitation of extension of the knee to 10 degrees warrants a 10 percent evaluation, limitation of extension to 15 degrees warrants a 20 percent evaluation, and limitation of extension to 20 degrees warrants a 30 percent evaluation. Limitation of extension of the knee to 30 degrees warrants a 40 percent evaluation and limitation of extension of the knee to 45 degrees warrants a 50 percent evaluation, the highest schedular evaluation under this diagnostic code. 38 C.F.R. § 4.71a. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Diagnostic Code 5251 provides a maximum rating of 10 percent for limitation of extension of the thigh to 5 degrees. In this case, at the time of the grant of service connection for right knee disability, the RO assigned a zero percent initial rating to the service-connected retropatellar pain syndrome of the right knee under Diagnostic Code 5020 for the entire initial rating period from August 11, 2003. Retropatellar pain syndrome is part of a group of disorders of patellofemoral pain syndrome that are characterized by anterior knee pain between the patella and the femur, especially on climbing or descending stairs or on squatting. There may be deep tenderness on palpation and pressure on the patella, crepitus on motion, a grinding sensation behind the patella, and occasionally swelling. 68 Fed. Reg. 7018 (February 11, 2003). The Veteran filed a claim for an increased rating in August 2011. He contended that his service-connected right knee disability has worsened over the previous eight years. He states that the right knee pain has increased and he has more frequent periods of intense pain, primarily from standing for long periods of time, jumping, running, or using stairs. The Veteran asserts that he can no longer function under the ordinary conditions of daily life, and a compensable rating is warranted for the service-connected right knee disability. See the October 2011 and the November 2012 statements by the Veteran. In a March 2013 statement, the Veteran contends that his service-connected right knee disability should be rated under Diagnostic Code 5258 based upon the findings of the April 2012 Magnetic Resonance Imaging report which shows that the Veteran has an oblique tear of the posterior horn of the medial meniscus cartilage of the right knee with trace effusion. After a review of the evidence, the Board finds that the preponderance of the evidence is against the assignment of a compensable disability rating for the service-connected right knee disability for any period. The weight of the evidence shows that, for the entire rating period, the service-connected right knee disability is manifested by pain, full range of motion, and normal gait, with no instability, fatigability, incoordination, or weakness of the knee joint, arthritis, or functional loss or impairment. The September 2011 VA examination report indicates that the Veteran reported that the right knee pain had been intermittent but now the right knee was more painful because he was on his feet all day. He indicated that he has been prescribed a knee brace and has undergone steroid injections in the knee in the past. He also stated that he took Aleve as needed for the pain. The Veteran stated that standing for long periods of time, squatting, and using stairs hurt his right knee; regular walking did not hurt his right knee so much. The Veteran reported that at the end of his work day his right knee hurt pretty bad. The Veteran did not report having any flare-ups of pain. Examination of the right knee in September 2011 revealed that range of motion was zero degrees to 140 degrees of flexion. There was no objective evidence of painful motion on flexion or extension. The Veteran was able to perform repetitive use testing with three repetitions. There was no additional limitation in range of motion testing in the knee or lower leg following repetitive use testing. There was no functional loss or functional impairment in the knee or lower leg. There was no tenderness or pain to palpation of the joint line or in the soft tissue of the knee. Muscle strength of the right leg was 5/5. There were no findings of instability in the right knee. There was no recurrent patellar subluxation or dislocation in the right knee. There was no evidence of tibial or fibular impairment or evidence of a meniscal or semilunar cartilage condition. There was no x-ray evidence or imaging evidence of degenerative or traumatic arthritis of the right knee. The VA examiner indicated that the right knee disability did not impact the Veteran's ability to work. The examiner stated that the Veteran had been able to work as a sterile processing supervisor since March 2010 despite the knee complaints, although the Veteran reported increased knee pain from increased standing and walking. The September 2012 VA examination of the right knee revealed similar findings that range of motion was zero degrees to 140 degrees of flexion. There was no objective evidence of painful motion on flexion or extension. The Veteran was able to perform repetitive use testing with three repetitions. There was no additional limitation in range of motion testing in the knee or lower leg following repetitive use testing. There was no functional loss or functional impairment in the knee or lower leg. There was no tenderness or pain to palpation of the joint line or in the soft tissue of either knee. Muscle strength of the right leg was 5/5. There were no findings of instability in the right knee. There was no recurrent patellar subluxation or dislocation in the right knee. There was no evidence of tibial or fibular impairment or evidence of a meniscal or semilunar cartilage condition. There was no x-ray evidence or imaging evidence of degenerative or traumatic arthritis of the right knee. The Veteran's service-connected right knee disability has been rated as zero percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5020, as for synovitis. Diagnostic Code 5020 directs that the disability is to be rated on limitation motion of the affected parts, as degenerative arthritis. 38 C.F.R. § 4.71a. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is 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 and 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of flexion and extension of the knee is rated under Diagnostic Codes 5260 and 5261. The weight of the competent and credible evidence shows that for the entire appeal period the Veteran's right knee disability had been manifested by pain with no limitation of motion. Range of motion of the right knee was from zero degrees to 140 degrees upon VA examination in September 2011 and September 2012. A VA physical therapy record dated in December 2012 indicates that active range of motion of the right knee was -1 degrees to 135 degrees. However, as noted, upon VA examination in September 2012, range of motion of the right knee was zero degrees to 140 degrees, which was normal motion. See 38 C.F.R. § 4.71, Plate II. There was no swelling, effusion, tenderness, spasm, joint laxity, or muscle atrophy. Reconciling these examination reports in light of the whole recorded history, which includes reports of symptoms with more extensive usage, and in the context of largely negative clinical findings and measures on two comprehensive VA examinations, the Board finds that the Veteran's right knee motion more nearly approximates full motion. Even with notation of some limitation of flexion to 135 degrees on one outpatient treatment visit, such evidence does not show "at least noncompensable" limitation of flexion (limited to 60 degrees under Diagnostic Code 5260 to warrant a 0 percent rating), which is required to warrant a 10 percent rating under Diagnostic Codes 5020-5003 (rated as degenerative arthritis) for painful arthritic motion that results in at least noncompensable limitation of motion. See VAOPGCPREC 9-98 (interpreting that for a 10 percent rating for arthritis with painful motion, the limitation of motion must at least meet the criteria for a zero-percent rating under the limitation of motion rating code). The Board finds that the preponderance of the evidence is against the assignment of an increased (compensable) rating for the right knee disability under Diagnostic Codes 5003, 5260, or 5261. The weight of the competent and credible evidence shows that, notwithstanding reports of pain with more extensive usage of the knee, the Veteran has full range of motion of the right knee, even with considerations of additional limitations of motion and function due to pain, recognizing that functional loss due to pain is to be rated at the same level as the functional loss where motion is impeded. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca; Schafrath at 592; VAOPGCPREC 9-98. In the present case, the weight of the competent and credible evidence shows that the Veteran did not have impaired function of the right knee due to pain. There was full range of motion of the right knee with no objective evidence of painful motion. Examination findings of the right knee were normal and muscle strength was normal. The VA examiners concluded that there was no functional loss or impairment of the right knee or lower leg. See the VA examination reports dated in September 2011 and 2012. In reaching this conclusion, the Board has considered the degree of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, lack of endurance or pain on movement of a joint under 38 C.F.R. § 4.45 in assessing the actual limitations of motion and function, as well as considerations of limitations of motion due to pain under 38 C.F.R. § 4.59, but finds that, even with such considerations of reported pain, the criteria for a compensable disability rating is not demonstrated for either knee extension or knee flexion. See also DeLuca, supra. As noted, even with such considerations including pain, the evidence demonstrates that the Veteran does not even have noncompensable (0 percent) limitation of motion of the right knee for the time period in question so as to warrant a 10 percent rating for such painful (rated as degenerative arthritis) limitation of motion to a noncompensable degree under Diagnostic Code 5003. VA examinations of the knee in 2011 and 2012 showed full ranges of motion. The Veteran reported having pain in the right knee, but objective evidence shows full ranges of motion without objective evidence of pain. The Veteran had normal gait and normal muscle strength. There was no evidence of any functional loss or limitation of motion due to pain, or evidence of swelling, effusion, tenderness, muscle spasm, joint laxity, or muscle atrophy. The VA examiner who performed the September 2011 VA examination specifically noted that the right knee disability did not cause any functional loss. Based on the evidence of record, there is no basis for the assignment of additional disability due to pain, weakness, fatigability, or incoordination, and the Board finds that the assignment of additional disability pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59 is not warranted. The Board had considered the other diagnostic codes pertinent to rating a knee disability. Because ankylosis of the right knee is not shown, Diagnostic Code 5256 is not for application. Moreover, there are no findings of instability or recurrent subluxation right knee; thus, a separate compensable rating under Diagnostic Code 5257 is not warranted. The Veteran asserts that a 20 percent rating is warranted for the right knee disability under Diagnostic Code 5258 based upon findings of locking and effusion and based upon the findings of a meniscus tear upon the April 2012 Magnetic Resonance Imaging (MRI). With regard to this contention, the Board finds that a compensable rating is not warranted under Diagnostic Code 5258 for the right knee disability because the weight of the competent and credible evidence establishes that the service-connected retropatellar pain syndrome of the right knee is manifested only by pain. The evidence does not demonstrate that the service-connected right knee disability causes episodes of frequent locking and effusion or semilunar or dislocated cartilage. The Veteran has not reported symptoms of locking in the right knee. There is no competent evidence that the retropatellar pain syndrome of the right knee causes frequent episodes of effusion. The VA examination reports and VA treatment records do not document episodes of right knee effusion. The April 2012 MRI report indicates that the Veteran had minimal effusion of the right knee joint. This is the first time effusion is documented. Thus, the Board finds that an increased (compensable) rating is not warranted under Diagnostic Code 5258. In a March 2013 statement, the Veteran contends that his right knee disability should be characterized as an oblique tear of the posterior horn of the medial meniscus cartilage of the right knee with trace effusion as shown by the April 2012 MRI report. The Board notes that service connection is in effect for retropatellar pain syndrome, not meniscus tear, of the right knee. There is no medical evidence that relates the meniscus tear of the right knee, which was detected in July 2011, to the Veteran's period of service or to the service-connected retropatellar pain syndrome. The record shows that the Veteran had recently undergone two examinations of the right knee and the diagnosis was retropatellar pain syndrome. The Veteran himself asserts that his service-connected right knee disability should be diagnosed as a meniscus tear and he has not submitted any medical evidence that his service-connected right knee disability has been improperly or incorrectly diagnosed. The Board cannot rely on the Veteran's assertions in this regard because he is not shown to possess the type of medical expertise that would be necessary to render a diagnosis of an internal and unseen meniscus tear knee disability, or to interpret MRI reports or other medical evidence or objective tests, or to offer an opinion on a complex medical question of whether a meniscal tear injury is related to the service-connected retropatellar pain syndrome. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to the etiology of a meniscus tear knee disability, which is internal and not readily diagnosable by a lay person because it requires specialized and objective testing, and the question of whether the knee disability has been improperly diagnosed, which presupposes the ability to diagnose both disabilities and have an understanding of all symptoms and findings which define each and have the ability to ferret out overlapping symptomatology in rendering the diagnoses, falls outside the realm of common knowledge of a lay person. The question of etiology and diagnosis of a disease process, including the question of misdiagnosis with another knee disability, involves a complex medical issues that the Veteran is not competent to address. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). The Board also points out that the record does not demonstrate x-ray evidence of arthritis of the right knee or evidence of instability of the right knee at any time during the appeal period. As the Veteran's right knee has not been shown by x-ray evidence to involve arthritis and the medical evidence of record establishes that the right knee is stable and there are no findings of instability, separate or additional ratings under VAOPGCPREC 23-97 and VAOPGCPREC 9-98 are not warranted. Separate ratings for limitation of extension and limitation of flexion of the right knee are not warranted. See VAOPGCPREC 9-2004. As noted above, the weight of the competent and credible evidence shows that there was full range of motion of the right knee. In summary, the Board concludes that an increased (compensable) rating for the service-connected right knee disability is not warranted at any time during the appeal period. The Board further finds that a staged rating is not warranted in this case. The Board has examined the record and, as discussed above, finds that a compensable rating is not warranted at any time during the appeal period; the evidence shows for the entire appeal period that that the right knee was manifested by full range of motion, no instability or subluxation, and no functional loss. Extraschedular Consideration Finally, the Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (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 the service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate a veteran's level of disability and symptomatology and is found inadequate, it must determine whether the veteran'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"). When the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step, a determination of whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The service-connected right knee disability is manifested primarily by pain with full range of motion and no functional loss. The level of severity of the Veteran's right knee disability is adequately contemplated by the applicable diagnostic criteria. The diagnostic codes pertinent to rating a knee disability rate the knee disability based upon symptoms of limitation of motion, instability or subluxation, ankylosis, and dislocation or removal of knee cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5261. The Veteran's retropatellar pain syndrome has been rated under Diagnostic Codes 5020-5003, as degenerative arthritis, which includes considerations of whether the criteria for even noncompensable (0 percent) rating is met based on limitation of motion due to pain or other limiting orthopedic factors. Diagnostic Codes 5010-5003, 5260, 5261 incorporate as part of the schedular rating criteria various orthopedic factors including pain that limit motion or function of the knee. See 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca. The criteria provide for higher ratings for knee symptoms. Separate ratings are possible for knee symptoms such as instability in addition to a rating for limitation of motion. As discussed, the manifestations of the service-connected right knee disability are contemplated by the rating schedule in that the assigned ratings reasonably assess the severity of the overall condition. In this sense, they are not shown to be unusual or exceptional. The rating criteria reasonably describe his disability level and symptomatology and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. In view of the adequacy of the disability rating assigned under the applicable diagnostic criteria, consideration of the second step under Thun is not for application in this case. Accordingly, the claim will not be referred for extraschedular consideration. Service Connection for Left Knee Disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A §§ 1110, 1131. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Where the evidence shows a "chronic disease" listed under 38 C.F.R. § 3.309(a) in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection can be granted for a disability that is aggravated by a service-connected disability. Compensation can be paid for any additional impairment resulting from the service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Except as provided in 38 C.F.R. § 3.300(c) (claims for secondary service connection based on the effects of tobacco products received after June 9, 1998), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level." Id. The Board must analyze the credibility and probative value of the evidence, account for the persuasiveness of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr, 21 Vet. App. at 308-09 (varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence; therefore, the veteran prevails in his claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against a veteran's claim that the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that he has a left knee disability, and that the left knee disability is due to the service-connected right knee disability. He asserts that a VA orthopedist related the left knee disability to the right knee disability. The Veteran also contends that service connection for a left knee disability on the basis of aggravation by the right knee disability. See the October 2011 statement by the Veteran. The Veteran states that he has pain in his left knee, and that the pain has increased. At the September 2011 VA examination, the Veteran stated that he believed he has been putting more pressure on his left knee because of the service-connected right knee disability. After reviewing all the evidence, lay and medical, and considering the Veteran's contentions, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a current left knee "disability." The Veteran was afforded VA examinations in September 2011 and September 2012 to obtain medical evidence as to the nature and etiology of the claimed left knee disability. The September 2011 VA examination report indicates that the VA examiner found no objective evidence of left knee pathology. Physical examination of the left knee revealed full range of motion, from zero degrees to 140 degrees. There was no objective evidence of painful motion of the left knee. There was no evidence of additional limitation of motion of the left knee after repetitive testing. The examiner indicated that there was no functional loss or functional impairment of the left knee or left lower extremity. Muscle strength on the left lower extremity was 5/5 and normal. There was no instability or subluxation in the left knee. The VA examiner opined that there was no evidence of a left knee abnormality on examination. The VA examiner stated that the service treatment records document one episode of left knee pain, date unknown, and the pain was attributed to marching exercises with an essentially negative examination diagnosed as knee hyperextension. The examiner indicated that there was no documentation of a chronic left knee condition in active duty. The examiner noted that a July 2001 VA orthopedic consult record shows a diagnosis of peripatellar synovitis secondary to the patellar maltracking. The examiner indicated that there was no objective evidence of synovitis on the current examination and specifically, there was no redness, heat, edema, deformity, medio-lateral/anterior or posterior instability, or tenderness on examination. The examiner noted that the July 2011 bone scan was silent for any left knee condition. The examiner further stated that there was no evidence of peripatellar tenderness or other abnormality on the left knee exam. The bilateral leg lengths were symmetric. Gait was normal and the Veteran was able to squat although he reported difficulty and knee discomfort. The examiner stated that there was no definite evidence of patellar misalignment The reported pain was generalized above and below the patella, not medially, and there was no tenderness on palpation. There was no genu valgum and apprehension sign on mobilization of the patella was negative. The examiner indicated that body weight puts stress on the knees and the Veteran had gained and lost much weight over the years; he was 300 pounds when he was a truck driver, was currently 267 pounds; and was 203 pounds when he left service. The Veteran was afforded another VA examination in September 2012. The VA examiner examined the Veteran and reviewed the claims folder and the VA treatment records dated since the previous September 2011 VA examination. The examiner noted that the VA treatment records showed that the Veteran continued to be treated for pain in the left knee, peripatellar synovitis, and global patellofemoral instability. See the VA treatment records dated in 2001 and 2012 including the July 2011 orthopedic consult and the December 2011 physical therapy record. The examiner reviewed the claims folder and concluded that there was no objective evidence of left knee abnormality. The Board finds that the VA examination reports have high probative value because the examiners reviewed and considered the Veteran's medical history pertinent to the left knee and also reviewed the pertinent evidence in the claims file. The VA examiners relied on sufficient and accurate facts and data in formulating their opinions. The VA examiners noted the detailed examination findings which supported the medical conclusion that there is no objective evidence of a left knee abnormality, that is, no diagnosed left knee disability. The Veteran contends that he has a current left knee disability because he experiences left knee pain. The Veteran is competent to report an observable symptom such as pain; however, the Veteran is not competent to render a clinical diagnosis of a specific type of disease process within the joint of the knee without the requisite medical training and expertise, as such internal and unseen disorder or disease process is not visible and requires specialized and objective testing. See Kahana, 24 Vet. App. 435 (stating that lay competency does not include the ability to ascertain whether or not an ACL tear occurred based only on symptoms). He is not competent to interpret medical records and render a diagnosis without the requisite medical training and expertise. The Veteran contends that the July 2011 VA orthopedic consult record shows that the left knee peripatellar synovitis secondary to the patellar tracking shows that he has a left knee disability due to the right knee disability. Rendering a diagnosis of a disease of the joint such as arthritis or patellar pain syndrome or rendering an opinion as to etiology of a disease or disability falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). As discussed above, the VA examiners reviewed the July 2011 VA orthopedic consult record and concluded found that the Veteran did not have a current left knee disability. The weight of the competent evidence shows that the Veteran does not have an identifiable disability of the left knee, including that examination of the left knee in September 2011 and September 2012 was negative. As noted above, the VA examiners considered the Veteran's report of left knee pain, the treatment for left knee pain, and the findings of synovitis and patellofemoral instability, and the examiners concluded that there was no current left knee abnormality or disability. A diagnosis of left knee disability was not made following such history, review, and examination. The Court has held that Congress specifically limited entitlement to service connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The report of the symptoms of pain alone does not equate to a diagnosis of current left knee disability. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). The Veteran was recently provided two examinations of the left knee, and a current left knee disability was not diagnosed or detected. With any claim for service connection (under any theory of entitlement), it is necessary for a current disability to be present. See Brammer, 3 Vet. App. at 225. In this case, the weight of the record of evidence indicates that the Veteran does not currently have a diagnosed left knee disability. For these reasons, service connection for a left knee disability must be denied. As the preponderance of the evidence weighs against the Veteran's claim for service connection for a left knee disability, the benefit of the doubt doctrine is not applicable, and the claim for service connection under any theory, direct or secondary, must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER An increased (compensable) rating for the service-connected right knee retropatellar pain syndrome is denied. Service connection for a left knee disability, including as secondary to service-connected right knee disability, is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs