Citation Nr: 1323981 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 09-41 456 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 20 percent prior to January 1, 2009, for left knee degenerative joint disease, and in excess of 10 percent on and after January 1, 2009, to include the propriety of the reduction from 20 percent to 10 percent, effective January 1, 2009. 2. Entitlement to a rating in excess of 30 percent prior to January 1, 2009, for left knee instability, and in excess of 10 percent on and after January 1, 2009, to include the propriety of the reduction from 30 percent to 10 percent, effective January 1, 2009. REPRESENTATION The Veteran is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from January 1988 to January 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision rendered by the Department of Veterans Affairs (VA) Regional Office in Seattle, Washington. During the pendency of this appeal, the Veteran's claims file was transferred to the Regional Office in Waco, Texas (RO). FINDINGS OF FACT 1. The Veteran received notice of the proposed reduction of his 20 percent rating for his left knee degenerative joint disease and of his 30 percent rating for his left knee instability via a July 2008 rating decision and an August 2008 letter; he was notified of his right to submit additional evidence and request a predetermination hearing. 2. An October 2008 rating decision reduced the rating assigned to the Veteran's left knee degenerative joint disease from 20 percent to 10 percent and reduced the rating assigned to his left knee instability from 30 percent to 10 percent, both effective January 1, 2009. 3. At the time of the October 2008 rating decision, neither the 20 percent evaluation for the Veteran's left knee degenerative joint disease nor the 30 percent rating for his left knee instability had been in effect for five years or longer. 4. At the time of the October 2008 rating decision, the medical evidence reflected material improvement in both the Veteran's left knee degenerative joint disease and instability under the ordinary conditions of his life. 5. Prior to January 1, 2009, the Veteran's left knee degenerative joint disease was manifested by symptoms, including pain on use, productive of functional impairment that more nearly approximated flexion limited to no worse than 30 degrees. 6. On and after January 1, 2009, the Veteran's left knee degenerative joint disease was manifested by symptoms, including pain on use, productive of functional impairment that more nearly approximated flexion limited to no worse than 45 degrees. 7. Prior to January 1, 2009, the Veteran's left knee instability was assigned the maximum schedular rating available. 8. On and after January 1, 2009, the Veteran's left knee instability more nearly approximated slight instability. CONCLUSIONS OF LAW 1. The reduction of the rating from 20 percent to 10 percent for the Veteran's left knee degenerative joint disease, effective January 1, 2009, was proper, and restoration of the 20 percent rating is not warranted. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.105, 3.344, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2012). 2. The reduction of the rating from 30 percent to 10 percent for the Veteran's left knee instability, effective January 1, 2009, was proper, and restoration of the 30 percent rating is not warranted. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.105, 3.344, 4.6, 4.71a, Diagnostic Code 5257 (2012). 3. A rating in excess of 20 percent, prior to January 1, 2009, for left knee degenerative joint disease is not warranted. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260 (2012). 4. A rating in excess of 10 percent on and after January 1, 2009, for left knee degenerative joint disease is not warranted. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010, 5260 (2012). 5. A rating in excess of 30 percent, prior to January 1, 2009, for left knee instability is not warranted. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.6, 4.71a, Diagnostic Code 5257 (2012). 6. A rating in excess of 10 percent on and after January 1, 2009, for left knee instability is not warranted. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.6, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Inasmuch as this appeal concerns claims of entitlement to increased ratings, VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO's November 2007 letter to the Veteran satisfied the duty to notify provisions relating to his claim for an increased rating for left knee instability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The November 2007 letter notified the Veteran that he must submit, or request that VA obtain, evidence of the worsening of his disability; the different types of evidence available to substantiate his claim for a higher rating; and the need to submit evidence of how such worsening affected his employment. The record does not reflect that the Veteran was provided VCAA notice with regard to his claim for an increased rating for left knee degenerative joint disease. However, the Board finds that the Veteran has not been prejudiced by this notice defect as the record reflects that he had actual knowledge of the information and evidence necessary to substantiate his claim. In this regard, the Board notes that the Veteran was provided notice of the rating criteria associated with the diagnostic codes under which the relevant ratings were assigned via a September 2009 statement of the case. Thereafter, the Veteran's claims were readjudicated in two supplemental statements of the case. As such, the Board finds that no further development is required regarding the duty to notify because the discussed deficiency is not prejudicial. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records and VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Further, there was no indication in the record that additional evidence relevant to the issues being decided herein was available and not part of the record. See Pelegrini, 18 Vet. App. at 120. The Veteran was afforded VA (including fee-basis) examinations in December 2007, January 2010, and August 2010. Subsequent to these examinations, the Veteran took exception to some of the VA examiners' findings. Specifically, with respect to the January 2010 VA examination, the Veteran claimed that he did not "refuse" to flex his left knee, but that he was then experiencing so much pain that he was unable to flex his knee beyond 5 degrees. However, as noted by the examiner in the resulting report, it was observed that the Veteran was able to sit with his left knee flexed to 90 degrees without similar pain. As such, the Board finds that the Veteran's statements as to his left knee range of motion during the January 2010 VA examination are not credible. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (noting that the credibility of statements may be impeached by inconsistent statements and consistency with other evidence). The evidence of record was otherwise silent as to how the January 2010 VA examination was deficient and, thus, the Board finds that it is adequate for rating purposes. Additionally, in October 2011 and May 2013 briefs, the Veteran's representative asserted that the August 2010 VA examination was inadequate because the examiner failed to address the stability of the Veteran's left knee. However, review of the August 2010 examination report showed that the examiner noted that the Veteran complained of feelings of instability while ascending and descending stairs. Further, the examiner specifically determined that McMurray's, Lachman's, and anterior and posterior drawer tests were negative. Moreover, the examiner found that the Veteran's left knee was stable to varus and valgus stress. Although the examiner did not provide a characterization of the Veteran's left knee instability, such as mild, moderate, or severe, the examiner included a clinical assessment thereof. As such, given the absence of other evidence or argument that the August 2010 VA examination was deficient, the Board finds that it is adequate for rating purposes. In sum, the examiners reviewed the Veteran's claims file, treatment records, and administered clinical evaluations, all of which allowed for fully-informed examinations of the claimed disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Clinical findings relevant to the rating criteria were provided. As such, a remand to provide the Veteran another VA examination is not warranted. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the Veteran's claims, 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); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974)("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). With regard to the restorations/propriety of the reductions appeals, the Board notes that such appeals stem from a 38 C.F.R. § 3.105(e) reduction, not a claim or application for benefits. As such, it arises from an action initiated by the RO, not the Veteran. The regulations pertaining to the reduction of disability evaluations contain their own notification and due process requirements. See 38 C.F.R. § 3.105(e), (i). For this reason, the above-discussed notice and assistance provisions do not apply to the Veteran's claims concerning the restorations or the propriety of the reductions. Generally, 38 C.F.R. § 3.105(e) allows for a reduction in the evaluation of a service-connected disability when warranted by the evidence, but only after following certain procedural guidelines. First, there must be a rating action proposing the reduction, and the Veteran must be given 60 days to submit additional evidence and to request a predetermination hearing. If a hearing is not requested, and reduction is considered to be still warranted, a rating action will be taken to effectuate the reduction. 38 C.F.R. § 3.105(e), (i)(2). The effective date of the reduction will be the last day of the month in which a 60-day period from the date of notice to the Veteran of the final action expires. 38 C.F.R. § 3.105(e), (i)(2)(i). The Board concludes that VA has complied with the notification and due process requirements applicable to the reduction of a disability evaluation. Specifically, as an attachment to an August 2008 VA letter, a July 2008 rating decision informed the Veteran of the proposed reductions, the evidence, and the reasons and bases for the proposed reductions. The August 2008 letter to the Veteran informed him of his right to submit additional evidence or argument and to present such evidence or argument at a personal hearing, pursuant to 38 C.F.R. § 3.105(e), (i). The reductions, following the 60-day period to allow evidence to be submitted, were adjudicated in an October 2008 rating decision, which is, in part, the subject of this appeal. In the October 2008 rating decision and via an October 2008 letter, the RO informed the Veteran that the reductions would take effect January 1, 2009. As discussed above, the Board notes that the Veteran's VA treatment and private treatment records have been obtained. The Veteran has been provided adequate VA examinations. Further, neither the Veteran nor his representative has indicated that there is any additional evidence that should be obtained to substantiate the claims. The Board is satisfied that the originating agency properly processed the Veteran's claims after providing the required notice and that any procedural errors in the development and consideration of the claims by the originating agency were insignificant and non-prejudicial to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Accordingly, the Board will address the merits of the claims herein. The 20 percent rating assigned to the Veteran's left knee degenerative joint disease became effective on May 26, 2004, and the 30 percent rating for his left knee instability became effective on July 1, 2004. As these ratings were in effect for less than five years prior to the October 2008 reductions, the provisions of 38 C.F.R. § 3.344(a),(b), which provide additional regulatory hurdles to rating reductions, do not apply. The provisions of 38 C.F.R. § 3.344(c) hold that ratings in effect for less than five years can be reduced upon a showing that the disability has improved. The Veteran received notice of the proposed reduction of the 20 percent rating assigned to his left knee degenerative joint disease, and of his 30 percent rating assigned to his left knee instability, in a July 2008 rating decision provided as an attachment to an August 2008 letter, in which he was notified of his right to submit additional evidence and request a predetermination hearing. An October 2008 rating decision reduced the Veteran's disability rating for left knee degenerative joint disease from 20 percent to 10 percent, and reduced his disability rating for left knee instability from 30 percent to 10 percent, both effective January 1, 2009. Notice of that determination was provided that same month. Thus, he was given proper notice and time to respond before the disability ratings were reduced. 38 C.F.R. § 3.105. In Brown v. Brown, 5 Vet. App. 413 (1993), the Court of Appeals for Veterans Claims (Court) identified general regulatory requirements which are applicable to all rating reductions, including those which have been in effect for less than five years. Pursuant to 38 C.F.R. § 4.1, it is essential, both in the examination and in the evaluation of the disability, that each disability be viewed in relation to its history. Brown, 5 Vet. App at 420. Similarly, 38 C.F.R. § 4.2, establishes that "[i]t is the responsibility of the rating specialist to interpret reports of examination in light of the whole record history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of the disability present." Id. The Court has held that these provisions "impose a clear requirement" that rating reductions be based on the entire history of a veteran's disability. Id. Furthermore, per 38 C.F.R. § 4.13, the rating agency should assure itself that there has been an actual change in the condition, for better or worse, and not merely a difference in the thoroughness of the examination or in use of descriptive terms. Additionally, in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but that such improvement reflects improvement in ability to function under ordinary conditions of life and work. See Brown, 5 Vet. App. at 420-421; see also 38 C.F.R. §§ 4.2, 4.10. A claim as to whether a rating reduction was proper must be resolved in the Veteran's favor unless VA concludes that a fair preponderance of evidence weighs against the claim. Brown, 5 Vet. App. at 421. 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). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). 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. This involves a factual determination of the current severity of the disability. Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2012). Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). 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. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. Id. Under Diagnostic Code 5257, which concerns instability, a 10 percent evaluation is assigned for "slight" recurrent subluxation or lateral instability of the knee; a 20 percent evaluation is assigned for "moderate" recurrent subluxation or lateral instability of the knee; and a maximum 30 percent evaluation is assigned for "severe" recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board observes that the words "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. VA General Counsel opinions provide for separate evaluations for knee instability and knee arthritis in certain cases. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2012); see also VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997) (knee arthritis and instability may be rated separately under Diagnostic Codes 5003 and 5257, provided that any separate rating is based upon additional disability); VAOPGCPREC 9-98; 63 Fed. Reg. 56704 (1998) (if a disability rating under Diagnostic Code 5257 for instability of the knee is in effect, and there is X-ray evidence of arthritis, a separate rating for arthritis based on painful motion can be assigned under 38 C.F.R. § 4.59). Normal flexion of the knee is to 140 degrees, and normal extension of the knee is to 0 degrees. See 38 C.F.R. § 4.71, Plate II (2012). Limitation of motion of the knee is evaluated as noncompensable if there is more than 45 degrees of flexion, and less than 10 degrees of limitation of extension. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. A 10 percent evaluation is warranted when extension is limited to 10 degrees or when flexion is limited to 45 degrees. Id. A 20 percent evaluation is for application when extension is limited to 15 degrees or when flexion is limited to 30 degrees. Id. A 30 percent evaluation is warranted when extension is limited to 20 degrees or when flexion is limited to 15 degrees. Id. Moreover, separate ratings for compensable knee extension and compensable knee flexion can be assigned. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). In October 2007, the Veteran submitted a claim of entitlement to increased ratings for his service-connected left knee degenerative joint disease and instability. Pursuant to these claims, the Veteran was provided a VA examination in December 2007. Based primarily on the results generated by this examination, in a July 2008 rating decision, the RO proposed to reduce the ratings assigned to the Veteran's left knee degenerative joint disease and instability. After being afforded the requisite 60-day period to submit evidence and/or request a hearing, the RO issued an October 2008 rating decision reducing the 20 percent rating assigned to the Veteran's left knee degenerative joint disease to 10 percent, and reducing the 30 percent rating assigned to the Veteran's left knee instability to 10 percent, both effective January 1, 2009. Thereafter, the Veteran perfected an appeal seeking, not just the restoration of the previous ratings, but also ratings in excess thereof. These claims have been certified to the Board for appellate review. For the sake of economy, the Board will undertake a single recitation of the pertinent evidence before conducting the appropriate analyses. A November 2006 VA orthopedic consultation report showed that the Veteran appeared for an evaluation of left knee. After briefly describing the onset and course of his left knee disabilities, the Veteran stated that he underwent a surgical procedure in 2002, which he stated healed his pain to some degree, but that his pain had returned. The Veteran reported that is left knee gave out on him three weeks ago without warning, with about three additional such episodes occurring the same day. Since then, he stated that he "occasionally" experienced a feeling of instability. Further, the Veteran endorsed pain of 6 on a 10-point scale that was localized to the inferior border of his left knee. He denied the use of a knee brace and undergoing physical therapy. Physical examination demonstrated full extension and flexion to 110 degrees; some tenderness of the anterior portion of the knee; a positive McMurray's test; negative and anterior and posterior drawer testing. Radiological evaluation of the Veteran's left knee demonstrated that his joint space compartments remained well preserved. There was no significant osteoarthritic change, fracture, or dislocation seen. The radiologist's impression was "no evidence of osteoarthritis or acute skeletal trauma." In reviewing the x-rays, a VA nurse practitioner stated that they revealed very mild medial component and patella femoral compartment arthritis. The assessment was left knee pain due to arthritis, but that an underlying meniscal tear was possible. According to an April 2007 VA orthopedic report, the Veteran described the onset and course of his left knee disabilities. He endorsed ongoing left knee pain and stated that his left gave out on him "at times" due to "significant pain." He denied any locking or catching, but endorsed an inability to keep his left knee flexed in a 90-degree angle for prolonged periods and an inability to run. He stated that his left knee pain only occurred with ambulation, and that his left knee pain sometimes aggravated him at night. The Veteran said his left knee pain could be 10 on a 10-point scale, but that it typically scored a 5. Physical examination revealed no effusion, tenderness to palpation over the tibial tubercle, and quadriceps strength of 4 out of 5. The Veteran exhibited a positive end point with testing of varus and valgus stress as well as anterior and posterior drawer testing. Lachman's testing was negative. Radiological examination showed a tibia tubercle ossicle, which was the assessment. A July 2007 VA orthopedic notes demonstrated that the Veteran appeared for a follow-up appointment two weeks after the surgical removal of an ossicle on his left patellar ligament. The Veteran reported that it was slightly tender to activate his quadriceps from extension. He denied working since the operation. Physical examination revealed that the Veteran was able to extend fully and could flex beyond 90 degrees with some discomfort over the level of his incision. This range of motion was described as "excellent." There was no effusion, erythema, or other concerning cutaneous findings. Distally, he was neurovascularly intact. The Veteran was described as "doing well." According to a separate VA orthopedic note dated on the same day in July 2007, the Veteran endorsed anteriomedial joint line pain that was aggravated with left knee flexion, but denied weight bearing being bothersome. Physical examination demonstrated, among other things, no pain to palpation to joint line. Range of motion was from full extension to 80 degrees of flexion, limited by pain. A 2-centimeter area of decreased sensation to light touch was observed on the lateral aspect of the Veteran's left knee. The assessment was status post ossicle excision in left patellar ligament, July 6, 2007. It was stated that the Veteran was "recovering well." According to an August 2007 private treatment report, the Veteran presented for a follow-up appointment subsequent to a July 2007 arthroscopic surgical procedure. The Veteran reported undergoing physical therapy, and that "things [had] been relatively stable." However, he endorsed "some" ongoing pain, swelling/firmness over the distal aspect of the anterior knee, mild tenderness to palpation, and pain on ambulation. Range of motion was determined to be "full" extension and flexion to 120 degrees. McMurray's and Lachman's testing was negative, and his gait was normal. The assessment was knee pain status post surgery. It was recommended that the Veteran undergo imaging studies in order to evaluate the swelling. An August 2007 VA orthopedic note showed that the Veteran appeared for a follow-up appointment 6 weeks post surgical removal of ossicle from left patellar ligament. The Veteran noticed that the surgical site had increased in swelling and was larger than it was pre-operatively. He endorsed pain on the anterior aspect of his left over the incision site, mostly with weight bearing activities. Physical examination showed no erythema or inflammation; no increase in warmth; obvious swelling to surgical site; mild tenderness to palpation; and an area of numbness on the medical aspect of his incision site. Range of motion testing showed full extension and 100 degrees of flexion, and no increased in pain with resisted extension. The assessment was that the area was mostly irritated as the tendon had to be disrupted intraoperatively and that it would take time for the tendon to heal. A November 2007 VA outpatient treatment report showed that the Veteran complained of left knee pain, status post excision of a painful accessory ossicle of the left patella ligament. A physical examination revealed a hypertrophic tibial plateau, a well-healed surgical scar, no redness or warmth, no induration, and mild tenderness. He was advised to return within a few days to be fitted with the appropriate crutches. A VA physical therapy initial consultation report demonstrated that the Veteran presented three days later. The initial diagnosis was left knee status post excision of an ossicle on the left patellar ligament in July 2007. He was seen for the purposes of obtaining crutches. The Veteran reported ongoing left knee pain since the July 2007 operation, rating the pain as a 7 on a 10-point scale. The physical therapist observed that the Veteran arrived without the use of an assistive device and in no acute distress. The Veteran was then provided with the appropriate assistive device, including for use on stairs. In December 2007, the Veteran underwent a VA examination to assess the severity of his left knee degenerative joint disease and instability. The Veteran endorsed the following left knee symptoms: constant pain, giving out, weakness, swelling, and fatigability, which prevented him from prolonged walking or driving his manual car. With respect to this pain, the Veteran described it as "aching" and "sharp," rating it as a 9 on a 10-point scale. He denied stiffness, heat, redness, lack of endurance, locking, and dislocation. He also denied receiving any treatment for his left knee. Physical examination revealed a gait within normal limits, equal leg length, no abnormal weight bearing, and use of a brace. There was no sign of edema, effusion, weakness, redness, heat, guarding of movement, or subluxation. Tenderness was observed in the anterior aspect, but no locking, genu recurvatum, or crepitus. Range of motion testing showed that the Veteran was able to extend his left knee to zero degrees and flex to 90 degrees. The examiner stated that the Veteran's joint function was not additionally limited after repetitive use due to pain, fatigue, weakness, lack of endurance, and that pain was the major functional impact. However, the examiner also stated that the joint function was additionally limited by incoordination, but that the additional limitation was by zero degrees. Stability testing of the anterior and posterior cruciate ligaments, the medial and collateral ligaments, and the medial and lateral meniscus were within normal limits. Radiological examination of the Veteran's left knee revealed thickening of the distal patellar tendon adjacent to the soft tissue; findings that were consistent with Osgood-Schlatter's disease. Ultimately, the diagnosis was Osgood-Schlatter's disease and tendonitis. As mentioned above, the December 2007 VA examiner stated that the Veteran's left knee function was additionally limited by incoordination, but that the additional limitation was by zero degrees. In an addendum to the opinion, it was explained that, although the examiner stated that the Veteran's left knee function was additionally limited by incoordination, by stating that there were zero degrees of additional limitation, it actually meant that there was no additional limitation of function after repetitive motion. A May 2008 VA ambulatory care note showed that the Veteran complained of left knee pain since a July 2007 surgical procedure. He denied undergoing physical therapy, but that he was utilizing a brace and crutches. He rated his pain as ranging from 5 to 7 on a 10-point scale, but denied taking any pain medication. Physical examination revealed mild swelling in the patellar area. The Veteran exhibited a full range of left knee motion. The assessment was left knee pain, status post arthroscopic surgery. It was recommended to the Veteran that he continue the use of the brace and undergo physical therapy. According to a June 2008 VA physical therapy consultation report, the Veteran complained of constant pain in the center of his left knee and swelling as a result of surgery the previous year. He stated that his pain rated an 8 on a 10-point scale. Prior to the surgery, the Veteran stated that he had no pain, but that his knee was giving out. He asserted that he had to change jobs due to left knee pain such that he is working in a seated position the majority of the time. Physical examination demonstrated no swelling, enlargement of the left tibial tuberosity area, and good muscle size and tone in the left lower extremity. Upon palpation, his left knee exhibited a normal temperature, but tenderness over the anterior and inferior left knee area. Active range of motion testing demonstrated that the Veteran's left knee extension was "within normal limits" and flexion was a "min[imal] loss." Passive range of motion testing regarding left knee extension demonstrated an increase, but that the Veteran endorsed pain during the movement. Anterior and posterior drawer, valgus stress, and varus stress testing were all negative, but painful. General strength in the Veteran's left lower extremity was determined to be 3+ to 4- on a 5-point scale with no muscle weakness. The Veteran was provided a transcutaneous electrical nerve stimulation unit. The assessment was chronic left knee pain. A December 2008 VA orthopedic consultation report demonstrated that the Veteran complained of left knee discomfort and a sense of giving away for "some time." The Veteran stated that the discomfort was mostly along the front line of his left knee when he sat for prolonged periods. Consequently, the Veteran stated that he sat with his left leg extended. He endorsed occasional popping, but no locking. He stated that his left knee will give away "at times," so he wears a brace "part time." Physical examination showed that the Veteran ambulated with a normal gait, though he tended to decrease left knee motion when being observed. There was no erythema or swelling, but the Veteran stated that his left knee felt numb to palpation. It was observed that the Veteran "voluntarily" avoided contracting his quadriceps except for modified effort, and "refuse[d]" to flex his left knee more than 35 degrees during the examination, which limited provocative testing, but no crepitus or grinding was observed. The Veteran's left knee was stable to stress testing, including patella. Radiological examination revealed no bone, joint, or soft tissue abnormality, and no evidence of trauma. The impression was that the Veteran's left knee was normal in appearance. The diagnoses were anterior left knee pain, chronic, non-specific; status post surgical procedures, left patellar tendon; and subjective versus objective discrepancies notable. In November and December 2008 statements, the Veteran reported that he continued to use a left knee brace, and that there was no change in his left knee symptoms, including pain and an inability to bend his knee. Additionally, the Veteran stated that there was a lump on his left knee, and that he was provided a transcutaneous electrical nerve stimulation unit for use at home. An April 2009 private treatment report demonstrated that the Veteran endorsed left knee pain and that he wanted a steroid injection. Physical examination revealed tenderness to palpation. The assessment was left knee pain, "unchanged." According to a June 2009 private treatment report, the Veteran complained of left knee pain. The Veteran reported that his left knee "went out" three times since his last appointment, which was a higher frequency than in the past. He reported that he had been going to physical therapy. Physical examination showed no swelling of the left knee and "no changes." A June 2009 VA ambulatory care note showed that the Veteran appeared for a routine visit. He asserted that he had "fallen" three times since his last visit due to his left knee giving out, but that he was able to catch himself on each occasion, with the exception of once, which occurred on June 11, 2009. Physical examination revealed no left knee swelling. The assessment was left knee pain. The Veteran planned to follow-up with his private orthopedist. An August 2009 private treatment report showed that the Veteran endorsed falling "a couple of times" since his last appointment, and endorsed "a little swelling" in his left knee after walking a mile. Physical examination revealed mild left knee effusion. Range of left knee motion testing demonstrated that the Veteran was able to extend to zero degrees and flex to 90 degrees. Additionally, the Veteran's left knee ligaments appeared intact. The impression was left knee pain, "unchanged." An October 2009 private treatment report showed that the Veteran said his left knee "went out" twice since his last appointment and that he continued to experienced left knee "issues." He stated that his left knee felt "unstable." Further, the Veteran said he experienced left knee stiffness, and the examiner opined that his range of left knee motion was "limited." Physical examination revealed a normal appearing left knee. Range of motion testing appeared to indicated that the Veteran's was able to extend his left knee to 5 degrees and flex to 10 degrees. Joint ligaments were intact as were distal motor and sensory function. The impression was left knee pain, "unchanged." According to a private treatment report dated later in October 2009, the Veteran appeared for the administration of a steroid injection for his left knee. Physical examination showed left knee crepitus. Range of left knee motion testing demonstrated flexion limited to 30 degrees, while extension was "normal." Further, his ligaments were "intact." The impression was left knee pain, "unchanged." As part of the Veteran's October 2009 substantive appeal, the Veteran asserted that his was "still" in pain, stated that he self-administered treatment using a transcutaneous electrical nerve stimulation unit, and continued to use a brace. Further, the Veteran stated that his left knee "went out" 9 times during the previous year, and that he was undergoing physical therapy. The Veteran described the occupational impact of his left knee disabilities, and reported that he could not ascend and descend stairs without help. An October 2009 letter from Jordan Loftis, M.D., indicated that the Veteran had been the doctor's patient since February 10, 2009. Dr. Loftis stated that the Veteran experienced "issues" with pain and a "limited" range of motion in his left knee. The doctor then stated that he had administered oral medications and intra-articular steroid injections. Dr. Loftis then reiterated that the Veteran experienced chronic left knee pain and decreased knee flexion, which limited his ability to work certain jobs. Further, the doctor stated that the Veteran's situation was likely one that, given the nature, will be a chronic issue and did not stand to have significant improvement in baseline functioning. In January 2010, the Veteran underwent a VA examination to assess the severity of his left knee degenerative joint disease and instability. After the examiner detailed the onset and course of the Veteran's left knee disabilities, the Veteran stated that he continued to experience daily/constant left knee pain, rating his pain as a 10 on a 10-point scale. The Veteran said that his left knee had a tendency to "slip out of joint," and that he had instability. He stated that his left knee symptoms result in falls, but that he was able to catch himself "most of the time." He denied flare-ups. The Veteran stated that he had a desk job because he had to stop working in a warehouse as a manager due to an inability to drive trucks. The Veteran said that his walking was limited as he fatigued easily, and that he had decreased endurance due to pain. With respect to treatment, the Veteran reported that he took Ibuprofen for pain and that a private doctor administered a series of steroid injections in 2009 without relief. The Veteran continued the use of a brace and the transcutaneous electrical nerve stimulation unit, but that the latter was not helping. The examiner reviewed February 2009 magnetic resonance imaging that revealed patellar tendinosis, thickening of the distal patellar tendon, and chondromalacia of the femoral tibial compartment. Physical examination showed that the Veteran ambulated with a "slight" limp. Further, the examiner observed suprapatellar effusion, joint line tenderness, and the Veteran's ability to flex his left knee to 90 degrees while in seated position. During range of motion testing while in supine position, the Veteran "refuse[d]" to flex his left knee more than 5 degrees because he stated that to do so would be too painful. The examiner stated that no collateral ligament laxity was noted. The cruciate ligaments could not be appreciated because of the Veteran's refusal to flex sufficiently his left knee. With limited repetitive motion testing, there was no change in the Veteran's range of motion, coordination, fatigue, endurance, or pain level. The impressions were patellar tendinitis; fragmentation of the tibial tubercle, post fragment removal; and chondromalacia of the femoral tibial joint. According to an April 2010 letter from Dr. Loftis, the Veteran's active range of motion was flexion to "around" 15 degrees, but that his passive range of motion was flexion to 40 degrees. No measurements were provided for the Veteran's left knee extension, either on active or passive range of motion testing. The doctor then expressed concern about the Veteran's left knee "moderate" lateral instability, which had led to falls due to giving away. In August 2010, the Veteran underwent a VA examination to assess the severity of his left knee degenerative joint disease and instability. The Veteran reported that he was experiencing left knee pain, specifically along the distal patellar pole and the anterolateral aspect of the patellar tendon, rating it as a 9 on 10-point scale. He stated that his pain did not improve. The Veteran also complained of swelling, feelings of locking, and feelings of giving away that have caused him to fall. Further, the Veteran endorsed a feeling of instability while ascending and descending stairs, and stated that he had notice heat, but not redness. He denied incapacitating flare-ups. To treat his swelling, the Veteran applied ice and heat. He also stated that he was taking Ibuprofen three times per day, which helped "take the edge off" his pain. Moreover, the Veteran stated that he used a sports brace. He endorsed no limitation with standing, but that he shifted his weight to his right leg. He endorsed a limit of 25 yards with respect to his ability to walk. With respect to his activities of daily living, the Veteran asserted that he had difficulty tying his shoes and use of a shower seat, but that he was capable of independently taking care of his personal hygiene, dressing, and performing household chores. Additionally, the Veteran reported that he had to change positions at his workplace such that he was able to avoid ascending and descending stairs and able to walk on level surfaces. The Veteran stated that he was undergoing vocational rehabilitation and attending school in order to start social work. Physical examination of the left knee demonstrated a slightly antalgic gait; palpable subpatellar crepitus; and a range of motion from zero degrees of extension to 90 degrees of flexion, with complaints of pain from 80 to 90 degrees. Further, McMurray's, Lachman's, and anterior and posterior drawer testing were negative. The Veteran's left knee was stable to varus and valgus stress. There was no swelling, but tenderness to palpation was present in the peripatellar region, especially along the distal pole of the patella and into the patellar tendon. The examiner found that the Veteran did not demonstrate any additional functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination on repetitive motion testing. The Veteran did, however, endorse increased pain on repetitive motion testing. The assessment was patellar tendinosis with chondromalacia. I. Propriety of the Reductions As required by law, the Board must also review the history of the Veteran's left knee degenerative joint disease and instability in order to ascertain whether the October 2008 reductions were proper. 38 C.F.R. § 4.2; Brown, 5 Vet. App at 420. The 20 percent rating for the Veteran's left knee degenerative joint disease and the 30 percent rating for his left knee instability were assigned via a December 2004 rating decision. The 20 percent rating assigned to the Veteran's service-connected left knee degenerative joint disease was predicated on findings of "marked pain" and a range of motion from zero degrees of extension to 35 degrees of flexion. Further, with respect to the Veteran's service-connected left knee instability, the 30 percent rating assigned thereto was based upon finding that the Veteran's left knee was "unstable" and would buckle under him, which the RO deemed to be severe instability. Significantly, the disability picture at the time of the December 2004 rating decision represented the severity of the Veteran's left knee degenerative joint disease and instability subsequent to a January 20, 2004 surgical procedure. The doctor who performed this operation stated that the Veteran's condition would improve throughout the ensuing year. A. Left Knee Degenerative Joint Disease The evidence of record demonstrated that, at the time of the October 2008 rating decision wherein the reductions were effectuated, the Veteran's left knee degenerative joint disease and instability were manifested by the following: constant pain described as "aching" and "sharp," with an average score of 6 or 7 on a 10-point pain scale, with episodic increases, as rated by the Veteran. Additionally, range of motion testing demonstrated extension to zero degrees and flexion to between 80 degrees and 120 degrees, with no additional limitation of function after repetitive motion. Based on the above, since the December 2004 rating decision, the Veteran's left knee extension has retained full extension to zero degrees. With respect to left knee flexion, the Veteran's range of motion has demonstrated actual improvement of at least 45 degrees and as much as 85 degrees. Although the evidence demonstrated that the Veteran still experienced constant pain and that pain was the major functional impact, this pain did not result in any additional functional limitation, and neither did incoordination. See 38 C.F.R. §§ 4.40, 4.59 (2012); see also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 37-44 (2011) (holding that pain itself is not functional loss, but can cause functional loss to the extent that it affects the normal working movements of the body such as excursion, strength, speed, coordination, or endurance). Thus, at the time of the October 2008 rating decision, a fair preponderance of evidence demonstrated that the disability picture presented by the Veteran's left knee degenerative joint disease more nearly approximated the criteria for a 10 percent rating for degenerative joint disease with limited, but not compensable, range of left knee flexion. 38 C.F.R. § 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2012). Consequently, the Board finds that the October 2008 reduction of the rating assigned to the Veteran's left knee degenerative joint disease from 20 percent to 10 percent was proper. 38 C.F.R. § 4.2; Brown, 5 Vet. App at 420. B. Left Knee Instability Since the December 2004 rating decision, the Veteran consistently reported that his left knee gave out on him. The evidence demonstrated that the Veteran endorsed this giving out occurred "occasionally" or "at times." Further, the Veteran stated that he experienced a feeling of instability. Clinical evaluation demonstrated that the Veteran's left knee disabilities were productive of incoordination; however, stability testing of the anterior and posterior cruciate ligaments, the medial and collateral ligaments, and the medial and lateral meniscus were within normal limits. Moreover, the evidence demonstrated negative anterior and posterior drawer testing and positive end point with testing of varus and valgus stress. Significantly, the evidence also demonstrated no subluxation. Comparing this disability picture with the disability picture present at the time of the December 2004 rating decision, the Board finds that the Veteran's service-connected left knee instability underwent an actual improvement under the ordinary conditions of his life and work by a fair preponderance of the evidence. Further, the disability picture manifest at the time of the October 2008 rating decision more nearly approximated "slight" recurrent subluxation or lateral instability. 38 C.F.R. §§ 4.6, 4.7, 4.71a, Diagnostic Code 5257. Where the applicable diagnostic code is not predicated on a limited range of motion alone, the provisions of 38 C.F.R. §§ 4.40 and 4.45, with respect to pain, do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Inasmuch as Diagnostic Code 5257 is not based on limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 do not apply. Consequently, the Board finds that the October 2008 reduction of the rating assigned to the Veteran's service-connected left knee instability from 30 percent to 10 percent was proper. 38 C.F.R. § 4.2; Brown, 5 Vet. App at 420. II. Increased Rating Claims The Board will now address the Veteran's perfected claims of entitlement to increased ratings for his service-connected left knee degenerative joint disease and instability for the relevant periods both before and after January 1, 2009. Preliminarily, with respect to the period both before and after January 1, 2009, the Board considered the Veteran's claims under other potentially applicable diagnostic codes throughout the pendency of this appeal. Schafrath, 1 Vet. App. at 595. However, there was no evidence of, or the relevant diagnostic codes did not provide, a rating in excess of the ratings already granted for, limitation of extension; genu recurvatum; removal of the semilunar cartilage; dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion; knee ankylosis; or malunion or nonunion of the tibia and fibula. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5261, 5262, 5263. Thus, a separate evaluation or an evaluation in excess of the ratings already assigned for the Veteran's service-connected left knee degenerative joint disease and instability is not warranted under these diagnostic codes before or after January 1, 2009. A. Left Knee Degenerative Joint Disease and Instability Prior to January 1, 2009 As discussed above, the evidence of record dated prior to the October 2008 rating decision did not demonstrate that the Veteran's service-connected left knee degenerative joint disease or instability warranted a rating in excess of 20 percent or in excess 30 percent, respectively. The Board will not reconsider this evidence here, as it would not serve to support the Veteran's claims of entitlement to increased ratings. Instead, the Board will focus its analyses on the evidence of record dated after the October 2008 rating decision and before January 1, 2009. Prior to January 1, 2009, a rating of 20 percent was assigned to the Veteran's service-connected left knee degenerative joint disease pursuant to Diagnostic Code 5260. In order for the maximum 30 percent rating to be warranted, the evidence of record must demonstrate that the Veteran's left knee degenerative joint disease was productive of or more nearly approximated flexion limited to 15 degrees. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5260. The evidence of record dated after the October 2008 rating decision and before January 1, 2009 demonstrated that Veteran's left knee degenerative joint disease was manifested by ongoing pain or discomfort and occasional popping. With respect to range of motion testing, the evidence reflected that the Veteran "refused" to flex his left knee more than 35 degrees, which the Veteran asserted was due to extreme pain. During this period, the evidence of record did not include additional results from range of motion testing. Although the Board does not doubt that the Veteran's left knee degenerative joint disease was productive of pain, the evidence of record is not supportive of finding resulting functional impairment comparable to range of left knee flexion limited to 35 degrees for any distinct period prior to January 1, 2009. The evidence of record dated prior to and subsequent to his "refusal" to flex his left knee beyond 35 degrees showed that his left knee range of motion was zero degrees of extension to at least 80 degrees of flexion. As such, the Board finds that his reported inability to flex his left knee beyond 35 degrees is not credible and, thus, will not be considered herein. See Caluza, 7 Vet. App. at 511. However, even considering such evidence, the Board finds that the relevant symptoms associated with the Veteran's left knee degenerative joint disease does not more nearly approximate the criteria associated with the maximum 30 percent rating under Diagnostic Code 5260, that is, flexion limited to 15 degrees. 38 C.F.R. § 4.7, 4.40, 4.59; see also DeLuca, 8 Vet. App. at 206; Mitchell, 25 Vet. App. at 37-44. Consequently, based upon a review of all the relevant evidence dated prior to January 1, 2009, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran's service-connected left knee degenerative joint disease. With regard to the Veteran's service-connected left knee instability, prior to January 1, 2009, the maximum 30 percent schedular rating has already been assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5257. As such, additional consideration is not warranted. B. Left Knee Degenerative Joint Disease and Instability on and after January 1, 2009 On and after January 1, 2009, a 10 percent rating has been assigned to the Veteran's service-connected left knee degenerative joint disease, and a separate 10 percent rating has been assigned to his service-connected left knee instability. With regard to the Veteran's service-connected left knee degenerative joint disease, the evidence of record dated after January 1, 2009 demonstrated that it was productive of the following: daily/constant pain that the Veteran rated as a 9 or 10 on a 10-point scale; effusion/swelling; stiffness; tenderness; subjective feelings of locking; and crepitus. With respect to the Veteran's range of left knee motion, the evidence of record demonstrated that the Veteran's left knee range of motion was from zero degrees of extension to 90 degrees of flexion, with complaints of pain from 80 to 90 degrees, but no additional functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive motion testing. The Board finds that this disability picture does not more nearly approximate the criteria associated with ratings in excess of 10 percent, even when considering the additional functional loss due to pain. 38 C.F.R. § 4.7, 4.40, 4.59, 4.71a, Diagnostic Code 5260; see also DeLuca, 8 Vet. App. at 206; Mitchell, 25 Vet. App. at 37-44. In order for a higher rating to be warranted pursuant to Diagnostic Code 5260, the evidence must demonstrate that the Veteran's left knee flexion was limited to, or more nearly approximated limitation to, at least 45 degrees, which the Board finds was not shown. As such, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's left knee degenerative joint disease on and after January 1, 2009. In making this determination, the Board acknowledges the presence of evidence demonstrating that the Veteran's left knee range of motion was limited, on separate occasions, to 10 degrees of flexion, 30 degrees of flexion, and "around" 15 degrees of flexion. First, the Board observes that each of these measurements was obtained by the Veteran's private doctor who did not consider whether the Veteran exaggerated his symptoms, especially when viewed in the context of the other range of motion testing results of record. Second, these measurements stand in stark contrast to the results from the other range of motion tests of record. Finally, the January 2010 VA examiner noted that the Veteran was able to sit with his left knee flexed to 90 degrees; however, during range of motion testing during the ensuing examination, the Veteran refused to flex his knee beyond 5 degrees due to pain. Eight months later, the Veteran underwent another VA examination in August 2010. Range of motion testing on that occasion showed extension to zero degrees and flexion to 80 degrees (taking into consideration the Veteran's report of pain). Based on the above, the Board finds that the evidence of record demonstrating that the Veteran's flexion was limited to between 5 and 30 degrees is not credible and, thus, will not be considered herein. See Caluza, 7 Vet. App. at 511. With respect to the Veteran's service-connected left knee instability, the evidence of record dated after January 1, 2009 showed that the Veteran reported feelings of instability or that his left knee was unstable. Further, the Veteran asserted that his left knee had a tendency to slip out of joint, and that his left knee was giving out at a higher frequency, especially when he ascended or descended stairs. However, clinical evaluations consistently demonstrated that his left knee ligaments were intact and that there was no collateral ligament laxity. Moreover, McMurray's, Lachman's, and anterior and posterior drawer testing were negative, and the Veteran's left knee was determined to be stable to varus and valgus stress. While the Veteran's statements are competent and credible as to the lay observable manifestations of his service-connected left knee instability, the Board finds that his statements are not competent evidence as to the severity of his left knee ligament laxity so as to meet applicable rating criteria. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a veteran's statements are competent evidence of what comes to him/her through his/her senses). The evidence of record did not demonstrate that the Veteran possessed the ability, knowledge, or experience to provide competent opinions of such a nature. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Additionally, the Veteran's report of symptoms (i.e., increased frequency of falls, feelings of instability, etc.) are contradicted by the clinical evidence of record, which showed that his left knee ligaments were intact, that there was no collateral laxity, and that his left knee was stable. While the Veteran's statements are competent evidence as to the frequency of falls and feelings of instability, the Board finds that the clinical evidence of record is more probative as to the severity of the Veteran's left knee instability for the purpose of rating the instability under the rating criteria of Diagnostic Code 5257. Layno, 6 Vet. App. at 469. Based on this evidence, the Board finds that the evidence of record did not demonstrate that the Veteran's service-connected left knee instability more nearly approximated "moderate" instability. 38 C.F.R. §§ 4.6, 4.7, 4.71a, Diagnostic Code 5257. Consequently, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's service-connected left knee instability on and after January 2009. In making this determination, the Board acknowledges the presence of evidence demonstrating that the Veteran's private doctor expressed concern about the Veteran's left knee "moderate" lateral instability. However, the doctor did not provide supportive clinical findings or an underlying explanation for the conclusion that the Veteran's left knee instability was "moderate." Further, the doctor did not state that his use of the word "moderate" was reflective of the moderate level of severity contemplated in Diagnostic Code 5257. Consequently, the Board finds that this opinion is not probative and, thus, will not be considered herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding that the articulated reasoning enables the Board to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion). C. Extraschedular 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 veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. As such, 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), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (finding that "[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 a veteran'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 veteran's disability level and symptomatology, then the veteran'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 Veteran's disability picture, both before and after January 19, 2009, is not so unusual or exceptional in nature as to render the already assigned schedular ratings inadequate. The Veteran's left knee disabilities were evaluated as a musculoskeletal disability pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his left knee degenerative joint disease and instability. Id. Prior to and on and after January 1, 2009, the evidence demonstrated that the Veteran's left knee degenerative joint disease was manifested by the following symptoms: pain, decreased range of flexion, swelling, crepitus, and tenderness. A rating in excess of 20 percent prior to January 1, 2009, is provided for certain manifestations of left knee degenerative joint disease, but the Board finds that the requisite symptoms were not then present. Likewise, the Rating Schedule provides for ratings in excess of 10 percent on and after January 1, 2009, for certain manifestation of left knee degenerative joint disease; however, the evidence of record did not demonstrate that these symptoms were present. With respect to the rating assigned to the Veteran's left knee instability, the Board acknowledges that the Rating Schedule does not include specific rating criteria and, instead, provides the general requirement of there being "slight," "moderate," or "severe" instability. In such cases, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. With this in mind, the Board finds that the Veteran's disability pictures are more than adequately represented by the currently assigned schedular disability ratings. Prior to January 1, 2009, the Veteran's left knee instability has been assigned the maximum rating available pursuant to Diagnostic Code 5257. On and after January 1, 2009, clinical findings demonstrated that the Veteran's left knee more nearly approximated "slight" instability. The Rating Schedule provides for ratings in excess of 10 percent for certain manifestations of left knee instability, but the Board finds that the evidence of record did not demonstrate that sufficient symptoms were then present on and after January 1, 2009. Based on the above, the Board finds that schedular evaluations are adequate and no referral is required. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010, 5257, 5260; see also VAOPGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Thus, the threshold determination for a referral for extraschedular consideration was not met and, consequently, the Board finds that a referral for an extraschedular rating is not warranted. Thun, 22 Vet. App. at 115. Finally, in reaching these decisions the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claims for ratings in excess of those already assigned, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Total Rating for Compensation Purposes Based on Individual Unemployability (TDIU) Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service- connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that either disability at issue renders him totally unemployable. Indeed, on VA examination in August 2010, it was reported that although the Veteran had had to change positions, he was employed, was participating in vocational rehabilitation, and was studying social work. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER As the October 2008 reduction of the rating for the Veteran's left knee degenerative joint disease, from 20 to 10 percent, effective January 1, 2009 was proper, restoration of a higher schedular rating is denied. As the October 2008 reduction of the rating for left knee instability, from 30 to 10 percent, effective January 1, 2009 was proper, restoration of a higher schedular rating is denied. A rating in excess of 20 percent, prior to January 1, 2009, for the Veteran's left knee degenerative joint disease is denied. A rating in excess of 10 percent, on and after January 1, 2009, for the Veteran's left knee degenerative joint disease is denied. A rating in excess of 30 percent, prior to January 1, 2009, for the Veteran's left knee instability is denied. A rating in excess of 10 percent, on and after January 1, 2009, for the Veteran's left knee instability is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs