Citation Nr: 1324194 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 07-24 146 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. 1. Entitlement to service connection for left knee disorder, claimed as secondary to service-connected patellofemoral pain syndrome of the right knee. 2. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome of the right knee. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from June 1994 to June 1998. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In his substantive appeal, the Veteran requested a RO hearing, which was scheduled for November 2007; however, he failed to appear for his hearing. In March 2011, the Board remanded the case for additional development and it now returns for further appellate review. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal, other than a March 2006 notice letter and the Veteran's representative's July 2013 Written Brief Presentation. FINDINGS OF FACT 1. A left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of service discharge, and such was not caused or aggravated by service-connected patellofemoral pain syndrome of the right knee. 2. For the entire appeal period, patellofemoral pain syndrome of the right knee is manifested by arthritis and symptoms resulting in functional loss of limitation of flexion to 100 degrees and limitation of extension to zero degrees, without ankylosis, subluxation or lateral instability, dislocated or the removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for a left knee disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2006), (2012). 2. The criteria for a disability rating in excess of 10 percent for patellofemoral pain syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5259 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. With regard to the Veteran's claim for service connection for a left knee disorder, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a December 2005 letter fully addressed all of the notice elements and was sent prior to the initial RO decision in this matter. Through the letter, VA informed him of what evidence was required to substantiate the claim for service connection on a secondary basis, when a disorder is either caused or aggravated by a service-connected disability. VA also informed him that VA would seek to provide federal records and that it was his responsibility to support his claim with appropriate evidence, though VA would help him obtain records from any non-federal sources. In a March 2011 letter, VA subsequently informed him that his direct service connection claim must be supported by evidence indicating a current disability, evidence that the injury or disease was incurred or aggravated during service, and medical evidence of a nexus between the current disability and the in-service injury or disease. With regard to the increased rating claim for patellofemoral pain syndrome of the right knee, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). In this case, the December 2005 letter also informed the Veteran that the evidence must support a worsening of his disability to substantiate the increased rating claim. The letter also informed him of VA's duty for obtaining pertinent evidence under federal control and that it would aid him in obtaining pertinent evidence not under federal control, but that it was his responsibility to obtain such evidence. Additionally, with respect to the Dingess requirements, in March 2006 (as documented in Virtual VA) and again in March 2011, the RO provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the remaining notice requirements with respect to the issues on appeal. VA cured any timing errors in regard to the timing of the March 2011 notice letter by the AOJ's readjudication of the claims in a March 2012 supplemental statement of the case. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this regard, the Veteran's service treatment records and post-service VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Relevant to the Veteran's service connection claim, he was afforded VA examinations in March 2006 and April 2011. The Board finds that such VA examinations and accompanying opinions are adequate to decide the issue as they are predicated on an interview with the Veteran; a review of the record, to include his service treatment records; and a physical examination with diagnostic testing. The opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the service connection claim decided herein has been met. Additionally, with regard to the Veteran's increased rating claim, he was afforded VA examinations in March 2006 and April 2011. Neither the Veteran nor his representative has alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected right knee as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. As noted previously, in March 2011, the Board remanded the case for additional development, to include obtaining additional VA treatment records and affording the Veteran a VA examination to determine the etiology of his left knee disorder and severity of his right knee disability prior to readjudicating the claims. As discussed in the preceding paragraphs, VA treatment records dated through April 2011 have been obtained, the Veteran was afforded a VA examination in April 2011 so as to determine the etiology of his left knee disorder and severity of his right knee disability, and the issues were readjudicated in the March 2012 supplemental statement of the case, in accordance with the March 2011 remand directives. Therefore, the Board finds that the AOJ has substantially complied with the March 2011 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection Claim 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; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include arthritis, to a degree of 10 percent within three years from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the Veteran's skin disorders are not recognized as chronic under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable to such claim. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran's appeal, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In an October 2005 statement, the Veteran reported that he had a left knee disorder due to the instability of his right knee. Alternatively, during his April 2011 VA examination, the Veteran reported that he hurt his left knee in service as a result of the same fall in the desert that caused his service-connected right knee disability. The service treatment records do not document any complaints of, or treatment for, for the left knee. However, there is a November 1996 record of a right knee injury. The May 1998 separation examiner found that the Veteran's lower extremities were normal. In his report of medical history, the Veteran denied having a "trick" or locked knee. Following his June 1998 separation from service, the medical evidence does not document any complaints of, or treatment for, the left knee for years following the Veteran's discharge. In this regard, at a May 1999 VA examination for the right knee, the VA examiner noted performing a left knee physical examination, with findings of a normal ligamentous examination and no effusions, medial or lateral joint line tenderness, apprehension sign or tenderness. The first medical record documenting complaints of the left knee is a September 2005 VA medical record. At that time, the Veteran complained of bilateral knee pain, with the right side being worse than the left side, and the past use of knee braces. The VA medical provider found that the Veteran had a full range of motion without edema, cyanosis or clubbing; pulses were intact on examination of both knees. In a February 2006 VA medical record, the Veteran reported continued knee discomfort, which worsened at the end of his work day. In March 2006, the Veteran underwent a VA examination. The Veteran complained of bilateral knee pain following an in-service injury. Following physical examination, the examiner diagnosed patellofemoral pain syndrome of the bilateral knees. The March 2006 VA examiner opined that it is less likely than not that the Veteran's left knee conditions were related to his already service-connected right knee condition or his military service. A June 2006 VA medical record documents that the Veteran complained of continued discomfort of the knees. The VA medical provider noted a benign knee examination, with no effusion, erythema or warmth, and a normal range of motion. The VA medical provider noted bilateral knee pain. An April 2010 VA medical record documents that VA issued the Veteran bilateral knee braces. A May 2010 VA addendum noted that the Veteran had not reported for his scheduled knee x-rays and would not be rescheduled due to multiple failures to report. In April 2011, the Veteran underwent another VA examination. At that time, he reported that he developed his left knee problems at the same time he developed his right knee problems, and that he has had chronic problems since an in-service fall. The April 2011 VA examiner, following physical examination and claims file review, diagnosed the Veteran with left knee degenerative joint disease. The VA examiner opined that the left knee disorder, diagnosed as minor degenerative joint disease, is less likely as not (less than 50/50 probability) caused by or a result of patellofemoral pain syndrome of the right knee. The VA examiner explained that, though the Veteran reported that his problems started in service, the service treatment records did not mention left knee problems. Additionally, the examiner noted that there was no documentation of a left knee complaint until October 2005, at which time the Veteran reported that the left knee pain was secondary to the right knee. Additionally, the VA examiner noted that X-rays of both knees showed symmetrical minor degenerative joint disease, which would not be the cause of or indicate any evidence of aggravation as it related to the left knee from the right knee. The Board initially notes that the Veteran has current diagnoses of a left knee disorder, including patellofemoral pain syndrome and degenerative joint disease. However, the Board finds that the preponderance of the evidence is against finding that the left knee disorder is related to service, manifested within one year of his service discharge, or is secondary to his service-connected right knee disability. In this regard, there is no record of complaints of, or treatment for, a left knee disorder during active service. In addition to the lack of any indication of a left knee disorder during service, there is no documentation of complaints of, or treatment for, a left knee disorder for years following separation from service. The first indication of a disorder of record is the September 2005 VA medical record. In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and therefore the probative value, of proffered evidence in the context of the record as a whole. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Moreover, while the Veteran is competent to testify as to experiencing left knee disorder symptoms during service and since such time, the Board finds that such statements are not credible as they are outweighed by the remainder of the evidence of record and were made under circumstances indicating bias or interest. 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. Caluza, supra. In this regard, the Board observes that the Veteran's statements that he has experienced chronic left knee symptoms during service are inconsistent with the contemporaneous evidence. As indicated previously, his service treatment records are negative for any complaints, treatment, or diagnoses referable to left knee symptomatology. Moreover, he specifically made a complaint for the right knee in November 1996, but did not complain of a left knee problem at that time, though he currently contends that he injured his left knee at the same time he injured his right one). Furthermore, in his May 1998 separation examination the examiner found that the lower extremities were normal. In his report of medical history, the Veteran himself denied having knee problems. Likewise, sought treatment for his left knee following service, he did not mention his right knee until September 2005. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Moreover, the Veteran has repeatedly provided inconsistent histories as to when his left knee disorder developed. In his January 1999 initial claim for VA benefits, the Veteran only reported having a right knee condition. He did not note a left knee condition at that time. During his May 1999 VA examination for the right knee, the Veteran reported that he had twisted his right knee at the time of his in-service injury. The May 1999 VA examiner noted a normal findings for the left knee, including a normal ligamentous examination, and no medial or lateral joint line tenderness, apprehension sign, crepitus or tenderness over the patellar tendon. During his March 2006 VA examination, the Veteran did not contend that he had injured his left knee in service. Rather, he reported injuring his service-connected right knee. He reported that the service-connected right knee caused his left knee claim, indicating that the left knee pain or symptoms did not start at the same time that the right knee disability started. In contrast, during his April 2011 VA examination, the Veteran reported that he had injured his left knee at the same time as the service-connected right knee and has had chronic problems since that time. The Board cannot ignore the fact that the Veteran has repeatedly altered his history of when he believes he began having left knee symptoms. Moreover, the Board notes that the Veteran provided a post-service onset to the March 2006 VA examiner. The documentation noted above carries far more weight, credibility and probative value than the recent lay statements. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Such contemporaneous records are more reliable, in the Board's view, than the unsupported assertions of events now over a decade past, made in connection with his claim for monetary benefits from the government. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a Veteran's testimony simply because the Veteran is an interested party; personal interest may, however, affect the credibility of the evidence). The Board finds that the Veteran's current statements made in connection with his pending claim for VA benefits that he has experienced left knee symptoms since service are inconsistent with the contemporaneous evidence of record and the Veteran's own statements. Furthermore, the record fails to show that the Veteran manifested degenerative joint disease to a degree of 10 percent within the one year following his service discharge in June 1998. As such, presumptive service connection, to include on the basis of continuity of symptomatology, is not warranted. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In this regard, the Veteran did not have a diagnosis of degenerative joint disease until years following his discharge from service. Although the October 2005 X-ray report noted findings of minor degenerative changes bilaterally, the Veteran did not receive a diagnosis of degenerative joint disease until the April 2011 VA examination. Furthermore, as determined previously, the Veteran's statements regarding the continuity of left knee symptomatology since his discharge are not credible. As to whether the Veteran's left knee disorder is directly related to his service or secondary to his service-connected right knee disability, the only medical opinion evidence of record addressing the Veteran's claim are the March 2006 and April 2011 VA examination opinions. As noted in the March 2011 Board remand, however, the March 2006 VA examiner did not provide a rationale for the negative etiology opinion or provide an opinion on aggravation. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight of the credibility of the evidence in the adjudication of the merits. See Hernanadez-Toyens v. West, 11 Vet. App. 379, 382 (1998). However, as relevant to the April 2011 medical opinion, the Board notes that the VA examiner considered the Veteran's claims file and medical history in the report. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Additionally, the VA examiner provided an etiological opinion, complete with the rationale described above. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Consequently, the Board assigns great probative value to the April 2011 VA examiner's opinion. The April 2011 VA examiner found that it was less likely than not that the Veteran's left knee disorder was caused by the Veteran's service or service-connected right knee disability. The VA examiner discussed pertinent medical evidence in the formation of her opinion, as well as, a discussion of the Veteran's reported history. Similarly, the April 2011 VA examiner found that it was less likely than not that the Veteran's left knee disorder was aggravated by the service-connected right knee disability. The VA examiner explained that the Veteran's X-rays showed symmetrical minor degenerative joint disease that would not be the cause or indicate aggravation related to the left knee from the right knee. The only evidence of record supportive of the Veteran's claim is his contention that he has a chronic left knee disability due to his service or, alternatively, due to his service-connected right knee disability. 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 issues in this case, i.e., whether the Veteran has a medically diagnosed disorder left knee disability etiologically related to service or the service-connected right knee disability, such questions falls outside the realm of common knowledge of a lay person as they involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The weight of the probative evidence demonstrates that the Veteran does not have a current left knee disorder related to any aspect of service or a service-connected disability. As the preponderance of the evidence is against this claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for a left knee disorder is denied. II. Increased Rating Claim Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian life. Generally, the degree of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity to the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. The assignment of separate evaluations for separate and distinct symptomatology under 38 C.F.R. § 4.14 is possible, however, where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 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. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). 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, 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. See 38 C.F.R. §§ 4.40, 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. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The normal range of knee motion for VA purposes is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Disability of the knee may be rated on the basis of limitation of motion. A 10 percent rating is warranted when flexion is limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A 10 percent rating is warranted when extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted with extension limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Symptoms associated with the removal of semilunar cartilage warranted a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Degenerative or traumatic arthritis, established by x-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. In the absence of limitation of motion, x-ray evidence of involvement of two or more major joints or two or more minor joint groups will warrant a 10 percent rating. Absent limitation of motion, a 20 percent rating is warranted for x-ray evidence of involvement of two or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board must address which diagnostic codes related to loss of function due to pain and limitation of motion are applicable but do not result in rating the same manifestations under different diagnostic codes. 38 C.F.R. § 4.14. In VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997), the VA Office of General Counsel held that a knee disability rated under Diagnostic Code 5257 for impairment due to subluxation or lateral instability may also be rated under other diagnostic codes for a manifestation of limitation of motion. In VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998), the VA General Counsel clarified 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. Additionally, separate ratings may be awarded for limitation of flexion and limitation of extension of the same knee joint. VAOPGCPREC 09-04, 69 Fed. Reg. 59990 (2004). Specifically, separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. Id. The Veteran contends that his service-connected right knee disability is more severe than indicated by his current 10 percent disability rating. In a September 2005 VA medical record, the Veteran complained of bilateral knee pain, with the right side being worse than the left side, and the past use of knee braces. The VA medical provider found a full range of motion without edema, cyanosis or clubbing. The provider further noted that pulses were intact on examination, but that the right knee had swelling and tenderness. In a February 2006 VA medical record, the Veteran reported continued knee discomfort, which worsened at the end of his work day. During his March 2006 VA examination, the Veteran complained of bilateral knee pain. The examiner noted a negative surgical history and that the Veteran complained of daily flare ups of pain. The March 2006 VA examiner found no evidence of infection or effusion, though there was mild patellofemoral crepitation with pain at the patellofemoral joint. The examiner further noted a normal range of motion from zero to 140 degrees. The examiner found no evidence of instability, and varus and valgus stress testing of anterior and posterior drawer, McMurray's and Appleys were negative. The examiner found no specific medial or lateral joint line tenderness, though there was a vastus medialis obliques deficiency. The examiner noted that the October 2005 X-rays showed normal knees and diagnosed the Veteran with patellofemoral pain syndrome of the right knee. The examiner found no weakened movement, but that there was excess fatigability with use with repetitive deep knee bends. However, there was no incoordination nor painful motion or pain with use except with repetitive activity. The examiner noted a five degree loss of functional range of motion with repetitive exercise in flexion after repetitive activity. A June 2006 VA medical record documents continued knee discomfort. However, the VA medical provider reported a benign knee examination, with no effusion, erythema or warmth, and a normal range of motion. The VA medical provider found bilateral knee pain. An April 2010 VA medical record documents that VA issued the Veteran bilateral knee braces. The Veteran underwent another VA examination in April 2011. The Veteran reported right knee symptoms including: giving way, instability, pain, stiffness, weakness, incoordination, decreased speed of joint motion and popping. He denied dislocation or subluxation, but reported several locking episodes a week, as well as effusion, swelling and tenderness. He reported that his symptoms affected his joint motion and that he would have weekly flare-ups that would last two to three days and were of moderate severity. He reported that precipitating factors were bending, standing and walking, prolonged sitting, attempting to run, elliptical use. He reported alleviation form sitting in the hot tub, elevation and stretching. The April 2011 VA examiner found that the right knee had palpable tenderness to the entire knee joint and mild crepitus on flexion/extension. The examiner found no clicks or snaps, grinding, instability, patellar or meniscus abnormality, abnormal tendons or bursae or other abnormalities. Ranges of motion were zero to 100 degrees of flexion and normal extension to zero degrees. The examiner further found objective evidence of pain following repetitive motion, but no additional limitations after three repetitions of range of motion. The examiner found no ankylosis and noted X-ray evidence of minor degenerative joint disease, with small right knee joint effusion. The April 2011 VA examiner diagnosed the Veteran with patellofemoral pain syndrome of the right knee. The examiner noted that it caused significant effects on the Veteran's usual occupation, including decreased mobility and problems with lifting and carrying, as well as pain. The examiner noted moderate effects on chores, shopping, exercise, sports, recreation and driving and mild effect on driving. The RO originally granted service-connected for chondromalacia of the right knee, with a disability rating of 10 percent pursuant to Diagnostic Code 5099-5024 (tenosynovitis, which is rated on limitation of motion). In the March 2006 rating decision, the RO continued the 10 percent disability rating, but noted that the Veteran's disability had been recharacterized as patellofemoral pain syndrome of the right knee. The RO rated the right knee under Diagnostic Codes 5014-5260, for osteomalacia rated on limited motion of the right knee. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In the instant case, the Board notes that the Veteran right knee disability is currently characterized as patellofemoral pain syndrome, which is rated under Diagnostic Code 5014-5260; however, for the below reasons, the Board finds that the Veteran's right knee disability is more appropriately rated under Diagnostic Code 5003-5260. The Board initially notes that the RO appears to have rated the Veteran under Diagnostic Code 5014 for osteomalecia. No medical evidence of record documents a diagnosis of osteomalacia of the right knee. Therefore, rating the Veteran under Diagnostic Code 5014 is not warranted. However, Diagnostic Code 5260 contemplates limitation of flexion. The Board notes that the Veteran, in his October 2006 notice of disagreement, claimed that the March 2006 VA examiner did not accurately assess his range of motion or severity of his disability. The March 2006 VA examiner noted a normal range of motion from zero to 140 degrees, with five degree loss of functional range of motion with repetitive exercise in flexion. The VA examiner also found no evidence of instability. In the instant case, even if, for the sake of argument, the Board were to discount the March 2006 VA examiner's findings, the remaining probative evidence of record fails to demonstrate the presence of a compensable level of limitation of flexion. VA medical providers found full ranges of motion (in September 2005 and June 2006). Furthermore, the April 2011 VA examiner noted zero to 100 degrees of flexion, with objective evidence of pain following repetitive motion, but no additional limitations after three repetitions of range of motion. Based on the foregoing, the objective medical evidence shows that the Veteran's right knee does not have flexion limited to 45 degrees or less, such that a compensable rating for limitation of flexion alone (under Diagnostic Code 5260) would be warranted. Additionally, Diagnostic Code 5261 pertains to limitation of extension. In the instant case, the evidence demonstrates that the Veteran's right knee range of motion was no worse than zero to 100 degrees, to include in contemplation of pain, at any point during the appeal period. Specifically, even if the Board were to discount the findings of the March 2006 VA examiner, the April 2011 VA examiner found extension to zero degrees. As such, the Veteran does not demonstrate a compensable limitation of extension. The Board finds that the Veteran's limitation of motion of the right knee is manifested by extension to zero degrees and flexion to 100, even after repetitive motion and in consideration of pain. In this regard, the Board has specifically considered the Court's holdings in DeLuca, supra, and Mitchell, supra; however, the evidence fails to show that such symptoms result in functional loss of extension of 10 degrees or more or of flexion of 45 degrees or more. As such, the Veteran is not entitled to a compensable rating under Diagnostic Code 5260 or 5261 for his right knee disability. However, the April 2011 VA examiner also diagnosed the Veteran with degenerative joint disease of the right knee, based on X-rays. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings can be rated at 10 percent for noncompensable limitation of motion. As such, the Veteran is correctly rated under Diagnostic Code 5003-5260, for 10 percent based on his arthritis with noncompensable limitation of flexion. The Board has considered whether the Veteran is entitled to a higher rating under Diagnostic Code 5003; however, as there is no X-ray evidence of involvement of two or more major joints, a 20 percent rating is not warranted under Diagnostic Code 5003 for the Veteran's knee disability. In changing the Diagnostic Code under which the Veteran's right knee disability is evaluated, the Board notes that, in Murray v. Shinseki, 24 Vet.App. 420 (2011), the Court held that a VA medical examination showing that the symptoms upon which a disability rating was based are no longer present cannot act to reduce that disability rating if it has been in effect for more than 20 years, and thus protected by regulation. 38 C.F.R. § 3.951(b). Additionally, the Court held that change of Diagnostic Codes under which Veteran's disability was rated was error where the change effectively reduced to zero disability rating which had been in effect for more than 20 years, and thus protected by regulation. Id. In the instant case, the Veteran's 10 percent rating under Diagnostic Code 5099-5024 has been in effective since June 20, 1998, i.e., less than 20 years, and therefore, is not protected. As such, Murray is inapplicable in the instant case. The Board has also considered whether the Veteran is entitled to a rating under Diagnostic Code 5257 for recurrent subluxation or lateral instability. However, there is no competent, i.e., clinical, evidence of instability or subluxation of the right knee. Rather, the objective medical evidence shows that the Veteran's right knee is stable without instability or subluxation. In this regard, while the Veteran has complained of instability. In his October 2006 notice of disagreement, he claimed to have recurrent subluxation, with joints popping out of place. During his April 2011 VA examination, he reported locking episodes. The medical records also repeatedly note that the Veteran uses knee braces. However, the Veteran, as a layperson is not competent to diagnose internal instability or subluxation. In this regard, while he is competent to report that his knee feels unstable or locks, there is no indication that he possesses the requisite knowledge to administer or interpret specialized testing that would reveal instability or subluxation. See Woehlaert, supra. Rather, medical professionals have found no instability of the right knee. Specifically, the March 2006 and the April 2011 VA examiners found no instability. Similarly, the Veteran's medical providers repeatedly tested the Veteran's right knee, to include a drawer test by the September 2005 VA medical provider. However, none of the VA medical providers noted instability or subluxation. Furthermore, the Board notes that the Veteran has been inconsistent in his reports of subluxation. The Veteran claimed subluxation in his October 2006 notice of disagreement; however, he specifically denied it to his April 2011 VA examiner. 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. Caluza, supra. Based on the foregoing, the objective medical evidence shows that the Veteran's right knee is stable without instability or subluxation. Therefore, Diagnostic Code 5257 is inapplicable. The Board has also considered rating the Veteran under f Diagnostic Code 5258 (pertaining to the dislocation of semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint) or Diagnostic Code 5259 (pertaining to symptomatic removal of semilunar cartilage). The Board notes that "semilunar cartilage" is defined as either of the crescent-shaped wedges of fibrocartilage found in the knee. The meniscus is a crescent-shaped wedge of fibrocartilage. See Dorland's Illustrated Medical Dictionary 1127 (30th ed. 2003). None of the medical evidence of record documents either the dislocation of semilunar cartilage or the symptomatic removal of it. During his March 2006 VA examination, the Veteran reported that he did not have a history of knee surgery. None of the later medical records document knee surgery or findings regarding cartilage, including the VA X-rays or by the VA examiners. The April 2011 VA examiner specifically found no patellar or meniscus abnormality. The evidence of record thus does not support finding that a rating is warranted under Diagnostic Codes 5258 or 5259. Additionally, as the evidence of record fails to demonstrate ankylosis, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5262, or 5263, respectively. In reaching this decision, the Board has specifically considered the Veteran's contentions with respect to the nature of his service-connected right knee disability and notes that his lay testimony is competent to describe certain symptoms associated with such disability, to include flare-ups, pain, swelling, popping, clicking, weakness, and tenderness, and sensations of locking, giving way, and instability. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and the Board finds that, even in contemplation of such symptoms, the right knee disability does not result in functional loss that more nearly approximates ratings in excess of 10 percent. In this regard, despite such reports, his flexion and extension are not limited to a compensable degree. Additionally, as discussed previously, the competent evidence fails to demonstrate instability or subluxation. Therefore, the Board finds that his symptoms are contemplated by the 10 percent disability rating assigned. As such, while the Board accepts the Veteran's lay evidence with regard to the matters he is competent to address and which the Board has not found to be non credible, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the right knee pathology. The Board has considered whether staged ratings under Hart, supra, are appropriate for the service-connected right knee disability. However, the Board finds that the Veteran's symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected right knee disability with the established criteria found in the rating schedule. The Board finds that the Veteran's right knee symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, the Veteran has been assigned a 10 percent rating for the knee based on his symptoms that result in functional loss due to arthritis with noncompensable limitation of flexion. There are no additional symptoms of his right knee that are not addressed by the rating schedule, as that rating code contemplates pain and other symptoms resulting in limitation of motion. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Moreover, to the extent that the Veteran's knee disability may interfere with his employment, the Board notes that the Veteran has been continuously working, fulltime, as a telephone technician throughout the appeal period. With regard to any difficulty he may have had to work due to knee flare-ups, such interference is addressed by the schedular rating criteria. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Veteran has not raised the issue in regard to the right knee and has been working full time during the appeal period. Therefore, the Board finds that the issue of entitlement to a TDIU does not warrant consideration. The Board has also considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for right knee disability. Therefore, the benefit of the doubt doctrine is not applicable in the instant appeal and the increased rating claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER Service connection for a left knee disorder is denied. A disability rating in excess of 10 percent for patellofemoral pain syndrome of the right knee is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs