Citation Nr: 1324362 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 07-05 423 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for left knee, post operative arthritis, limitation of motion. 2. Entitlement to an initial disability evaluation in excess of 20 percent for left knee instability, associated with osteoarthritis, left knee, since May 31, 2005. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. Coyle, Counsel INTRODUCTION The Veteran had active service from December 1978 to June 1983 and from May 1985 to January 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, which granted service connection for left knee instability, associated with osteoarthritis, with an initial evaluation of 10 percent; and continued the 10 percent evaluation of the left knee osteoarthritis, limitation of motion. The January 2006 rating decision stated that the date of the Veteran's claim for an increased rating for her service-connected knee disability was May 31, 2005; thus, an effective date of May 31, 2005, was established for the award of service connection for left knee instability. The Board notes, however, that the RO received a claim for an increased rating for the Veteran's service-connected knee disability on April 16, 2004, which was not adjudicated or withdrawn. Thus, the appropriate date of claim is April 16, 2004, and the Veteran's appellate period has been tolled since that time. As a result, the Board will contemplate such in the decision below. Given the outcome reached below, the Veteran has not been prejudiced in this regard and no additional action is required. In her February 2007 substantive appeal, the Veteran requested a Board hearing, which was to be held at the RO. In October 2009, the Veteran submitted a written waiver of that hearing. The request for a hearing is deemed withdrawn. By a June 2012 rating decision, the Appeals Management Center (AMC) increased the initial evaluation assigned to the Veteran's left knee instability, associated with osteoarthritis, to 20 percent, effective from May 31, 2005. On a claim for an original or increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy where less than the maximum benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Thus, the issue remains in appellate status. In September 2012, July 2011, and February 2010, the Board remanded these issues for additional evidentiary development, which has been completed. The case has been returned to the Board for appellate adjudication. FINDINGS OF FACT 1. A claim for an increased rating for the Veteran's service-connected knee disability was received by the RO on April 16, 2004. 2. Throughout the appeal period, post-operative arthritis of the left knee is not manifested by compensable limitation of motion, or recurrent dislocation or subluxation. 3. Since April 16, 2004, the Veteran's left knee symptoms have been manifested by moderate lateral instability. 4. Throughout the appeal period, no evidence of ankylosis, a dislocated semilunar cartilage, or impairment of the tibia and fibula is present. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 10 percent for post-operative arthritis of the left knee, with limitation of motion, are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.59, 4.40, 4.45, 4.71a, Diagnostic Code 5010-5260 (2012). 2. Since April 16, 2004, the criteria for an initial disability evaluation of 20 percent, but no higher, for left knee instability are met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.59, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2012). 3. Throughout the pendency of the appeal, the criteria for an initial disability evaluation in excess of 20 percent for left knee instability are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.59, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the veteran 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 veteran is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Letters dated in September 2005 and November 2008 fully satisfied the duty to notify provisions with respect to the claim for an increased rating for post-traumatic arthritis of the left knee with limitation of motion. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was aware that it was ultimately her responsibility to give VA any evidence pertaining to the claim. The Veteran was advised to submit evidence or information that would help to substantiate her claim, including the need to show the impact of her disability on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Her claim was readjudicated by a June 2012 Supplemental Statement of the Case (SSOC). Prickett v. Nicholson, 20 Vet. App. 370 (2006). Thus, any notice timely defect was cured by issuance of the SSOC. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Regarding the duty to assist, VA medical treatment records and private treatment records have been obtained; the Veteran has not identified any outstanding private or VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not reflect, that she is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2). There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. The Veteran received VA examinations of her left knee in October 2005, December 2008, April 2009, August 2011, and October 2012. The most recent examination is adequate, as the claims file was reviewed; the examiner reviewed the pertinent history, examined the Veteran, and provided adequate findings in sufficient detail. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In addition, although the October 2005, December 2008, and April 2009 examinations did not state with specificity whether functional loss during flareups and repetitive motion resulted in limitation of flexion or extension of the knee, the October 2012 VA examiner ameliorated these errors by concluding that there was additional limitation of flexion, not extension, during flareups or repetitive motion. The examiner is competent to provide such an opinion, which is reasonably based upon his physical examination of the Veteran and review of the evidence of record. Thus, the October 2005, December 2008, and April 2009 examinations are adequate for rating purposes in light of his clarification. Moreover, the opinion substantially complies with the Board's September 2012 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). There is no objective evidence indicating that there has been a material change in the service-connected knee disabilities since the Veteran was last examined. 38 C.F.R. § 3.327(a). The duties to notify and assist the Veteran have been met. Applicable Law and Regulations Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Evaluation of a service-connected disorder requires a review of the Veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The U.S. Court of Appeals for Veterans Claims (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); see also Fenderson v. West, 12 Vet. App. 119 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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 basis of disability evaluations 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. It is also necessary to evaluate the disability from the point of view of the Veteran working or seeking work and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. §§ 4.2, 4.3. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Diagnostic Code 5010 directs that arthritis due to trauma be rated as degenerative arthritis under 38 C.F.R. § 4.71a, DC 5003. Under that code, the Schedule directs that degenerative arthritis that has been established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints involved. It further states that when the limitation of motion is noncompensable under the code, a rating of 10 percent is for application for each such major joint affected by limitation of motion. 38 C.F.R. § 4.71a, DC 5003. X-ray studies of record confirm post-traumatic arthritis of the left knee. Thus, Diagnostic Codes 5010 and 5003 are applicable and direct the Board's attention to DCs 5260 and 5261 for limitation of motion referable to the knee. Under Diagnostic Code 5260, when limitation of flexion of the leg is limited to 60 degrees, the rating is noncompensable. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. The maximum rating under this Diagnostic Code (30 percent) is for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg is rated under Diagnostic Code 5261. A noncompensable rating is warranted when extension is limited to 5 degrees; a 10 percent rating when limited to 10 degrees; a 20 percent rating when limited to 15 degrees; a 30 percent rating when limited to 20 degrees; a 40 percent rating when limited to 30 degrees; and a 50 percent rating when limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A separate evaluation of 20 percent has also been assigned for moderate lateral instability of the left knee under Diagnostic Code 5257. The maximum rating under this Diagnostic Code is for severe impairment, which warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Functional loss, which is the inability to perform the normal working movements of the body within normal limits, specifically due to pain and weakness on motion, also is to be considered when ascertaining the severity of musculoskeletal disabilities. 38 C.F.R. §§ 4.40, 4.45 and 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). Facts Service connection for post-traumatic arthritis of the left knee with limitation of motion was granted in a May 1996 rating decision, and a 10 percent disability was assigned under Diagnostic Code 5010-5260 for noncompensable limitation of flexion. A claim for an increased rating for the Veteran's service-connected left knee disorder was received by the RO on April 16, 2004. In January 2006, the RO denied entitlement to a higher rating for post-traumatic arthritis, and awarded a separate 10 percent disability evaluation for slight lateral instability under Diagnostic Code 5257, effective May 31, 2005 (erroneously stated as the date of the Veteran's claim for an increased rating). In June 2012, the evaluation for lateral instability was increased to 20 percent, effective May 31, 2005. As noted above, a claim for an increased rating for the service-connected left knee symptoms was received by the RO on April 16, 2004, which was neither adjudicated nor withdrawn by the Veteran. That claim has been pending since that time. Thus, it is necessary to determine entitlement to an increased rating for the service-connected post-traumatic arthritis and left knee instability from April 16, 2004, or at any point in the one-year period prior to that date. See 38 C.F.R. § 3.400(o) (the effective date of an evaluation and award of compensation for an increased rating claim is the date of receipt of the claim or the date entitlement arose, whichever is the later, unless a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of the claim for increased compensation). A July 2003 private treatment record reflects reports of knee pain, mainly on walking and standing, which was relieved with sitting and lying down. There was crepitus of the left knee with "no instability." The diagnosis was "[k]nee pain most likely osteoarthritis" and "continued pain management" was recommended. A November 2003 clinical note contains reports of increased left knee pain, predominantly in the lateral aspect of the knee. An X-ray showed valgus positioning and lateral compartment wear within the left knee. On physical examination, the knee was stable with no effusions; however, there was crepitus and "minimal warmth" with range of motion testing. Lachman and drawer tests were negative. The clinician prescribed an unloading brace. An orthopedic consult conducted in November 2003 showed that extension of the knee was full to 0 degrees; flexion was to 130 degrees. The knee was tender to palpation along the medial and lateral joint lines and on patellar grind testing. A patellar apprehension test was negative. Crepitus was noted with range of motion testing; additionally, the possibility of "some laxity to anterior translation" was noted. The orthopedist diagnosed "severe osteoarthritis" and agreed that a lateral unloading brace would alleviate some of the Veteran's pain. A total left knee arthroplasty was not recommended due to the Veteran's young age, but it was noted that the Veteran would need a knee replacement in the future. During a November 2003 rheumatology consult, swelling was noted with full flexion of the joint; however, "no medial or lateral laxity [was] seen." The Veteran used 1600 to 2400 milligrams of ibuprofen per day for pain control, and occasionally took a narcotic pain medicine. The Veteran began a course of corticosteroid injections to alleviate her pain, which were of little effect. In February 2004, the Veteran reported that her knee was actually more painful than before. She was wearing her unloading brace and denied joint warmth or redness. She had been off work for 2 weeks and did not feel that she would be able to continue as an electrician in her current state of health. In March 2004, the Veteran's private clinician wrote that the Veteran had been issued a medial unloading brace, when in fact she required a lateral unloading brace. There was tenderness to palpation along the medial and lateral joint lines, as well as in the patellar compartment. There was 7 degrees of valgus deformity on X-ray. The Veteran was encouraged to find a line of work which was not so taxing on her knee. Although a correct unloading brace was needed, the clinician noted that this would only be a "temporary relief." The Veteran was advised not to take narcotics for her pain. The clinician also noted that it might be useful to undergo arthroscopic surgery to alleviate any symptoms caused by a torn meniscus. In April 2004, the Veteran reported that her new lateral unloading brace alleviated her pain somewhat. She asked for a more powerful pain medication, which was prescribed. In May 2004, the Veteran was wearing her brace on her left knee and walked with an antalgic gait, favoring the knee. The Veteran was still using her brace in June 2004, which she reported gave her "additional stability in the knee" and made it easier for her to walk and to work as an electrician; however, she was still experiencing the same level of pain in the knee. She was considering taking a medical retirement from her job as an electrician, and seeking retraining. She was also going to work on losing weight. In July 2004, the Veteran stated that she was ineligible for medical retirement from her work, but stated that she could no longer do the duties of her job, in part as a result of her knee pain. She was looking into retraining for a different career. In August 2004, the Veteran reported that her left knee pain was increasing even more. She requested that a knee replacement take place sooner rather than later. Her attempts at alleviating her pain were either unsuccessful or provided only fleeting relief. In September 2004, the Veteran indicated that her knee was so painful that it was causing sleep disturbance. She was walking with a cane. Although the ranges of motion of the Veteran's left knee were not stated in degrees, the clinician did note that there was "limitation of movement with some pain associated with mild movement of the ... left knee." In a September 2005 VA clinical note, the Veteran had a normal gait, with some mild tenderness in the left knee area and "some laxity appreciated." The Veteran underwent a VA examination in October 2005. She reported that her pain was a 3-4/10 on a good day, and 7-8/10 on a bad day, with swelling, locking, and instability. Steroid injections had some effect on the pain. She walked with a cane. On range-of-motion testing, extension was full to 0 degrees and flexion was to 115 degrees. There was a positive McMurray's sign on the left knee, indicative of lateral instability. The examiner noted that an additional loss of motion, characterized as loss of flexion by the October 2012 examiner, of 20 to 25 degrees, as well as instability, was expected with repetitive motion or flareups. A December 2005 clinical note reflects range-of-motion as extension to 0 degrees and flexion to 120 degrees. She could walk 1 to 2 blocks. She had some resting pain and some night pain. Her symptoms included swelling and giving out. The Veteran was said to have exhausted all non-surgical options for pain relief. In July 2006, the Veteran's VA clinician described her as "very functional" despite the pain in her left knee. During an orthopedic consultation in September 2007, the Veteran reported constant pain in the knee, even when standing. The knee felt unstable and was prone to giving way. On physical examination, there was "some laxity" on varus stress testing, although McMurray's sign was essentially negative. Extension was full to 0 degrees, and flexion was limited to 115 degrees. The Veteran underwent a VA examination in December 2008. Although the examination report refers to the right knee, in a July 2009 addendum the examiner clarified that he had examined the left knee, and not the right, during the examination. The Veteran reported increased pain, including pain that woke her at night. Her pain was a 5-6/10, with episodes of acute pain rated at 8-9/10. She also described popping and giving way of the joint, with a feeling of instability. She experienced additional pain with prolonged standing, sitting, and walking more than a block. She used a cane and an offloading brace. Three to four times a week, she had episodes of increased weakness and fatigability, as well as swelling and stiffness. Overnight rest usually ameliorated these episodes. On physical examination, there was generalized tenderness and trace effusion. Range of motion testing showed extension to 0 degrees and flexion to 95 degrees, limited by pain. There was no additional limitation of motion upon repetitive motion testing. Muscle strength was full. There was moderate crepitus, as well as positive J sign, positive Ober's, and positive McMurray's. The impression was osteoarthritis with instability and limited range of motion. The examiner speculated that there would be an additional 5 to 10 degrees of lost motion during a flare-up, with weakness, fatigability, and loss of coordination. In a June 2009 addendum, the examiner stated that he did not note "appreciable instability on ligaments stress testing" in December 2008. The Veteran underwent another VA examination of her knee in April 2009. She reported an increase in pain and swelling with repetitive movements. She had a brace on the left knee, which she did not wear often. She used a cane daily. Flare-ups of symptoms occurred every 2 to 3 months, and were represented by feelings of the knee wanting to "catch" and cause her to stumble. She reported no locking of the knee joint. She had to be very careful on stairs, but was independent in all activities of daily living. She used hydrocodone for pain control. Range-of-motion testing showed extension to 0 degrees and flexion to 120 degrees. There was no additional limitation of motion after repetition. There was some instability of the medial collateral ligament with negative McMurray's. There was edema and moderate joint effusion. The examiner speculated that there would be an additional loss of motion of 10 to 15 degrees, later characterized as loss of flexion, associated with repetitive movement flares. On VA examination in August 2011, the Veteran's reported symptoms were essentially unchanged from those noted on previous examinations. She walked with an antalgic gait and varus deformity of the left knee, using a cane to ambulate. Range of motion testing showed extension to 0 degrees and flexion to 90 degrees, with no additional limitation of motion after repetitive motion testing. There was painful motion past 70 degrees of flexion. A small joint effusion was observed. There were findings consistent with lateral instability. X-ray studies from September 2009 showed a bone-on-bone lateral compartment causing valgus deformity and lateral instability "of a moderate nature." The medial collateral ligament was "intact but stretched." The examiner found that a flareup would likely cause an additional 20 degrees of limitation of flexion; thus, flexion would be limited to 70 degrees. In April 2012, the Veteran fell on her left knee, causing a fracture of the medial-tibial plateau. However, on VA examination in October 2012, the Veteran's reported symptoms were unchanged, and there was no evidence of chronic residuals as a result of the fall. Extension was to 0 degrees and flexion was limited to 85 degrees, with painful motion beginning at 40 degrees. Flexion was limited to 65 degrees after repetitive motion testing; there was also incoordination, impaired ability to execute skilled movements smoothly, painful motion, swelling, deformity, instability, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. Joint line tenderness was noted on palpation. Muscle strength was slightly diminished. Medial-lateral instability testing showed 5 to 10 millimeters of movement. There was no X-ray evidence of patellar subluxation. The Veteran missed approximately 1 day every other month as a result of her knee pain. Analysis Limitation of Motion, Flexion Initially, as noted since 1996 a 10 percent rating has been assigned for the Veteran's limited range of motion of the left knee. The record does not show that the assignment of a higher rating in this regard is warranted. Since April 16, 2004, flexion of the knee joint has been limited at most to 85 degrees on physical examination, and 65 degrees during periods of flare ups. In 2005, flexion was to 120 degrees; in 2007, it was to 115 degrees; in 2009, flexion was to 120; in 2011, it was to 90 degrees with pain beginning at 70 degrees; and, in 2012, flexion was to 85 degrees and 65 degrees during flare ups. In order to show entitlement to a compensable rating for limitation of flexion, flexion must be limited to 45 degrees or less. 38 C.F.R. § 4.71a, DC 5260. Accordingly, entitlement to an increased rating on the basis of limitation of flexion has not been shown. Id. The Board has considered whether factors including functional impairment, swelling and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, 4.45 would warrant a higher rating. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). Each VA examiner since October 2005 has speculated that there would be additional limitation of motion (characterized as limitation of flexion by the October 2012 examiner) as a result of flare-ups or repetitive motion. See DeLuca, supra; see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). However, even if the examiners' speculations as to additional limitation of motion were to be taken as truth, there would still be no disability tantamount to a compensable level of limitation of flexion or limitation of extension, as no functional losses beyond a possible limitation of flexion to 65 degrees (post repetitive range of motion testing) as shown in October 2012 have been identified. See Mitchell, supra. Instability Private clinical notes dating from April 16, 2004, to May 31, 2005, are mostly negative for instability of the left knee, with the exception of a finding of possible "laxity to anterior translation" in November 2003. The Board notes, however, that the Veteran reported severe pain in the knee joint, and was prescribed unloading braces which reportedly ameliorated at least some of her symptoms. In June 2004, the Veteran advised her treating physician that the knee had instability, but the brace made her knee feel more stable and that the feelings of additional stability made it easier for her to do her job as an electrician. The Veteran is competent to report the sensation of instability in the knee joint. Layno v. Brown, 6 Vet. App. 465, 467-69 (1994). In light of the Veteran's credible reports of instability and pain alleviated by the application of lateral unloader brace, the swelling in the joint on full flexion, the amount of medication required by the Veteran to control her pain, the November 2003 finding of "possible" laxity in the knee joint, and the effects of her instability on her ability to maintain employment as an electrician, the Board finds that an initial disability evaluation of 20 percent for moderate lateral instability of the left knee under Diagnostic Code 5257 is warranted from April 16, 2004. A preponderance of the evidence is against a finding that the instability was "severe." As noted, the benefit of the doubt is afforded based on the Veteran's subjective complaints, use of a brace, and notation of "possible" laxity and swelling in the joint. 38 C.F.R. § 4.71a, DC 5257. The medical evidence does not demonstrate severe instability. Since May 31, 2005, the Veteran has undergone several VA examinations and has sought clinical treatment for her left knee instability. The severity of the Veteran's left knee instability was not specifically noted on the October 2005, December 2008, and April 2009 examinations. Additionally, instability was found on some of these examinations (October 2005, April 2009) and not found on others (December 2008). Clinical evaluations of the Veteran's knee after May 31, 2005, showed only intermittent instability. However, the Veteran reported to her treating physicians that her knee joint felt unstable, and there is nothing in the record which diminishes the credibility of her reports. The August 2011 VA examiner found that the instability was of a "moderate" nature. Although he did not characterize the instability in terms of "slight," "moderate," or "severe" when he examined the Veteran in October 2012, he did note that the instability was characterized as "2+" for 5 to 10 millimeters of movement, with "3+" representing 10 to 15 millimeters of movement. These findings appear to be consistent with a finding of moderate instability. The Veteran's stated history of instability in the left knee joint that is so severe that it causes her to stumble. However, she is independent in her activities of daily living and has stated on more than one occasion that she is capable of managing her symptoms so they do not interfere with her occupational or social functioning. Thus, during the entire pendency of the appeal, the Veteran's left knee instability more nearly approximates the 20 percent level for moderate instability, rather than a higher 30 percent level for severe instability. Accordingly, at no time during this appeal is a rating in excess of 20 percent under Diagnostic Code 5257 warranted. Consideration of Other Diagnostic Codes Higher alternative ratings are offered under Diagnostic Code 5261 for limitation of extension; Diagnostic Code 5256 for ankylosis of the knee joint; Diagnostic Code 5258 for dislocated semilunar cartilage; and Diagnostic Code 5262 for impairment of tibia and fibula; however, there is no indication that the Veteran suffers from any of these disorders. Extension has consistently been full at zero degrees and evidence of ankylosis, a dislocated semilunar cartilage, or impairment of the tibia and fibula is not present. Lay statements As noted above, the Board has also considered the statements of the Veteran and her described knee symptoms. While the Veteran is competent to attest to the symptoms she experiences, the Board finds that the objective evidence of record consistently confirms that her knee disabilities are productive of slight to moderate limitation of motion and moderate instability. Thus, the assigned separate ratings of 10 percent and 20 percent adequately contemplate the Veteran's disability picture. Entitlement to higher ratings has not been shown at any point. See Hart, supra; Fenderson, supra. Additional Considerations Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the relevant service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the veteran'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 those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran'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 C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's left disabilities are not shown to cause any impairment that is not already contemplated by the relevant diagnostic codes, as cited above, and the Board finds that the rating criteria reasonably describe her disabilities. As previously noted, the objective evidence of record consistently confirms that her knee disabilities are productive of slight to moderate limitation of motion and moderate instability. The assigned separate ratings of 10 percent and 20 percent adequately contemplate the Veteran's disability picture. Moreover, the Veteran has not been hospitalized for treatment of her left knee, and although she can no longer work as an electrician as a result of her left knee symptoms, she has undergone successful vocational rehabilitation and is working in a new field as an administrative assistant. The Veteran has consistently reported that she is independent in her activities of daily living. Therefore, referral for consideration of an extraschedular rating is not warranted. ORDER Entitlement to a disability evaluation in excess of 10 percent for left knee, post operative arthritis, limitation of motion, is denied. Effective April 16, 2004, an initial disability evaluation of 20 percent, but no higher, for left knee instability is granted. Entitlement to an initial disability evaluation in excess of 20 percent for left knee instability, associated with osteoarthritis, left knee is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs