Citation Nr: 1324526 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 09-09 247 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUES 1. Entitlement to an increased rating for left knee patellofemoral syndrome with arthritis, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for right knee patellofemoral syndrome with arthritis, evaluated as 20 percent disabling prior to August 18, 2009. 3. Entitlement to an increased rating for service-connected right knee disability, status-post total knee arthroplasty, evaluated as 30 percent disabling from October 1, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. D. Simpson INTRODUCTION The Veteran served on active duty from February 1986 to August 1987. These matters come before the Board of Veterans Appeals (Board) on appeal from a March 2008 rating decision by the St. Louis, Missouri, Regional Office (RO) of the Department of Veterans Affairs (VA), and a June 2008 rating decision by the Sioux Falls, South Dakota RO. In July 2012, the Board remanded the appeal for further development. Prior to August 18, 2009, the Veteran was receiving a 20 percent rating for her service-connected right knee disability under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260 for right patellofemoral syndrome and degenerative joint disease. However, the record reflects that on August 18, 2009, the Veteran underwent a total right knee replacement. The intended effect of such surgery was to ameliorate some difficulties relating to the right knee disability, such as pain due to arthritis. In this regard, under the schedule of ratings for the musculoskeletal system, 38 C.F.R. § 4.71a, Diagnostic Code 5055 (knee replacement) is ordinarily intended to replace ratings previously assigned under Diagnostic Code 5010-5260 for the Veteran's right knee disability following replacement. The Board has thus re-characterized the issues as shown on the title page. (A 100 percent rating was assigned by the RO following the prosthetic surgery from August 18, 2009, until October 1, 2010, which is a rating that is not on appeal before the Board.) A review of the Virtual VA paperless claims processing system shows that updated VA treatment records are available. The agency of original jurisdiction (AOJ) considered these records in a January 2013 Supplemental Statement of the Case. FINDINGS OF FACT 1. The Veteran's left knee disability is manifested by complaints of pain, occasional flare-ups of sharp pain, and crepitus. Limitation of flexion to 60 degrees, extension to 10 degrees or objective evidence of subluxation or lateral instability is not demonstrated. 2. Prior to August 18, 2009, the Veteran's right knee disability was manifested by complaints of pain, swelling, crepitus, and occasional flare-ups of sharp pain. Limitation of flexion to 60 degrees, extension to 10 degrees or objective evidence of subluxation or lateral instability was not demonstrated. 3. Beginning October 1, 2010, the Veteran's right knee disability has been manifested by complaints of pain, swelling, crepitus, and occasional flare-ups of sharp pain. Limitation of flexion to 60 degrees, extension to 10 degrees or objective evidence of subluxation or lateral instability has not been demonstrated. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2012). 2. Prior to August 18, 2009, the criteria for a rating in excess of 20 percent for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2012). 3. Beginning October 1, 2010, the criteria for a rating in excess of 30 percent for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5257, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in her possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in December 2007, the RO notified the Veteran of the evidence needed to substantiate her claims for increased ratings for both knees. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist her in obtaining and the evidence it was expected that she would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's veteran status has been substantiated. She was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of her claims, in the December 2007 letter. The Court held in Vazquez-Flores v. Peake that 38 U.S.C.A § 5103(a) requires, at a minimum, that the Secretary notify the Veteran that, to substantiate an increased rating claim, the Veteran must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated sub nom, Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Additionally, the Veteran must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. Id. Furthermore, the Court directed that as with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation -- e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Id. The December 2007 letter told the Veteran that evidence of worsening could substantiate the increased rating claims. She was notified in the December 2007 letter that medical or lay evidence could be submitted to substantiate her increased rating claims and was provided with specific examples. The letters stated that the Veteran could submit letters from individuals who could describe the manner in which her disability had worsened. The December 2007 letter explained that disability ratings are determined by applying VA's rating schedule under which the RO would assign a rating from 0 to 100 percent, and that it would consider evidence of the nature of the symptoms of the condition, their severity and duration, and their impact upon employment. VA has fulfilled its duty to notify. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate her claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to her claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained the Veteran's service treatment records and all of the identified relevant post-service VA treatment records and private medical records. In addition, she was afforded an August 2012 VA examination to assess the severity of her service-connected knee disabilities. Her bilateral knee disability has not materially increased in severity since August 2012. Snuffer v. Gober, 10 Vet. App. 400 (1997). In the July 2012 remand, the Board instructed the AOJ to locate any temporary folder held at the RO, obtain updated VA treatment records, schedule another VA examination, and readjudicate the claims following the development. The AOJ obtained the Veteran's temporary claims folder and updated VA treatment records. Additionally, a VA examination was conducted in August 2012 to assess the severity of her service-connected knee disabilities. This examination was thorough, contained all pertinent findings, and was responsive to the questions posed by the Board. Accordingly, the AOJ substantially complied with all of the Board's relevant July 2012 remand instructions and VA has no further duty to obtain any additional records or conduct additional examinations. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two 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 evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. For purposes of this decision, the Board notes that normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Painful motion of a major joint or groups of minor joints caused by degenerative arthritis, where the arthritis is established by X-ray, is also deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even though there is no actual limitation of motion. See 38 C.F.R. §§ 4.40, 4.59, 4.71a, Diagnostic Code 5003; VAOPGCPREC 09-98 (August 14, 1998), citing Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range-of-motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. In addition to the limitation of motion diagnostic criteria, the rating schedule also includes ratings for subluxation or lateral instability of the knee. A 10 percent rating applies for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5055 applies to prosthetic replacement of the knee joint. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). A total rating for the year following the implantation of the prosthesis and a minimum 30 percent rating thereafter is automatically awarded. A 60 percent rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion the disability is to be rated by analogy to diagnostic codes 5256, 5261, or 5262. The 100 pct rating for 1 year following implantation of prosthesis will commence after initial grant of the 1-month total rating assigned under § 4.30 following hospital. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology 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). The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998). Moreover, the General Counsel also held more recently that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and under Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September, 2004). 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). (i) Left Knee The Veteran's left knee patellofemoral syndrome with degenerative arthritis has been rated as 10 percent disabling under Diagnostic Code (DC) 5099-5010. (Hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27 (2012). Here, it is patellofemoral syndrome. The first two digits of the first diagnostic code indicate the most closely related body part followed by a "99." Id. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id.; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. Here, DC 5010 is for arthritis due to trauma. It directs that traumatic arthritis be rated as degenerative arthritis under DC 5003. 38 C.F.R. § 4.71a, DCs 5003 and 5010.) Private medical records from December 2007 show that the Veteran sought medical attention for her right knee disability. The Veteran had a January 2008 VA examination. She reported having a gradual worsening of pain over the anterior left knee under the kneecap and at the tibial femoral joint lines on either side of the kneecap. It swelled frequently and popped during ambulation. Although it was slightly unstable, it had not locked, nor given way. She related that she did not need ambulatory assistive devices for her left knee. She described her left knee pain severity as 5/10 with flare-ups rising to 7/10. The flare-ups occurred three times per week and lasted from two to three hours. They were precipitated by activity. Clinical examination did not show warmth or increased effusion. She had mild tenderness to palpation and moderate crepitation of the patella with normal excursion. Flexion was to 110 degrees limited by pain and stiffness. Repetitive testing was not possible due to pain. Anterior and posterior drawer signs were negative. Varus and valgus stress testing was also negative. X-rays showed mild degenerative joint disease. The examiner diagnosed patellofemoral syndrome with mild degenerative arthritis of the left knee. Left knee X-rays taken in April 2008 were within normal limits. In August 2008, the Veteran's friend reported on her observations. She witnessed the Veteran having difficulty with shopping, driving, and using stairs due to her knee disability. VA treatment records from August 2008 reflect that the Veteran requested pain relief medication for knee pain. During clinical examination, no overt swelling was found and she did not flinch upon palpation. She wore a brace on her left knee. Edema was not found. The examiner assessed bilateral knee osteoarthritis. A subsequent social worker note indicates that she needed assistance in bathing and single story housing due to her inability to climb stairs. In October 2008, the Veteran sought treatment for left knee pain. She denied any trauma, but recently was unable to bear weight on her left knee. Left knee flexion was to 130 degrees. The examiner observed mild effusion, but assessed it as stable. She again complained about knee pain in December 2008 with the left being worse than the right and inquired about a scooter due to extremely limited mobility. Flexion was to 110 degrees and extension was to -5 degrees. It appears these range-of-motion findings were for both knees. X-rays taken in April 2009 reflect that the Veteran had mild to moderate degenerative arthritis in her left knee. VA reexamined the Veteran in May 2009. She provided subjective complaints of weakness and instability, but denied any instance of her knees giving way. Her right knee was more painful than her left knee. Clinical examination of the left knee was unremarkable. She had mild medial line joint tenderness and mild crepitus with motion. Anterior drawer, Lockman, and McMurray tests were all negative. No signs of lateral medial collateral instability were found. Flexion was to 115 degrees without further loss of motion on repetition. The examiner further commented that additional functional impairments (fatigue, weakness, pain, etc) were considered, but could not be stated with any certainty. The Veteran had 5/5 muscle strength and normal neurovascular findings. The examiner diagnosed osteoarthritis of the knees. VA treatment records from November 2011 show that the Veteran had ongoing left knee pain. Clinical examination did not show effusion, but she had positive lateral joint line tenderness. Flexion was to 120 degrees with crepitus. X-rays taken in November 2011 showed mild tricompartmental left knee degenerative joint disease within medial compartment. The examiner offered a steroid injection for pain relief, but the Veteran declined. She was scheduled for a six month follow-up visit. In an April 2012 phone consultation, the Veteran reported that she had pain and stiffness in both knees. VA treatment records from May 2012 continue the overall "fair" knee assessment of the Veteran's knees. She reported minimal pain from her left knee. Clinical examination showed crepitus in the left knee. However, both knees were stable without effusion or palpable pain. The Veteran had her most recent VA examination in August 2012. The examiner recounted her treatment history. She continued to have pain in her left knee and ambulated with a cane. She described the pain as constant at 6/10 and occasionally sharp, reaching 8-9/10. Flexion was to 125 degrees without pain. Extension was full without pain. No additional motion was lost upon repetition. The examiner noted pain upon palpation of the joint line. She exhibited full muscle strength and joint stability testing was normal. No evidence for subluxation or dislocation was observed. The examiner diagnosed degenerative arthritis. He commented that there was no disorder of the tibia or fibula and the observed range of motion was not painful. He did not find effusion or instability based upon objective clinical testing. No demonstrable locking or subluxation was observed. He assessed the Veteran's subjective complaints of intermittent sharp pain as mild and noted there were no plans for total knee replacement surgery. The Veteran had a neurology consultation in September 2012. She had slightly diminished strength in both legs, but no other pertinent findings were made. VA treatment records from October 2012 show that the Veteran had significant valgus in both knees and weakness in her legs. The examiner believed her leg weakness was contributing to her instability. He recommended long-term physical therapy for muscle strengthening exercises and a medial unloader brace. In November 2012, clinical examination showed left knee flexion was to 100 degrees. No further findings were made for the left knee. The Veteran's most recent available primary care clinic records are from December 2012. She complained about a sore throat, cough, and malaise. No additional findings were made for her left knee. The Veteran contends a rating in excess of 10 percent is warranted for her left knee. She is currently in receipt of a 10 percent rating due to degenerative arthritis manifested by painful motion. 38 C.F.R. § 4.71a, DCs 5003, 5010. A higher rating is not warranted pursuant to Diagnostic Code 5257 as several clinical stability tests conducted on different occasions were negative for joint instability or subluxation. 38 C.F.R. § 4.71a, Diagnostic Code 5257; (See also VA examination reports taken January 2008, May 2009 and August 2012; VA treatment records from October 2008 and May 2012). Although leg weakness has been recently noted as causing instability, it is not characterized as part of her knee joint disability. (See October 2012 VA treatment records). Based upon the above record, instability or subluxation has not been demonstrated. The Board has also considered a separate rating for limitation of motion (flexion and extension). Esteban, 6 Vet. App. at 262; VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5003, 5260, and 5261. However, all range-of-motion studies for both flexion and extension do not show that the Veteran ever met the criteria for a compensable rating for either. (See VA examination reports taken January 2008, May 2009 and August 2012; VA treatment records from October 2008, November 2011, November 2012). A compensable rating under DCs 5260 or 5261 is not warranted. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5260, and 5261. The Board has considered 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206 -07. However, an increased rating for complaints about pain, excess fatigability, decreased functional ability, etc. is not warranted. As detailed, on multiple VA examinations, with regard to the left knee, pain was the major functional impact. Likewise, pain had an effect on functional impairment. Her functional impairment due to pain and flare-ups of pain has been considered. The Board notes that she has provided occasional reports of flare-ups and on the January 2008 examination could not perform repetitive motion. However, the most recent examination report shows her performing repetitive motion. She did identify flare-ups as a significant impairment. In the August 2012 medical opinion, the examiner noted sharp pain, but assessed it as mild and did not identify additional functional impairment due to flare-ups. His assessment is based upon the contemporaneous clinical examination. Thus, her functional impairment due to pain and flare-ups of pain has been considered. While acknowledging the effects on her daily activities reflected in the VA examination reports of record, there is no basis for a higher rating based on additional functional loss due to pain, weakness, impaired endurance, fatigue, incoordination, or flare-ups. The record does not show any disorder or malunion with the tibia or fibula of the left leg to warrant a rating under DC 5262. 38 C.F.R. § 4.71a, DC 5262; (See August 2012 VA examiner medical opinion) In summary, a rating in excess of 10 percent for painful motion associated with arthritis and a separate rating for reduced motion, instability, or subluxation of the left knee is denied. 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.71a, DC 5257, 5260, 5261. (ii) Right Knee The Veteran's right knee disability was rated as 20 percent disabling prior to August 18, 2009, and 30 percent disabling beginning October 1, 2010 under Diagnostic Codes (DC) 5010-5260. Here, DC 5260 is for limitation of flexion. 38 C.F.R. § 4.71a, DCs 5010 and 5260. Private medical records from December 2007 and January 2008 show that the Veteran had right knee pain without locking. She had recurrent swelling. No instability was found. X-rays confirmed moderate to advanced degenerative joint disease. The examiner commented that the Veteran would likely need knee replacement surgery in the future. The final diagnosis was degenerative arthritis with synovitis. The Veteran had a VA examination in January 2008. She reported that her right knee was unstable and weak, but that it had not given out. She described her right knee pain as 7/10 severity and 9-10/10 severity during flare-ups, which occurred three to four times per week and lasted from a few hours to two days. They were precipitated by activity. Clinical examination was negative for redness, warmth, and effusion. It was tender over the surgical scar. Flexion was limited to 115 degrees due to pain. Repetitive motion was not possible due to pain. Anterior and posterior drawer testing were negative. No varus or valgus instability was found. X-rays did not show any significant progression of degenerative changes. The examiner diagnosed patellofemoral syndrome with moderate degenerative joint disease. VA treatment records from April 2008 show that the Veteran had increased right knee pain. Clinical examination showed a "good" range of motion and stability. X-rays revealed cartilage narrowing. In May 2008, she returned to primary care for lower extremity edema symptoms. No significant clinical findings were made. The examiner attributed the edema to knee arthritis and obesity. VA treatment records from October 2008 reflect that the Veteran had a recent flare-up of knee pain. In December 2008, she inquired about obtaining a scooter due to limited mobility. Flexion was to 110 degrees and extension was to -5 degrees. It appears these findings were for both knees. X-rays taken in April 2009 reflect that the Veteran had severe degenerative arthritis in her right knee. The Veteran had another VA examination in May 2009. She reported bilateral knee pain with the right knee being worse than the left knee. She provided subjective complaints of weakness and instability, but denied any instance of her knees giving way. Clinical examination of the right knee showed a vertical 3.5 centimeter scar without adherence or pain. She had very mild crepitus with flexion motion. Anterior drawer, Lockman, and McMurray tests were all negative. No signs of lateral medial collateral instability were found. Flexion was to 115 degrees without further loss of motion on repetition. The Veteran had 5/5 muscle strength and normal neurovascular findings. X-ray of the right knee showed severe osteoarthritic changes. The examiner diagnosed osteoarthritis of the bilateral knees. In August 2009, the Veteran underwent total knee replacement surgery. VA treatment records from November 2011 show that the Veteran complained about chronic right knee pain. She also described swelling and tightness in her right knee. Clinical examination showed minimal soft tissue swelling. Effusion and joint line tenderness were not observed. Flexion was to 120 degrees. Contemporaneous X-rays revealed right knee total arthroplasty without loosening or radiographic complication. In an April 2012 phone consultation, the Veteran reported that she had pain and stiffness in both knees. VA treatment records from May 2012 continued the overall "fair" knee assessment of the Veteran's knees. She reported occasional sharp pain in the right knee. Clinical examination was unremarkable for the right knee and both knees were stable without effusion or palpable pain. The Veteran had her most recent VA examination in August 2012. The examiner recounted her treatment history. She currently had right knee swelling and locking, which was very painful. She described her right knee pain as 6.5/10 constantly and having periodic nonincapacitating pain. Flexion was to 110 degrees with endpoint pain. Extension was full without pain. No additional motion was lost upon repetition. No joint line or soft tissue pain was found. She exhibited full muscle strength and joint stability testing was normal. No evidence for subluxation or dislocation was observed. She was not found to have any residuals symptoms from her June 2003 meniscectomy. The examiner noted her recent total knee replacement and characterized her as having intermediate degrees of residual weakness, pain, or limitation of motion. He noted that she had scars from the two operations, but declined to characterize them as painful or unstable. The examiner diagnosed degenerative arthritis. He commented that the Veteran recovered from the total knee replacement with normal residuals. Her right knee was stable without effusion. He stated that the chronic operative residuals had stabilized and were not worsening. He cited recent X-ray studies. He described the observed pain on motion as mild and without weakness. The Veteran had a neurology consultation in September 2012. She had slightly diminished strength in both legs, but no other pertinent findings were made. VA treatment records from October 2012 show that the Veteran had significant valgus in both knees and weakness in her legs. Flexion was to 90 degrees. She did not have significant lateral or medial joint line tenderness, but reported pain near the patella, lower anterior thigh, and across upper anterior tibia. No effusion, warmth, nor redness was found. She had weakness in her right quadriceps. The examiner believed her leg weakness was contributing her instability. He recommended long-term physical therapy for muscle strengthening exercises and a medial unloader brace. In November 2012, clinical examination showed right knee flexion was to 100 degrees. Mild swelling was observed. She did not have effusion or specific tenderness. The examiner planned to reassess the Veteran in a year with updated X-rays. The Veteran's most recent available primary care clinic records are from December 2012. She complained about a sore throat, cough, and malaise. No additional findings were made for her right knee. The Veteran contends a rating in excess of 20 percent prior to August 18, 2009, and in excess of 30 percent beginning October 1, 2010, is warranted for her right knee. She is currently in receipt of a 30 percent rating due to status post total right knee replacement surgery on August 19, 2009. 38 C.F.R. § 4.71a, DCs 5055, 5260. A higher or separate rating is not warranted pursuant to Diagnostic Code 5257 as several clinical stability tests conducted on different occasions were negative for instability or subluxation. 38 C.F.R. § 4.71a, Diagnostic Code 5257; (See also private medical records from December 2007 and January 2008, VA examination reports taken January 2008, May 2009 and August 2012; VA treatment records from April 2008 and May 2012). Although leg weakness has been recently noted, it is not characterized as part of her joint disability. (See October 2012 VA treatment records). Based upon the above record, instability or subluxation has not been demonstrated. The Board has also considered a separate rating for limitation of motion (flexion and extension). Esteban, 6 Vet. App. at 262; VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5003, 5260, and 5261. However, all range-of-motion studies for both flexion and extension do not show that the Veteran ever met the criteria for a compensable rating for either. (See VA examination reports taken January 2008, May 2009 and August 2012; VA treatment records from April 2008, October 2008, November 2011, October 2012, and November 2012). A compensable rating under DCs 5260 or 5261 is not warranted. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5260, and 5261. The Board has considered 38 C.F.R. §§ 4.40 and 4.45, addressing the impact of functional loss, weakened movement, excess fatigability, incoordination, and pain. DeLuca, 8 Vet. App. at 206 -07. However, an increased rating for complaints about pain, excess fatigability, decreased functional ability, etc. is not warranted. As detailed, on multiple VA examinations, with regard to the right knee, pain was the major functional impact. Likewise, pain had an effect on functional impairment. Her functional impairments due to pain and flare-ups of pain have been considered. The Board notes that she has provided occasional reports of flare-ups and on the January 2008 examination could not perform repetitive motion. However, the most recent examination report shows her performing repetitive motion. In August 2012, she has identified flare-ups as a significant impairment. The VA examiner noted her reports of sharp pain, but assessed it as mild and did not identify additional functional impairment due to flare-ups. His assessment is based upon the contemporaneous clinical examination. Thus, her functional impairment due to pain and flare-ups of pain has been considered. While acknowledging the effects on her daily activities reflected in the VA examination reports of record, there is no basis for a higher rating based on additional functional loss due to pain, weakness, impaired endurance, fatigue, incoordination, or flare-ups. The record does not show a nonunion or malunion of the right tibia and fibula to warrant a higher or separate rating. 38 C.F.R. § 4.71a, DC 5262; (See VA examination reports from January 2008, May 2009, and August 2012). For the period following the total knee replacement, Diagnostic Code 5055 provides a 60 percent rating for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Here, the August 2012 examiner assessed the Veteran as having normal residuals from the total knee replacement that were static. He characterized her post operative residuals as intermediate degrees of residual weakness, pain, or limitation of motion. He did not identify or refer to severe painful right knee motion; nor has any similar finding been made in VA treatment records. (See August 2012 VA examination report; VA treatment records from November 2011, May 2012, and November 2012). The criteria for an increased rating under Diagnostic Code 5055 are not met. The Boards notes that the Veteran has two postoperative right knee scars, one from a June 2003 meniscectomy and the other from the August 2009 total knee replacement. Although a January 2008 examiner described the meniscus scar as tender, neither scar has been shown to be painful or adhere to underlying soft tissue. (See VA examination reports from July 2008, May 2009, and August 2012; May 2012 VA treatment records). A separate rating for scar residuals is not warranted. In summary, an additional separate rating or a rating in excess of the currently assigned 20 percent prior to August 18, 2009 and 30 percent beginning October 1, 2010 for the right knee is not warranted. 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.71a, DCs 5055, 5257, 5260, 5261. If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). After consideration of the evidence, the Board has determined that referral for an extraschedular rating is not warranted. The Board has considered all symptoms of the Veteran's service-connected bilateral knee disability jointly and singly. Mittleider v. West, 11 Vet. App. 181 (1998). The clinical examiners, including most recently in August 2012, have not identified any unusual or otherwise exceptional symptoms. The symptoms of limited motion and painful motion are clearly contemplated by the schedular rating criteria. The record does not otherwise suggest the presence of any extraordinary symptoms or manifestations. For these reasons, the Board considers the schedular evaluation to be adequate and referral for extraschedular consideration is not warranted. Thun, supra.; 38 C.F.R. § 3.321. The Board notes that the Veteran has not been regularly employed since November 2008. However, she has been engaged in temporary employment and does not otherwise assert that her bilateral knee disability precludes gainful employment consistent with her education and occupational experience. A total disability rating based upon individual unemployability (TDIU) is not for further consideration. Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A rating in excess of 10 percent for patellofemoral syndrome with degenerative arthritis of the left knee is denied. A rating in excess of 20 percent prior to August 18, 2009, for patellofemoral syndrome with degenerative arthritis of the right knee is denied. A rating in excess of 30 percent beginning October 1, 2010 for status post total knee replacement of the right knee is denied. ______________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs