Citation Nr: 1324993 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 06-12 530 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an increased evaluation for degenerative osteoarthritis of the left knee, currently evaluated as 10 percent disabling. 2. Entitlement to a separate compensable disability rating for a left knee scar. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, Appellant's Brother ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from September 1989 to June 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. This case was previously before the Board in April 2010 and remanded for additional development. In November 2011, the Board issued a decision granting a 20 percent disability rating for the appellant's service-connected left knee laxity relating to surgical repairs for osteochondrosis of the tibial tuberosity and denying the claim for an evaluation in excess of 10 percent for degenerative osteoarthritis of the left knee. The appellant appealed the Board's November 2011 decision to the U.S. Court of Appeals for Veterans Claims (Court). In August 2012, his representative and VA's Office of General Counsel, representing the Secretary of VA, filed a Joint Motion requesting that he Court vacate the Board's decision and remand the case for readjudication in compliance with directives specified on the issues of (1) entitlement to an increased evaluation for service-connected degenerative osteoarthritis of the left knee, and (2) entitlement to a separate compensable disability rating for the appellant's left knee scar. The Court issued an order that same month, granting the Joint Motion, and returned the case to the Board. As noted in the April 2010 remand, November 2011 decision, and March 2013 remand, in a June 2007 statement, the appellant indicated that he wished to file claims for entitlement to service connection for hypertension, fatty liver disease, a right knee condition, erectile dysfunction, and depression, to include as secondary to his service-connected left knee disabilities. There is no indication that these issues have been adjudicated. The AMC referred the issues to the RO in a June 2013 memorandum. The issues of entitlement to service connection for hypertension, fatty liver disease, a right knee condition, erectile dysfunction, and depression, to include as secondary to his service-connected left knee disabilities have been raised by the record but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. In August 2005, the appellant presented testimony at a personal hearing conducted at the Detroit RO before a Decision Review Officer (DRO). A transcript of this hearing has been associated with the appellant's claims file. FINDINGS OF FACT 1. The appellant's degenerative osteoarthritis of the left knee is manifested by pain, including on use, productive of knee flexion limited to no worse than 45 degrees and extension limited to no worse than 5 degrees, with no evidence of additional functional limitation due to pain, weakness, fatigue or lack of endurance with repeated motion. 2. The appellant's left knee scars are not deep, unstable or painful, are less than 6 square inches and do not cause limitation of motion or functional impairment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for degenerative osteoarthritis of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012). 2. The criteria for a separate compensable rating for a separate left knee scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.118, Diagnostic Codes 7801-7805 (as in effect prior to and from Oct. 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). More specific notice is required in claims for increased compensation. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's increased rating claims. Appropriate notice was provided in February 2005 and March 2006 letters. The claim was subsequently readjudicated, most recently in a June 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333; See Pricket v. Nicholson, 20 Vet. App. 370 (2006). The Board concludes VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file, including the records requested in the March 2013 remand. Private medical records identified by the appellant have been obtained, to the extent possible. The appellant's Social Security Administration records have been associated with the file in compliance with the April 2010 Board remand. See Dyment, 13 Vet. App. at 146-147; Stegall, 11 Vet. App. at 271. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the appellant. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the appellant's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran appropriate VA examinations in February 2005, July 2010, and May 2013. As discussed in the March 2013 Board remand, the July 2010 VA examination is inadequate because the examiner failed to indicate at what degree pain began in the knee. However, the May 2013 VA examination is adequate. The examination is based on a thorough examination, a description of the appellant's pertinent medical history, a complete review of the claims folder and appropriate diagnostic tests. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The appellant has not reported receiving any recent treatment specifically for this condition and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the appellant's service-connected disorders since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The VA examination reports are thorough and supported by VA treatment records and provided findings pertinent to the rating criteria. The examinations in this case are adequate upon which to base a decision. The May 2013 VA examination was also completed in compliance with the March 2013 Board remand. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Degenerative Osteoarthritis of the Left Knee Disability evaluations are determined by comparing a veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 4.1 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the appellant. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Nevertheless, where, as here, the appellant is appealing the rating for an already established service-connected condition, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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, 4.45, see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. The appellant's degenerative osteoarthritis of the left knee is currently evaluated under Diagnostic Code 5010. Diagnostic Code 5010 provides that traumatic arthritis, due to trauma and substantiated by x-ray findings, is to be evaluated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by the limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under diagnostic code 5260, flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Extension limited to 5 degrees warrants a noncompensable rating, to 10 degrees warrants a 10 percent rating, to 15 degrees warrants a 20 percent rating, to 20 degrees warrants a 30 percent rating, to 30 degrees warrants a 40 percent rating, and to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. VAOPGCPREC 9-2004 (Sept. 17, 2004) held that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. As such, if the evidence of record reflects compensable loss of both flexion and extension of the right leg, the appellant would be entitled to the combined evaluation under Diagnostic Codes 5260 and 5261, per the combined ratings table in 38 C.F.R. § 4.25. The appellant's claim for an increased rating was received on January 13, 2005. Entitlement to service connection for degenerative osteoarthritis of the left knee was granted by a July 2004 rating decision, effective March 17, 2004. As such, the rating period on appeal is from March 17, 2004. 38 C.F.R. § 3.400(o)(2) (2012). The appellant contends that he is entitled to an evaluation in excess of 10 percent for degenerative osteoarthritis of the left knee. For the reasons that follow, the Board finds that a higher evaluation is not warranted. As noted above, the appellant's degenerative osteoarthritis of the left knee is currently evaluated under Diagnostic Code 5010. In the present case, the evidence of record fails to reveal flexion or extension warranting an evaluation in excess of 10 percent. The February 2005 VA examination report indicated that the appellant developed pain with flexion from 50 degrees to approximately 80 degrees. No guarding was appreciated. There was no pain, fatigue, weakness, or lack of endurance following repetitive range of motion testing. A September 2005 University of Michigan Hospital and Health Center Outpatient Consultation record reflected that the appellant's left knee had passive range of motion from 5 degrees to 90 degrees with pain, and that he could only actively flex to 45 degrees. A June 2006 VA orthopedic treatment record noted that the appellant wore a knee brace and used a cane to assist with ambulation. He took oxycodone for pain. An August 2006 VA treatment record indicated that the appellant had positive anterior knee pain. Statements from the appellant's wife, father-in-law, mother-in-law, and co-workers from 2007 reflect that the appellant had physical problems due to left knee. The appellant's wife stated that the appellant could barely walk and fell at least 1 to 2 times a night because his knee gave out. The appellant's co-worker indicated he had fallen due to his knee. Lay statements may be competent to support a claim for service connection where the events or the presence of disability, or symptoms of a disability are subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds that lay statements to be credible, as they are consistent with the evidence of record. An April 2010 letter from Dr. A.M. indicated that the appellant was still suffering from chronic pain and causing him at times to be incapacitated. The appellant was evaluated at a July 2010 VA examination. As noted above, the July 2010 VA examination is inadequate because the VA examiner did not indicate at what degree pain on motion of the left knee began. Nevertheless, the appellant's statements to the examiner and the objective findings of the examination are relevant to rating the appellant's left knee disability. A July 2010 VA examination report indicates that on physical examination, the appellant's left knee, evaluated with a goniometer, had a range of motion of 0 to 75 degrees with the complaint of pain anteriorly in the front of the knee. The appellant reported that repetitive motion increased the pain without any additional loss of motion. He reported that he had a painful left knee with constant pain of 9 or 10 out of 10. There was no history of flare-ups. X-rays revealed metallic screws at the proximal tibial tubercle with evidence of bone surgery. The status was a left knee with limited motion and pain, but without any instability. There was no evidence of incoordination, weakness, or excess fatigability. There was no additional functional impairment due to weakened movement, excess fatigability, or incoordination. An August 2010 private examination report from E.M., M.D., reflects that the appellant's left knee had flexion of 0 to 75 degrees. Left knee extension was 0 degrees. The appellant had a significant antalgic gait because of his left knee straightening. He managed a few steps without a cane, but it was very painful. He could not squat. A July 2011 VA treatment record indicates that the appellant's gait and range of motion of the upper and lower extremities was normal. A March 2012 VA treatment record indicated that the appellant reported having left knee pain that was no longer controlled on 100 mg of morphine. He had bilateral lower extremity swelling, greater on the left. The record noted that the previous surgeries may have been contributing to some of his swelling but the appellant said when he was hospitalized and taken off morphine, the lower extremity swelling did not return until he was discharged from home and went back on morphine. August 2011 and April 2012 VA treatment records noted that the appellant had mild pitting edema of the left leg, greater than the right. His gait was normal. The appellant had upper and lower extremities strength of 5/5 and his range of motion was normal. The May 2013 VA examination report indicated that the appellant did not report having flare-ups that impacted the function of the knee and/or lower leg. On examination, the left knee had flexion of 80 degrees. Objective evidence of painful motion began at 80 degrees. The left knee had extension of 0 degrees. There was no objective evidence of painful motion on extension. The appellant was able to perform repetitive-use testing with three repetitions. The left knee had post-test range of motion flexion of 80 degrees and post-test extension of 0 degrees. The appellant did not have additional limitation in range of motion of the knee and lower leg following repetitive-use testing. The VA examiner noted that there was no functional loss for the left lower extremity. There was less movement than normal and swelling in the left knee. There was tenderness or pain to palpation for the joint line or soft tissues of the left knee. Muscle strength on flexion and extension was 5/5. The examiner noted that the appellant had leg length discrepancy. The length of the right leg was 91.5 cm while the left leg had a length of 94 cm. The VA examiner noted that the appellant had a history of a left knee surgery that had residuals of pain and swelling. The appellant reported that he used a brace and cane constantly. The VA examiner found that the service-connected disability affected the appellant's ability to work, but the appellant could do light duty sedentary work related jobs. The examiner noted that the appellant did several jobs on and off (factory worker, retail sales and office clerk) from 1992 through January 2010. He had not worked since January 2010. Based on the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted for the service-connected left knee disability. As noted above, a 10 percent evaluation is warranted under Diagnostic Code 5260 for flexion limited to 45 degrees and a 20 percent evaluation is warranted for flexion limited to 30 degrees. The evidence above reflects that the appellant's flexion was limited to no less than 45 degrees, including limitation due to pain. The September 2005 private treatment record indicated the appellant had active flexion limited to 45 degrees. The most recent VA treatment record in May 2013 indicated that the appellant's left knee had flexion of 80 degrees with pain beginning at 80 degrees. Thus, an evaluation of 20 percent is not warranted under Diagnostic Code 5260. Under Diagnostic Code 5261, extension limited to 5 degrees warrants a noncompensable evaluation while extension limited to 10 degrees warrants a 10 percent evaluation. The September 2005 University of Michigan Hospital and Health Center Outpatient Consultation record reflects that the appellant's left knee had passive range of motion from 5 degrees to 90 degrees with pain, indicating extension of 5 degrees. The other evidence of record indicated the appellant had normal extension of the left knee of 0 degrees. Extension limited to 5 degrees only warrants a noncompensable evaluation under Diagnostic Code 5261. Thus, the appellant is not entitled to a higher evaluation under Diagnostic Code 5261. The Board has also considered the complaints and findings of pain described above, but it does not find that the evidence reflects additional functional limitation comparable to a 20 percent evaluation under Diagnostic Code 5260 or a compensable evaluation under Diagnostic Code 5261. See 38 C.F.R. §§ 4.40, 4.45, and 4.59 and DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The Board acknowledges the appellant's consistent complaints of left knee pain in the VA treatment records, VA examination reports and private medical records. However, the Board finds that these complaints of pain have been contemplated by the current rating. The February 2005 VA examination report reflects that the appellant developed pain with flexion from 50 degrees. The May 2013 VA examination report reflects that the appellant's left knee flexion had objective evidence of painful motion beginning at 80 degrees. The appellant was able to perform repetitive-use testing with three repetitions and there was no additional limitation in range of motion of the knee and lower leg following repetitive-use testing. The range of motion with pain did not warrant a higher evaluation. The May 2013 VA examiner noted that there was no functional loss for the left lower extremity. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, No. 09-2169, 2011 WL 3672294, at *4 (Vet. App. August. 23, 2011). Consequently, the Board finds the evidence of record is against a finding that the appellant is entitled to a higher evaluation for his service-connected left knee degenerative osteoarthritis under Diagnostic Code 5010. The Board has considered the appellant's statements and the 2007 lay statements from his wife, father-in-law, mother-in-law and co-workers. As noted above, the Board finds the statements to be credible. However, the Board finds that the statements are consistent with a 10 percent rating for degenerative osteoarthritis of the left knee. The statements indicate the appellant fell due to his knee. The appellant is separately rated as 20 percent disabling for left knee laxity. The statements did not indicate the appellant had limited motion of the knee warranting a rating in excess of 10 percent. The Board has also considered whether the appellant is entitled to a higher evaluation for left knee degenerative osteoarthritis under another Diagnostic Code. As there is no evidence of ankylosis of the knee, a higher evaluation is not warranted under Diagnostic Code 5256. There is no evidence that the appellant had dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Thus, a higher evaluation is not warranted under Diagnostic Code 5258. There is also no evidence of malunion of the tibia and fibula. Thus, Diagnostic Code 5262 is not applicable. The appellant is separately evaluated under Diagnostic Code 5257 for laxity of the left knee and that issue is not before the Board at this time. In sum, the Board finds that the appellant is not entitled to an evaluation in excess of 10 percent for degenerative osteoarthritis of the left knee during the period on appeal. As discussed above, the evidence of record does not reflect that the appellant has limitation of motion warranting a higher evaluation under Diagnostic Code 5260 or 5261. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, the reported symptoms are consistent with the assigned schedular evaluation. The Board notes that in reaching this conclusion, the benefit of the doubt doctrine has been applied where appropriate. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee Scars The appellant has several left knee surgical scars. In a July 2010 VA examination, the examiner stated that: There is a surgical scar near the tibial tubercle which is well healed. The skin is of normal color without any swelling or edema. He complains of severe pain on touching the skin in the patellar area. Patellar position is normal. There is the complaint of pain on palpation near the tibial tubercle. In the November 2011 Joint Motion, the parties agreed that upon remand, the VA examiner should clarify whether the appellant's left knee scar is painful. The May 2013 VA examiner noted that the appellant had several surgical scars on his left knee due to surgeries in 1995, 1996, and 2000. The appellant denied having any specific residual problems related to the scars. He was not using any local medications. The scar was not painful and/or unstable, and did not have a total area of all related scars greater than 39 square cm. The VA May 2013 examiner noted that he appellant had a residual linear superficial surgical scar measuring 8.0 cm noted over the mid anterior aspect of the left knee. There were four small superficial arthroscopic surgical scars (one is 1.0 cm and three each measuring 0.5 cm) over the anterior and lateral aspects of the left knee. The scars were not tender, there were no inflammation, edema or keloid changes, and the scars were not disfiguring. The appellant's VA treatment records do not indicate the appellant had any complaints regarding his left knee scars. Based on the evidence of record, the Board finds that the appellant has left knee scars that are related to his service-connected disability. However, the Board finds that a compensable rating is not warranted. While the appellant's claim was pending, new rating criteria for evaluating skin disabilities became effective October 23, 2008; however, these regulations apply only to claims filed on or after October 23, 2008, or when requested by the appellant. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Although the appellant did not specifically request review under the revised criteria, he did request a review of his 10 percent disability rating when he appealed the denial of an increased rating for his left knee disability. The Board has an obligation to consider all potentially applicable provisions of law and regulation and to apply the diagnostic criteria in a manner that maximizes his benefits. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Bradley v. Peake, 22 Vet. App. 280 (2008). The revised diagnostic criteria are potentially applicable for purposes of establishing an appropriate rating from October 23, 2008, onward. See Fenderson v. West, 12 Vet. App. 119 (1999). Under the diagnostic criteria in effect prior to October 23, 2008, scars, other than of the head, face, or neck are to be rated under Diagnostic Code 7801 to 7805. Under Diagnostic Code 7801, which governs scars, other than the head, face, or neck, that is deep or cause limited motion, a 10 percent evaluation was assignable when the area or areas exceed six square inches (39 square centimeters). Under Diagnostic Code 7802, which governs scars other than the head, face, or neck, that are superficial and do not cause limited motion, a 10 percent evaluation was assignable for area or areas of 144 square inches (929 square centimeters) or greater. Under Diagnostic Code 7803, a 10 percent evaluation was assignable for scars that are superficial and unstable. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7803, Note (1), (2). Under Diagnostic Code 7804, a 10 percent evaluation was assignable for scars that are superficial and painful on examination. Under Diagnostic Code 7805, other types of scars will be rated based on limitation of function of affected part. Under the criteria in effect from October 23, 2008, a 10 percent rating warranted under Diagnostic Code 7801 for a scar, not of the head, face, or neck that is deep and nonlinear with an area of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). Under Diagnostic Code 7802, a scar that is superficial and nonlinear and of an area of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. Diagnostic Code 7804 provides that one or two scars that are unstable or painful warrant a 10 percent rating. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Diagnostic Code 7804 provides that VA should evaluate any disabling effects no considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. The Board finds that a separate, compensable rating is not warranted for the appellant's left knee scars under the criteria in effect prior to or from October 23, 2008. The appellant's scars do not exceed 6 square inches and are not deep and nonlinear. The appellant's scars do not cover an area of 144 square inches or greater. The scars have not been shown to be unstable. Although the July 2010 VA examination indicated the appellant had pain on palpation near the tibial tubercle, where one of the appellant's surgical scars was located, the May 2013 VA examination specifically noted that the scar was not painful on examination. Lastly, no limitation of function or other disabling effects due to the left knee scars have been shown. Consequently, a compensable rating is not warranted under the Diagnostic Codes in effect prior to or from October 23, 2008. 38 C.F.R. § 4.118, DCs 7801-7805 (as in effect prior to and from Oct. 23, 2008). Extraschedular Consideration The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the left knee disability. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the appellant's left knee disability are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the left knee disability is primarily manifested by limitation of motion due to pain and instability. The applicable diagnostic codes used to rate the disability provide for ratings based on limitation of motion and instability, and the effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The effects of the appellant's disabilities have been fully considered and are contemplated in the rating schedule. Consideration of whether the appellant's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU is an element of all appeals for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, TDIU consideration is not warranted. The appellant appealed the issue of entitlement to TDIU to the Board, however, in April 2010, the Board dismissed the appellant's claim for entitlement to TDIU after the appellant withdrew his appeal. The issue of TDIU has not been raised by the record since that time. The May 2013 VA examiner opined that the appellant could do light duty sedentary work-related jobs. Accordingly, the Board finds that the issue of entitlement to TDIU is not currently before the Board. ORDER Entitlement to an evaluation in excess of 10 percent for degenerative osteoarthritis of the left knee is denied. Entitlement to a separate compensable rating for a surgical scar of the left knee is denied. ____________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs