Citation Nr: 1325111 Decision Date: 08/07/13 Archive Date: 08/13/13 DOCKET NO. 08-27 175 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a rating in excess of 10 percent for residuals of a left knee injury based on limitation of motion. 2. Entitlement to a rating in excess of 20 percent for residuals of a left knee injury based on injury to the semilunar cartilage or instability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. R. Fletcher, Counsel INTRODUCTION The Veteran served on active duty from August to November 1998, in January 2001, and from October 2003 to July 2004. He also has service in the Army National Guard. This matter is on appeal from an August 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. Historically, in a June 2007 claim the Veteran sought an increased rating for his service-connected left knee disability, which had been rated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5260 (2012) (addressing traumatic arthritis and limitation of flexion, respectively). In a December 2011 decision, the Board denied the claim for an increased rating based on limitation of motion, but did assign a separate 20 percent rating based on a partial tear of the semilunar cartilage under 38 C.F.R. § 4.71a, Diagnostic Code 5258. See also VAOPGCPRECs 09-04 and 23-97. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In August 2012, the Court the Court granted a Joint Motion to Vacate and Remand of the parties (Joint Motion), vacated that part of the Board's decision that denied a rating in excess of 10 percent for residuals of a left knee injury based on limitation of motion and a rating in excess of 20 percent for residuals of a left knee injury based on injury to the semilunar cartilage or instability, and remanded the case to the Board for action consistent with the Joint Motion. In February 2013 the Board remanded the claim for additional development. The following decision is based on review of the Veteran's claims file in addition to his Virtual VA (VVA) file or "eFolder." FINDINGS OF FACT 1. Even considering his complaints of pain, pain on motion, and functional loss, the Veteran's left knee disability has not demonstrated limitation of extension, flexion limited to 30 degrees, or ankylosis of the knee. 2. Throughout the period of the appeal, the Veteran's left knee disability has been characterized by tears to the medial meniscus and lateral meniscus, with symptoms of effusion and frequent locking; however, severe instability and recurrent subluxation have not been shown. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of a left knee injury based on limitation of motion have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5010, 5256, 5260, 5261 (2012). 2. The criteria for a rating in excess of 20 percent for residuals of a left knee injury based on based on injury to the semilunar cartilage or instability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.71a, Diagnostic Codes 5257, 5258, 5259 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duty 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, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant 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 VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (Apr. 30, 2008)). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, a letter satisfying the notice requirements under 38 C.F.R. § 3.159(b)(1) and Dingess was sent to the Veteran in August 2007, prior to the rating decision that is the subject of this appeal. The letter informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. The Board also finds that the duty to assist requirements have been fulfilled. The paper claims file and the Virtual VA eFolder contain all available service treatment records (STRs) and post-service VA and private treatment records. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained, such as his STRs from his active duty service after November 1998. See May 2013 letter to the Veteran. The Veteran has not referred to any additional, unobtained, relevant, available evidence. Specific VA medical examinations were conducted to assess the severity of the Veteran's service-connected left knee disability, most recently in 2013. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the above VA examination report and medical opinion to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from the Veteran, reviewed the claims file and provided the information necessary to evaluate the Veteran's left knee disability under the applicable rating criteria. See 38 C.F.R. § 3.327(a); Caffrey v. Brown, 6 Vet. App. 377 (1994). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). As noted, this case was before the Board in February 2013 when it was remanded for additional action, including obtaining outstanding STRs, obtaining up-to-date VA treatment records and affording the Veteran a VA examination to ascertain the current nature and severity of his service-connected left knee disability. Regarding the STRs, the AOJ was directed to acquire the Veteran's STRs for any period of active service subsequent to 1998. In May 2013, after a search of the National Personnel Records Center and a request to the Veteran to submit any records in his possession, the AOJ made a formal finding as to the unavailability of the requested STRs. While no STRs were obtained, the Board determines that, in hindsight, they have limited probative value at this juncture and the Veteran's claim may be adjudicated without these records. Specifically, the Board notes that the claim on appeal was not submitted until June 2007 and nearly three years after the Veteran was discharged from his second period of active duty. When a veteran seeks an increased rating for a previously service-connected disability, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In this case, these STRs would be too old to represent his current level of disability, given that he did not submit the current claim until three years after service. Therefore, there is no prejudice to the Veteran by instead considering the claim based on the more recently acquired evidence. Moreover, neither the Veteran nor his representative has asserted that these STRs would be relevant to this appeal. As will be discussed in more detail below, VA treatment records were obtained in February 2013 and the Veteran was afforded a VA examination in March 2013. The March 2013 examination report reflects that the Veteran's records were reviewed and contains the requested opinion. The Board finds that there has been substantial compliance with its remand instructions and additional remand is not required. D'Aries v. Peake, 22 Vet. App. 97 (2008) (noting that substantial rather than strict compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Law and Regulations Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board observes that a claim for a total disability rating based on individual unemployability (TDIU) is generally part of an increased rating claim when that claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the Veteran has not asserted, and the record does not otherwise show, that he is unemployable due to service-connected left knee disability. On the contrary, the evidence of record shows that the Veteran has been gainfully employed as a postal clerk throughout the period of this appeal. See August 2007 and March 2013 VA examination reports. Therefore, the Board finds that entitlement to TDIU is not part of the increased rating claims currently on appeal. The provisions of 38 C.F.R. §§ 4.40, 4.45 and 4.59 must be considered in assigning an evaluation for the knee. Rating personnel must consider functional loss and clearly explain the impact of pain on the disability. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the Veteran may have by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). These factors include more or less movement than normal, weakened movement, premature or excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Functional loss due to pain is rated at the same level as functional loss where motion is impeded. See Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Moreover, although pain may cause functional loss, pain itself does not constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability, 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. The descriptive words "slight," "moderate" and "severe" are not defined in Diagnostic Code 5257 or elsewhere in the Rating Schedule, at least as specifically concerning knee disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decision is "equitable and just." 38 C.F.R. §§ 4.2, 4.6. Under Diagnostic Code 5259, a maximum disability rating of 10 percent is warranted for removal of semilunar cartilage, which is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Flexion of the leg limited to 60 degrees warrants a 0 percent 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 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Ankylosis of a knee warrants a 30 percent evaluation if it is at a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent evaluation is warranted if the ankylosis is in flexion between 10 and 20 degrees. A 50 percent evaluation is warranted if the ankylosis is in flexion between 20 and 45 degrees. A 60 percent evaluation is warranted where there is ankylosis of the knee, in an extremely unfavorable position, in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate II. VA's General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic 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 has also held that separate ratings may be assigned for disability of the same joint under Diagnostic Codes 5260 (for limitation of flexion) and 5261 (for limitation of extension). VAOGCPREC 9-2004 (September, 2004). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Factual Background Historically, the Veteran was awarded service connection for left knee disability (diagnosed as torn medical meniscus, torn lateral meniscus and degenerative joint disease) in an April 2003 rating decision. A 10 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5260. The Veteran submitted a claim for increased rating in June 2007. At a June 2007 private evaluation, the Veteran exhibited a full range of motion in the left knee. At a VA outpatient evaluation in July 2007, he again exhibited a full range of motion. There was no swelling and strength was 5/5. The Veteran reported good stability with the use of a knee brace. In fact, he stated that he had experienced "significant improvement" in the knee since completing physical therapy and reported that his pain was 1/10. An August 2007 VA examination report notes the Veteran's complaints of progressively worsening left knee pain, especially with jumping, climbing stairs and twisting. He also reported giving way, instability, stiffness, weakness and locking at least once a day. He denied any effusion, dislocation, or subluxation. The Veteran stated that he was functionally limited by his left knee in terms of being able to stand for 15-30 minutes at a time and to walk for one to three miles. He reported using a knee brace and taking tramadol. Occasionally he had to use crutches to walk. On examination, the Veteran's gait was antalgic. Active range of motion was from 0 degrees of extension to 120 degrees of flexion, with pain beginning at 90 degrees of flexion and -90 degrees of extension. Crepitation, locking and grinding were noted. There was no ankylosis, instability, effusion, or dislocation. The examiner opined that the Veteran's knee disability caused decreased mobility and pain, which would limit his ability to lift heavy objects, stand for long periods of time, and walk long distances. It was noted that the Veteran had worked full time as a window distribution clerk since 2005. A December 2007 VA primary care record notes that the Veteran was seen after completing 10 sessions of physical therapy for his left knee. He reported feeling better. Examination revealed no edema. Range of motion was intact. Muscle tone was adequate. In May 2008 the Veteran reported feeling well and had no complaints. A November 2009 VA primary care record notes that the Veteran was seen with complaints of left knee pain associated with locking and giving way for the past few months. On examination the Veteran was ambulatory and in no apparent distress. There was no edema or deformity. Mild tenderness was noted over the lateral joint line. Range of motion was intact. The Veteran was overweight and was encouraged to lose weight. March 2012 VA X-rays studies revealed moderate osteoarthritis of the left knee. June 2012 VA MRI studies revealed degenerative changes with tear of the meniscus and chondromalacia patella. An August 2012 VA physical therapy record notes that the Veteran reported feeling better. He had no pain in his left knee, only "the knocking of the knee." He reported to the clinic free of any assistive devices. An October 2012 VA outpatient treatment record notes the Veteran's complaint of an exacerbation of left knee pain. He reported that his knee pain was 5/10. He also reported some giving way. He denied taking any pain medication. On examination, there was small joint effusion with no erythema. Mild tenderness was noted on palpation of the lateral joint line. Active range of motion was from 0 degrees of extension to 120 degrees of flexion. Strength was 5/5. A February 2013 VA outpatient treatment record notes the Veteran's complaints of left knee pain that was improved with acetaminophen. On examination, the Veteran was ambulatory. The examiner noted that there was no history of falls. There was no edema. Range of motion was intact. Muscle tone was adequate. No deformities were noted. A March 2013 VA examination report notes the Veteran's history of meniscal tear and arthritis, and current complaints of constant left knee pain and locking, and occasional giving way. The Veteran reported that his symptoms are more severe in the morning and during cold, wet weather. He reported taking tramadol twice daily for pain. The Veteran indicated that he is unable to run, jump or participate in sports due to his left knee pain. He uses no assistive devices to ambulate. On examination, left knee flexion was to 120 degrees, with pain beginning at 120 degrees. After repetitive use testing, flexion was to 120 degrees (no additional limitation of motion). Left knee extension was to 0 degrees, with no objective evidence of painful motion. After repetitive use testing, extension was to 0 degrees (no additional limitation of motion). Strength was 5/5 on both flexion and extension. The left knee was not tender to palpation. Gait was not antlagic. Anterior instability (Lachman), posterior instability (posterior drawer) and medial-lateral instability (varus/valgus) tests were all normal for the left knee. There was no objective evidence of recurrent subluxation or dislocation. After examining the Veteran and reviewing his claims file, including his VA treatment records, the examiner opined that the Veteran's left knee disability did not impact his ability to work. He noted that the Veteran was working as a postal clerk, which allowed him to sit for long periods of time. The examiner noted that there was no evidence of instability on examination or on the June 2012 MRI study. He further noted that there was no evidence of muscle weakness or atrophy. There was mild limitation of active range of motion, but this did not prevent the Veteran from being totally independent in all activities of daily living, including ambulation. The examiner noted that the Veteran's left knee disability had actually improved significantly with conservative management such as physical therapy. Schedular Consideration Limitation of Motion A close review of the record reveals no distinct period during which the criteria for the next higher (20 percent) rating were met. See Hart, supra. Based upon the evidence of record, as noted above, the Board finds the Veteran's left knee disability has been manifested by flexion to no less than 90 degrees and extension to no worse than 0 degrees, including as a result of pain or functional loss. In so deciding, the Board has considered the additional limitation of motion that is brought about by pain when considering the appropriate disability rating. Nevertheless, even considering his complaints of pain on motion at his VA examinations, there is no evidence that the Veteran would experience limitation of flexion to 45 degrees or limitation to extension to 10 degrees, which would be necessary to support the assignment of compensable ratings under Diagnostic Codes 5260 or 5261. The fact that the Veteran complained of pain throughout the range of motion of the knee on examination in August 2007 does change this outcome as his functional impairment is clearly contemplated in the 10 percent rating that he receives for his left knee disability based on limitation of motion; and, for that matter, the impairment was not quantified in any measurable terms. See Mitchell, supra. A rating higher than 10 percent is not warranted. The Board (and the VA examiners) have noted the Veteran's complaints of pain, stiffness and weakness in his left knee. Notably, throughout the period of the appeal, muscle strength has been 5/5 or normal on examination, without any evidence of atrophy. Moreover, there has been no objective findings of edema, dislocation, or deformity. The March 2013 VA examiner determined that there was only mild limitation of active range of motion, which did not prevent the Veteran from being totally independent in all activities of daily living, including ambulation. Therefore, an increased evaluation for the Veteran's service-connected left knee disability is not warranted on the basis of functional loss due to pain or weakness, as the Veteran's symptoms are contemplated by the rating already assigned. Therefore, left knee flexion and extension do not warrant even the most minimum compensable rating of 10 percent under Diagnostic Codes 5260 and 5261. Also, because the Veteran has noncompensable extension and flexion, he cannot receive separate ratings as concerning his flexion and extension under VAOPGCPREC 9-2004. Additionally, the medical evidence does not demonstrate any ankylosis (Diagnostic Code 5256). Therefore, this diagnostic code is inapplicable in this case. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). Injury to the Semilunar Cartilage or Instability Close review of the record reveals no distinct period during which the criteria for the next higher (30 percent) rating have been met for the Veteran's service-connected left knee disability based on injury to the semilunar cartilage or instability. See Hart, supra. The Veteran's service-connected left knee disability has been rated 20 percent disabling on this basis under Diagnostic Code 5258, which the maximum rating available under this code. Moreover, based upon the evidence of record (as noted above), no findings of instability or subluxation have been found during the period of the appeal. The record clearly does not show severe subluxation or instability in the left knee so as to warrant the next higher (30 percent) rating. While the Veteran has reported complaints of giving way, the August 2007 VA examiner found no dislocation or instability. The March 2013 VA examiner specifically noted that objective testing revealed no instability whatsoever. Therefore, entitlement to a rating in excess of 20 percent based on recurrent subluxation or lateral instability must be denied. (His complaints of locking are contemplated by the current (maximum) 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint under Diagnostic Code 5258.) The Board has considered alternative rating criteria but has determined that none would result in a higher rating based on injury to the semilunar cartilage or instability. See Butts, supra. Conclusion The Board has also considered the Veteran's statements that his disability is worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, supra. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability to his left knee according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's left knee disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. For the reasons and bases discussed, the preponderance of the evidence is against the claims. There is no reasonable doubt to resolve in the Veteran's favor, and his claims must be denied. Gilbert, supra. Extra-schedular Considerations Lastly, in exceptional cases an extra-schedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of this VA regulation, for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, though, the Board finds that the rating criteria sufficiently contemplate the extent and severity of the service-connected left knee disability at issue, including insofar as addressing the Veteran's symptoms and complaints. With respect to his left knee, his primary complaints include pain, giving way, locking and weakness, and the effect these symptoms have on his range of motion. His existing ratings take this into account as described above. The rating criteria therefore are adequate to evaluate this disability and referral for consideration of an extra-schedular rating is not warranted. Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER A rating in excess of 10 percent for residuals of a left knee injury based on limitation of flexion is denied. A separate compensable rating for residuals of a left knee injury based on limitation of extension is denied. A rating in excess of 20 percent for residuals of a left knee injury based on injury to the semilunar cartilage or instability is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs