Citation Nr: 1325203 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 09-32 800 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine. 2. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the right knee. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty for training (ACTDUTRA) from October 1988 to March 1989 and on active duty service from September 1989 to November 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran testified at a hearing before the Board in October 2012. The Board remanded the Veteran's claims in January 2013. The Board notes that a claim of entitlement to service connection for a left knee disability was denied in an August 2008 rating decision. The Veteran perfected an appeal as to the denial of this issue. However, the Veteran was granted entitlement to service connection for a left knee disability in a June 2013 rating decision. Therefore, this issue has been resolved and is not before the Board. Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). FINDINGS OF FACT 1. The Veteran's degenerative disc disease of the lumbar spine was manifested by functional impairment that equated to forward flexion limited to no less than 80 degrees; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis was not shown. 2 . The Veteran's degenerative arthritis of the right knee was not manifested by compensable limitation of motion, recurrent subluxation or lateral instability; there was x-ray evidence of arthritis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for degenerative disc disease of the lumbar spine have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2012). 2. The criteria for a rating in excess of 10 percent for degenerative arthritis of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.10, 4.71, 4.71a, Diagnostic Code 5010 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claims. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claims; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in March 2007 and January 2013. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the March 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Where entitlement to compensation has already been established and an increase in the assigned rating is at issue, it is the present level of disability that is of primary concern. Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7. Vet. App. 55 (1994). However, 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. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2012). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon 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 the 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. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2012). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2012). However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2012). For the purpose of rating disability from arthritis, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae are considered groups of minor joints, ratable on a parity with major joints. 38 C.F.R. § 4.45 (2012). A. Lumbar Spine The Veteran contends that his service-connected degenerative disc disease warrants a higher initial rating. At an August 2007 VA examination, the Veteran reported non-radiating throbbing pain in his lower back on a daily basis which is aggravated with bending and lifting. He denied urinary and bowel incontinence. He indicated that he is able to perform all activities of daily living and that he has not missed any work secondary to his lower back pain. Physical examination revealed no gross deformity or gross malalignment of the lumbar spine. The back was tender to light and deep palpation along the paraspinous muscles from L5 to the sacrum on the right side. Range of motion testing revealed flexion to 85 degrees, extension to 20 degrees, right and left lateral flexion to 35 degrees, and right and left lateral rotation to 40 degrees. Straight leg raises were negative for radicular pain and muscle strength was 5/5. The examiner indicated that there was no objective clinical evidence that function was additionally limited by pain, fatigue, weakness, incoordination, or lack or endurance with repetition. X-rays of the lumbar spine revealed disc space narrowing at L5-S1 and slightly increased radiographic sclerosis of the facet joint from L3 to L5. The examiner diagnosed the Veteran with mild degenerative disc disease of the lumbar spine. Private treatment reports from Concentra Health Services reflect that the Veteran was referred for physical therapy after injuring his back at work in February 2010. At a December 2010 VA examination, the Veteran reported intermittent back pain with remissions. He denied radiation of pain, urinary incontinence, fecal incontinence, and erectile dysfunction. The Veteran indicated that there was one incapacitating episode of spine disease within the past twelve months. The Veteran reported that he was off of work for five days on doctor's orders in February 2010. Physical examination reveals that Veteran's posture was normal with no abnormal spinal curvatures including kyphosis, lumbar lordosis, lumbar flattening, reverse lordosis, scoliosis or ankylosis. There were no objective abnormalities of the thoracolumbar sacrospinalis. Range of motion testing of the lumbar spine revealed flexion to 80 degrees, extension to 25 degrees, left and right lateral flexion to 25 degrees, and left and right lateral rotation to 10 degrees. The examiner indicated that there was no objective evidence of pain or additional limitations after repetitions of range of motion. Sensory examination was normal. X-rays of the lumbar spine revealed mild degenerative changes. The examiner diagnosed the Veteran with mild degenerative disc disease of the lumbosacral spine without lower extremity radiculopathy. The Veteran was noted to have lost less than one week of work in the twelve months prior to the examination. The examiner indicated that the effects of the Veteran's low back disability on his occupation as an electrician was pain with bending, picking up and upper torso rotations. At an October 2012 Board hearing, the Veteran testified that he had back spasms every other day. He indicated that he had difficulty performing his job duties as an electrician because of his back. The Veteran indicated that he had been on bedrest a few times because of back pain but that he had not been prescribed bedrest by his physician. He testified that he used Tramadol and Ibuprofen for his back pain. He indicated that his pain had increased in severity since his last compensation examination. He testified that he was unemployed due to a lack of work. VA outpatient treatment reports reflect that in April 2008, the Veteran reported chronic low back pain since service. In June 2010 the Veteran reported that his back bothered him with climbing steps. He was prescribed Ibuprofen three times daily. The Veteran reported that he twisted his back and had increased pain which resolved in November 2012. At a January 2013 VA examination, the Veteran denied flare-ups of back pain that impact the function of his thoracolumbar spine. Range of motion testing of the lumbar spine revealed flexion to 85 degrees, extension to 25 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees with no objective evidence of painful motion in any range of motion. The Veteran was able to perform repetitive testing on three repetitions for all ranges of motion with no additional limitation of motion and no functional loss on repetitive testing. Physical examination revealed no localized tenderness to pain or palpation and no guarding or muscle spasm. Muscle testing was normal, reflex examination revealed hypoactive reflexes in the knees and ankles, and sensory examination was normal with the exception of decreased light touch in the left leg/ankle. The examiner indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiulopathy. The examiner also reported that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. The examiner indicated that the Veteran's lumbar spine disability did not have an impact on his ability to work. The examiner diagnosed the Veteran with mild degenerative disc disease of the lumbar spine without lower radiculopathy. The Veteran's degenerative disc disease of the lumbar spine has been rated under Diagnostic Codes 5242 which pertains to degenerative arthritis of the spine. 38 C.F.R. § 4.71a (2012). Diagnostic Code 5242 also references Diagnostic Code 5003 which pertains to degenerative arthritis. 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When 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 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. Disabilities of the spine, including Diagnostic Code 5242, are rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a (2012). The General Rating Formula for rating Diseases and Injuries of the Spine provides ratings as follows: Unfavorable ankylosis of the entire spine (100 percent); Unfavorable ankylosis of the entire thoracolumbar spine (50 percent); Forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine (40 percent); Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height (10 percent). 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). When rating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2012). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. Normal combined range of motion of the thoracolumbar spine is 240 degrees. Normal ranges of motion for each component of spinal motion provided are the maximum usable for calculating the combined range of motion. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note 2 (2012). Additionally, although the most recent VA examiner indicated that the Veteran does not have intervertebral disc disease, the evidence indicates that the Veteran's disability is currently manifested by disc disease. The rating criteria for intervertebral disc syndrome require rating of the disorder either on the total duration of incapacitating episodes resulting from intervertebral disc syndrome over the past 12 months, or by combining under 38 C.F.R. § 4.25 separate ratings of its chronic orthopedic and neurologic manifestations with rating for all other disabilities, whichever method results in the higher rating. A 10 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of least four weeks but less than six weeks during the past 12 months. Finally, a 60 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2012). The Board finds that the Veteran's degenerative disc disease of the lumbar spine does not warrant a rating in excess of 10 percent at any time during the pendency of the appeal. At the time of the August 2007 VA examination, there was evidence of tenderness to palpation along the paraspinous muscles from L5 to the sacrum on the right side. However, there is no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis at any of the examinations of record or in the treatment reports of record. Moreover, flexion was limited to no worse than 80 degrees at the examinations of record and the combined ranges of motion were no worse than 175 degrees. Additionally, there was no evidence of any functional loss which would equate to a higher rating. DeLuca v. Brown, 8 Vet. App. 202 (1995). Consequently, the Board finds that the Veteran does not warrant a rating in excess of 10 percent at any time during the appeal period. The evidence does not show any additional function loss due to pain or any other factors that would warrant any higher rating or any neurologic disability that would warrant any separate rating. The evidence of records reflects that the Veteran was prescribed one week of bedrest by his physician in February 2010. At no time during the appeal period at issue has the Veteran been prescribed more than one week of bedrest. Consequently, a higher rating is not warranted under Diagnostic Code 5243. 38 C.F.R. § 4.71a (2012). In sum, the Board finds that the Veteran's degenerative disc disease of the lumbar spine does not warrant a rating in excess of 10 percent at any time during the relevant appeal period. The preponderance of the evidence is against the assignment of any higher rating and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Right Knee At an August 2007 VA examination, the Veteran reported a dull, achy pain in his right knee three to four days a week lasting two to three hours as well as intermittent swelling and instability once per month. He denied stiffness, redness, and locking of the knee. He indicated that he had not missed any work due to his knee pain. The Veteran reported that he used Tylenol, Aspirin, and Ibuprofen on an as needed basis for knee pain. Physical examination of the right knee revealed no gross deformity or malalignment. The right knee was nontender to palpation. Range of motion testing revealed flexion from 0 to 130 degrees with repetition. There was no evidence of ligamentous laxity. X-rays of the right knee revealed mild arthrosis in the patellofemoral joint. A magnetic resonance imaging (MRI) of the right knee revealed chondromalacia of the medial and lateral patellar faces with a small cartilage defect and a partial tear of the posterior horn root a the lateral meniscus and anterior cruciate ligament ganglion cyst. The examiner diagnosed the Veteran with early degenerative arthritis of the right knee. The examiner indicated that there was no objective clinical evidence that function was additionally limited by pain, fatigue, weakness, incoordination, or lack or endurance with repetition. At a December 2010 VA examination, the Veteran reported intermittent knee pain with exacerbations of pain after climbing ladders or stairs. The Veteran denied deformity, giving way, instability, stiffness, weakness, incoordination, decreased speed of joint, episodes of dislocation or subluxation, episodes of locking, and effusions. The Veteran endorsed pain and swelling. The examiner indicated that the Veteran's gait was normal. Range of motion testing of the right knee revealed flexion to 135 degrees and extension to 0 degrees with no objective evidence or pain or additional limitations after repetitive range of motion testing. The examiner diagnosed the Veteran with a stable right knee joint with internal derangement chondromalacia patellar facets and partial tear of the lateral meniscus and anterior cruciate ligament with ganglion cyst. The examiner indicated that the Veteran's right knee had significant effects on his occupation as an electrician due to pain when climbing stairs. At an October 2012 Board hearing, the Veteran testified that he used Ibuprofen and Tramadol for knee pain. The Veteran indicated that his knee pain caused him difficulty performing his duties as an electrician. He reported that he used a brace on his right knee five times per week. He testified that he had swelling of the right knee once or twice per year. He reported some instability but no locking of the knee. He testified that he was currently unemployed due to a lack of work. At a January 2013 VA examination, the Veteran reported stiffness and swelling of the right knee. Range of motion testing of the right knee revealed flexion to 140 degrees or greater, extension to 0 degrees, and no objective evidence of painful motion. The Veteran was able to perform repetitive use after repetitive testing and there was no evidence of additional limitation of motion in range of motion and no functional loss or impairment on repetitive testing. Muscle strength testing and joint stability tests were normal. X-rays of the right knee revealed mild patellofemoral degenerative changes. The examiner concluded that the Veteran's right knee disability does not impact his ability to work. VA outpatient treatment reports reflect that the Veteran reported knee pain in September 2006. X-rays of the right knee obtained in May 2007 were unremarkable. An MRI of the right knee obtained in July 2007 revealed chondromalacia of the medial and lateral patellar facets with a small central full-thickness cartilage defect, partial tear of the posterior horn root lateral meniscus, and anterior cruciate ligament ganglion cyst. In September 2007, the Veteran reported knee pain worse when climbing stairs and bending his knee. The Veteran again reported right knee pain in January 2008. In November 2008, the Veteran reported moderate right knee pain with climbing, kneeling, and squatting as well as intermittent swelling and catching of the right knee. He was noted to take Ibuprofen for his right knee pain. The Veteran was assessed with early osteoarthritis of the right knee. He was treated with an injection of Lidocaine, Marcaine, and Celestone and advised to use a knee brace while at work. In June 2010, the Veteran reported that his knees bothered him with climbing stairs and he was given a brace for his left knee as well as his right knee. The Veteran reported knee pain again in December 2010. In May 2012, the Veteran requested steroid injections for knee pain. The Board finds that the Veteran's degenerative arthritis of the right knee does not warrant a rating in excess of 10 percent at any time during the pendency of the appeal. The Veteran's right knee disability has been rated as 10 percent disabling under Diagnostic Code 5010 (2012). Diagnostic Code 5010 provides that traumatic arthritis will be rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When 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 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. Normal knee joint motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2012). The words slight, moderate, and severe are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2012). Use of descriptive terminology such as mild by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. Separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee. Where a veteran has both compensable limitation of flexion and compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). Separate ratings may also be assigned for arthritis or limitation of motion and instability of the knee. VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate rating must be based on additional compensable disability. Diagnostic Code 5257 pertains to other impairment of the knee caused by recurrent subluxation or lateral instability. A 10 percent rating is warranted when slight. A 20 percent rating is warranted when moderate. A 30 percent rating is warranted when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The various examinations of record do not show findings consistent with recurrent subluxation or lateral instability. Consequently, the Board finds that an increased rating is not warranted under Diagnostic Code 5257 at any time during the pendency of the appeal because the objective medical evidence does not show recurrent instability or subluxation. Diagnostic Code 5261 pertains to limitation of extension. Limitation of extension of the leg to 5 degrees warrants a 0 percent rating. A 10 percent rating requires that extension be limited to 10 degrees. A 20 percent rating requires that extension be limited to 15 degrees. A 30 percent rating requires that extension is limited to 20 degrees. A 40 percent rating requires that extension be limited to 30 degrees. A 50 percent rating requires that extension be limited to 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). The findings of the VA examinations are consistent with noncompensable limitation of extension. Consequently, the Board finds a rating in excess of 10 percent is not warranted under Diagnostic Code 5261. Diagnostic Code 5260 pertains to limitation of flexion. Flexion 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. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). The examinations of record reveal flexion limited to no worse than 130 degrees during the VA examinations of record which does not warrant a compensable rating under Diagnostic Code 5260. Additionally, there was no evidence of any functional loss which would equate to a higher rating. DeLuca v. Brown, 8 Vet. App. 202 (1995). The evidence does not show any additional function loss due to pain or any other factors that would warrant any higher rating. Diagnostic Codes 5256 (ankylosis of the knee), 5258 (dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint), 5259 (removal of symptomatic semilunar cartilage), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable because the Veteran's right knee disability is not manifested by any of the disabilities or symptoms associated with those diagnostic codes. In sum, the Board finds that the Veteran's degenerative arthritis of the right knee does not warrant a rating in excess of 10 percent at any time during the relevant appeal period. The preponderance of the evidence is against the assignment of any higher rating and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Extraschedular Consideration The Board has considered whether an extraschedular rating is warranted in this case. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993); 38 C.F.R. § 3.321(b)(1) (2012). Factors for consideration in determining whether referral for an extraschedular rating is necessary include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1) (2012). The Board finds that referral is not warranted in this case. The evidence of record does not show that the Veteran's service-connected lumbar spine disability or right knee disability markedly interferes with employment, beyond that contemplated in the assigned rating, or to warrant frequent periods of hospitalization. Although the December 2010 VA examiner indicated that the Veteran's right knee disability had a significant impact on his usual occupation as an electrician because of pain, that finding is not tantamount to marked interference with employment because a significant effect is less than marked interference. Additionally, while that examiner indicated that the Veteran's lumbar spine disability resulted in pain when bending, picking things up, or with upper torso rotations, these findings rare similarly not tantamount to marked interference with employment. Moreover, the service-connected lumbar spine disability and right knee disability have not required frequent periods of hospitalization. Consequently, the Board finds that the evidence does not show that the criteria for referral are met because marked interference with employment and frequent hospitalizations are not shown. 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the lumbar spine is denied. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the right knee is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs