Citation Nr: 1325323 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 07-25 489 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a higher initial rating for residuals of torn right pectoral muscle, status post (s/p) unsuccessful surgical repair, rated 10 percent disabling prior to November 4, 2008. 2. Entitlement to a higher initial rating for residuals of torn right pectoral muscle, s/p unsuccessful surgical repair, rated 20 percent disabling from November 4, 2008 to August 24, 2011. 3. Entitlement to a higher initial rating for residuals of torn right pectoral muscle, s/p unsuccessful surgical repair, rated 40 percent disabling beginning August 25, 2011. 4. Entitlement to a higher initial rating for residuals of left wrist fracture, s/p external fixation, rated noncompensably disabling prior to November 4, 2008. 5. Entitlement to a higher initial rating for residuals of left wrist fracture, s/p external fixation, rated 10 percent disabling from November 4, 2008. 6. Entitlement to a higher initial rating for right knee degenerative joint disease (DJD), rated 10 percent disabling. 7. Entitlement to a higher initial rating for right knee instability, rated 10 percent disabling. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from June 1984 to November 2004. This matter initially came before the Board of Veterans' Appeals (Board) on an appeal from an October 2005 rating decision issued by the Regional Office (RO) in Atlanta, Georgia. It was remanded by the Board for additional development in June 2011 and has now been returned to the Board. As will be explained in greater detail below, the Board's remand directives have been complied with, and the issues are now appropriately before the Board for adjudication. The Veteran testified at a hearing before the undersigned Acting Veterans Law Judge in July 2010. A review of the virtual claims file reveals that it contains no pertinent evidence that is not also contained in the paper claims file. FINDINGS OF FACT 1. Prior to November 4, 2008, the symptoms of the Veteran's right pectoral muscle disability most closely approximated moderate disability. 2. From November 4, 2008 to August 24, 2011 the symptoms of the Veteran's right pectoral muscle disability most closely approximated moderate disability. 3. Beginning August 25, 2011, the Veteran was awarded the highest scheduler rating for his right pectoral muscle disability and it did not present an exceptional disability picture that rendered the scheduler rating inadequate. 4. Prior to November 4, 2008, painful motion of the left wrist was shown. 5. Beginning November 4, 2008, painful limited motion of the left wrist was shown, but there was no ankylosis. 6. The Veteran did not have the functional equivalent of range of motion of the right knee limited to 30 degrees or less of flexion or 15 degrees of extension at any time. 7. The symptoms of the Veteran's instability of the right knee most closely approximately slight instability. CONCLUSIONS OF LAW 1. For the period prior to November 4, 2008, the criteria for a rating of 20 percent, but no higher, for the Veteran's right pectoral muscle disability were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.56, 4.73, Diagnostic Code 5302 (2012). 2. For the period from November 4, 2008 to August 24, 2011, the criteria for a rating in excess of 20 percent for the Veteran's right pectoral muscle disability were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.56, 4.73, Diagnostic Code 5302 (2012). 3. For the period beginning August 25, 2011, the criteria for a rating in excess of 40 percent for the Veteran's right pectoral muscle disability were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.56, 4.73, Diagnostic Code 5302 (2012). 4. For the period prior to November 4, 2008, the criteria for a 10 percent rating for the Veteran's left wrist fracture were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2012). 5. For the period beginning November 4, 2008, the criteria for a rating in excess of 10 percent for the Veteran's left wrist fracture were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5215 (2012). 6. The criteria for a rating in excess of 10 percent for right knee DJD were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5010-5260 (2012). 7. The criteria for a rating in excess of 10 percent for right knee instability were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Cods 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims 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. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), 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. The Board notes that 38 C.F.R. § 3.159 was revised in part, effective May 30, 2008. See 73 Fed. Reg. 23,353-23,356. The third sentence of 38 C.F.R. § 3.159(b)(1), which stated that "VA will also request that the claimant provide any evidence in the claimant's possession that pertains to the claim," was removed. This amendment applies to all applications pending on, or filed after, the regulation's effective date. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g. Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sum nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was sent a letter in January 2005 which explained how VA could help him obtain evidence in support of his claims. The letter also explained what the evidence needed to show in order to establish service connection for a claimed disability. In January 2010 the Veteran was sent a letter that explained what the evidence needed to show in order to warrant increased ratings for his particular disabilities. The letter also explained the general manner whereby VA assigns ratings and effective dates for service connected disabilities. The Veteran's claims were thereafter readjudicated, most recently in a November 2012 supplemental statement of the case (SSOC). Nevertheless, all claims decided herein are deemed to have arisen from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran was provided sufficient VCAA notice with regard to his service connection claims in January 2005. This was dated prior to the RO rating decision that granted service connection for the disabilities on appeal. Therefore, no further notice is needed under VCAA for these claims. The Acting Veteran's Law Judge also identified the issues and took testimony about the severity of the Veteran's disabilities at the July 2010 hearing, soliciting information regarding whether there was any outstanding evidence and explaining what the evidence needed to show in order to substantiate the claims on appeal in compliance with 38 C.F.R. § 3.102. See Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010). VA also must make reasonable efforts to assist the claimant with obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record evidence including service treatment records, the written contentions of the Veteran, and a copy of the Veteran's testimony at the July 2010 hearing. The Veteran was also afforded VA examinations that adequately documented the symptoms and functional effects of his right pectoral muscle, left wrist, and right knee disabilities. In its June 2011 remand, the Board instructed that the RO attempt to obtain copies of the Veteran's private treatment records. In July 2011 the RO requested that the Veteran identify private health care providers and provide appropriate releases to enable VA to obtain the records. However, the Veteran failed to respond to this letter, so VA was unable to obtain copies of his private treatment records. The Veteran was also afforded a VA examination of all of the disabilities at issue in accordance with the instructions set forth in the remand. Therefore, the Board finds that there was substantial compliance with the instructions which were set forth in the July 2011 remand, and the VA examination afforded to the Veteran was adequate. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). The Board further finds that VA satisfied its obligations pursuant to the VCAA in this case. Initial Ratings The Veteran contends that the symptoms of his right pectoral muscle, left wrist, right knee arthritis, and right knee instability disabilities are worse than is encompassed by the ratings which were and are assigned for those disabilities. Disability ratings are determined by applying criteria that are set forth in the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4). Ratings are based on average impairments of earning capacity resulting from particular diseases and injuries and the residuals thereof in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities are described utilizing diagnostic codes set forth in 38 C.F.R. Part 4. Where there is a question as to which of two evaluations 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. See 38 C.F.R. § 4.7. In cases, such as this one, in which a claim for a higher evaluation arises out of the initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the claim and appellate process. See generally Fenderson v. West, 12 Vet. App. 119 (1999). See also Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Right Pectoral Muscle The Veteran's residuals of a torn right pectoral muscle were rated 10 percent disabling until November 4, 2008, 20 percent disabling from November 4, 2008 to August 24, 2011, and 40 percent disabling beginning August 25, 2011. The Veteran's residuals of a torn right pectoral muscle were initially evaluated pursuant to 38 C.F.R. § 4.73 diagnostic code 5321, muscle group XXI, dealing with the muscles of respiration. Subsequently, it was rated pursuant to diagnostic code 5302, muscle group II. Muscle group II involves the function of depression of the arm from vertical overhead to hanging at the side, downward rotation of the scapula, and acts with group III in forward and backward swing of the arm. After consideration of the various diagnostic codes and the evidence, the Board finds that Diagnostic Code 5302, pertaining to muscle group II, most closely approximates the Veteran's symptoms. This diagnostic code specifically includes the pectoralis major II (costosternal) and pectoralis minor muscles among the list of muscles which are part of muscle group II. The pectorialis major I (clavicular) is listed as part of muscle group III. See diagnostic code 5303. Diagnostic code 5321 refers to the muscles of the thoracic muscle group and does not mention the pectoral muscles. Accordingly, the Veteran's pectoral muscle disability is more appropriately evaluated pursuant to diagnostic code 5302. Although the pectoralis major I is part of muscle group III, none of the VA examiners indicated that the Veteran's pectoral muscle disability was part of muscle group III. In any event, the ratings for diagnostic codes 5302 and 5303 are the same. Additionally, application of diagnostic code is 5302 is more favorable to the Veteran than diagnostic code 5321, which was initially used to rate his disability. Pursuant to diagnostic code 5302, a 0 percent rating applies for slight disability of either the dominant or the non-dominant side. A 20 percent rating applies for moderate disability of either the dominant or non-dominant side or for moderately severe disability of the non-dominant side. A 30 percent rating applies for moderately severe disability of the dominant side or for severe disability of the non-dominant side. A 40 percent rating applies for severe disability of the dominant side. 40 percent is the highest scheduler rating for this disability. The severity of a muscle disability is evaluated pursuant to 38 C.F.R. § 4.56 according to the type of injury, history and complaint, and objective findings. A slight muscle disability is characterized by a simple wound of muscle without debridement or infection. The history is over a superficial wound in service with brief treatment and return to duty. Healing was with good functional results. There are no cardinal signs and symptoms of muscle disability. Cardinal signs of muscle disability consist of loss of power, weakness, lower threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. A moderate muscle disability is characterized by a through and through or deep penetrating would of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. The history shows a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings consisted of entrance and exit scars, small or liner, indicating a short track of the missile through muscle tissue. There is some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue as compared to the sound side. A moderately severe disability of the muscles in characterized by a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile with debridement, prolonged infection, or sloughing of soft parts and intramuscular scarring. The history shows hospitalization for a prolonged period for treatment of the wound. There is a record of consistent complaints of cardinal signs and symptoms of muscle disability and, if present, inability to keep up with work requirements. Objective findings include entrance and exit scars indicating the track of the missile through one or more muscle groups. There are indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles as compared with the sound side. Tests of strength and endurance compared with the sound side demonstrate positive evidence of impairment. A severe disability of the muscles consists of a through and through or deep penetrating wound due to a high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. There is a history showing hospitalization for a prolonged period for treatment of the wound. There is a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries and, if present, evidence of inability to keep up with work requirements. Objective findings include ragged, depressed and adherent scars indicating wide damage to muscle groups in the missile track. Palpation shows loss of deep fascia of muscle substance, or soft flabby muscles in the wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present the following are also signs of severe muscle disability: (a) x-ray evidence of minute multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of the missile; (b) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (c) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (d) visible or measurable atrophy; (e) adaptive contraction of an opposing group of muscles; (f) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle, and (g) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d). In applying these ratings, a through and through injury with muscle damage shall be evaluated as no less than a moderate muscle injury to the group of muscles damaged. 38 C.F.R. § 4.56(b). An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). The Veteran's pectoral muscle disability was first evaluated after service in July 2005. At that time, the Veteran reported that he sustained a tear of the right pectoral muscle while exercising. He reported decreased upper body strength and a deformed right anterior chest. He reported weakness, loss of strength, and fatigue. He reported that he was incapacitated by pectoral muscle pain for approximately two days per year. He was undergoing no treatment and had not lost any time from work. However, he claimed that he could not do strenuous work and could not keep up with work because of decreased strength in his right arm. The major functional impairment was difficulty holding weight with the right arm. The examiner identified this as a through and through wound although it was actually a tear. It was noted that the Veteran was right handed. Examination of the area showed loss of muscle substance. Strength was 4/5 with 5/5 being normal. The injury to the right pectoral muscle resulted in reduced strength. There was no muscle herniation and the injury involved muscle exclusively. In a letter (notice of disagreement) received by VA dated in December 2005 the Veteran disagreed with the objective measurement of his strength. He felt that he had less strength than what was measured. He also explained that surgery to repair this condition was unsuccessful and his right pectoral muscle was not attached to the shoulder girdle. He had a deep fissure and scar. He felt that his activities were limited by his right pectoral muscle disability. On his VA Form 9 dated in August 2007, the Veteran related that he felt his right pectoral muscle tear affected his daily activities and that he had changed careers as a result of it. He had muscle loss and a deep fissure of lost or unattached muscle. He felt that this condition had worsened since his previous examination. The Veteran was re-examined on November 4, 2008. At that time, the Veteran reported that he had constant pain in his shoulder, pectoral muscle, trapezius, and neck. The pain was worse with physical activity, stress, and work. It came on spontaneously and was relieved by medication. The Veteran was able to function with medication. The Veteran reported weakness and a deep fissure which had gotten wider. He reported loss of strength, weakness, fatigability, pain, and incoordination. There was intramuscular scarring and adhesion of the scar to the bone. He was unable to weight lift any more. This injury had caused him to change jobs while he was in the military. He felt that he was unable to keep up with his current work due to chest pain as well as wrist pain. Palpation of the muscle revealed loss of deep fascia and atrophy and contraction of the pectoralis muscle secondary to detachment of the tendon at insertion. Palpation of the muscle did not reveal loss of muscle substance and impairment of muscle tone, and there was no wound present. There were no signs of lowered endurance or impaired coordination. Muscle strength was 4. The Veteran's ability to depress the shoulder on the right was limited. There was no muscle herniation. The muscle injury did not involve any tendon, bone, joint, or nerve damage. The Veteran testified at a July 2010 hearing. The Veteran testified that he could no longer carry groceries or bags. He had a fissure where the pectoral muscle did not join the shoulder girdle. He had attempted to have this surgically repaired in service but the surgery was unsuccessful. He could not lift weight overhead. When he lifts weights he no longer uses his pectoral muscles and just uses his shoulder. At times he goes to the emergency room due to right pectoral muscle pain and had been given narcotic pain relievers in the past. He felt that his employment activities and opportunities had been restricted by his right pectoral muscle pain. He left his job at the post office because of the pain. He could lift 20 pounds but he was using his shoulder rather than his pectoral muscle. The Veteran was re-examined on August 25, 2011. He had a non-penetrating muscle injury. He tore his right pectoral muscle while lifting weights and an unsuccessful attempt was made to surgically repair it. The Veteran reported pain involving the right upper chest and shoulder which radiated to the right upper arm and elbow. He had difficulty opening doors and jars and with performing overhead activities and shifting gears in his car. He took over-the-counter pain relievers which helped partially, although they caused an upset stomach if he did not eat. Inspection of the right pectoral muscle showed some loss of deep fascia which was evident on palpation and visible atrophy. The Veteran reported consistent loss of power, weakness, fatigability, and pain. Strength in the shoulder and elbow were normal. The Veteran's work was affected in that he worked at the railroad and had difficulty climbing on box cars and tying hand brakes at work. He was able to perform his activities of daily living independently. The examiner assessed the Veteran's right pectoral muscle disability as being moderately severe in nature. The evidence shows that the Veteran had moderate muscle disability prior to November 4, 2008. While this was rated 10 percent disabling pursuant to diagnostic code 5321, this was an inappropriate diagnostic code due to the wrong muscle group being identified by the examiner. Subsequent examiners correctly identified the right pectoral muscle as being part of muscle group II. Moderate disability of a group II muscle warrants a 20 percent rating, so this level of disability should extend back to the effective date of service connection for this disability. Hence a rating of 20 percent for the period prior to November 4, 2008 is granted. However, the evidence shows that the Veteran was not entitled to a higher rating. There were subjective complaints of weakness and fatigue, but strength testing showed only slight loss of strength of 4/5 documented during this time, although the Veteran reported that he felt weaker. He reported being limited in his ability to perform strenuous activities, but there was no documented interference with ordinary daily activities. The objective findings of a medical professional are more probative than the lay statements of the Veteran. Similarly, only moderate muscle disability was shown prior to August 25, 2011. While there was some atrophy, there was no impairment of muscle tone, strength was 4 out of 5, endurance and coordination were normal upon examination, and there was no indication that the Veteran was limited in his activities, apart from weight lifting, due to his right pectoral muscle disability. While the Veteran reported some difficulties with work activities, this is contemplated by the moderate rating assigned during this time period. The evidence also shows there is no entitlement to a rating in excess of 40 percent for the Veteran's right pectoral disability beginning August 25, 2011. This is the highest schedular rating for this disability and, as discussed above, this is the Diagnostic Code most appropriate for the Veteran's disability. To the extent that the Veteran has described his symptomatology, he is certainly competent to do so, and his comments are considered credible and have been applied in determining the appropriate ratings. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, to the extent that they conflict with the notations contained on the examinations, the Board finds that the objective findings of a medical professional are more probative in determining the severity of the Veteran's disabilities than the Veteran's lay statements. Throughout the appeal period, the Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). Symptoms such as loss of fascia, atrophy, and weakness are contemplated by the rating schedule, and he does not complain of any symptoms not contemplated by the ratings assigned. Therefore, the diagnostic criteria adequately contemplate his symptomatology. The Veteran has not been hospitalized related to his right pectoral muscle after service, and although he reported some difficulties with certain work related activities, he was nonetheless able to effectively perform his job requirements. This level of interference with employment is contemplated by the ratings assigned. He is separately service connected for the scar associated with this disability. B. Left wrist fracture The Veteran's left wrist fracture was rated noncompensably disabling until November 4, 2008 and 10 percent disabling thereafter. The Veteran's left wrist disability is evaluated pursuant to 38 C.F.R. § 4.71a, diagnostic code 5215. A 10 percent rating applies for limitation of dorsiflexion to less than 15 degrees or palmar flexion in line with the forearm. 10 percent is the highest scheduler rating for this disability. Higher ratings pursuant to diagnostic code 5214 require ankylosis of the wrist, which is not at issue here. The Veteran's left wrist was first examined after service in July 2005. At that time, he reported tingling, numbness, and weakness of the fingers of his left hand which he attributed to carpal tunnel syndrome. However, the examiner did not diagnose carpal tunnel syndrome or any other neurological disability of the left wrist. Range of motion of the left wrist was 70 degrees of dorsiflexion, 80 degrees of palmar flexion, 20 degrees of radial deviation, and 45 degrees of ulnar deviation. This was the same as on the right side. Pain, fatigue, weakness, lack of endurance, and incoordination did not affect either wrist after repetitive use. X-rays of the left hand were normal but there were no x-rays specifically of the wrist. In a letter received by VA in December 2005, the Veteran stated that he had pain and deformity of the left wrist. He felt that his range of motion was limited. He thought x-rays of his wrist should have been performed at the July 2005 examination. On his VA Form 9 dated in August 2007, the Veteran contended that his left wrist was not examined in July 2005, although as previously noted there are specific findings related to the left wrist in the examination report. The Veteran's left wrist was re-examined on November 4, 2008. At that time, the Veteran reported that he had weakness, stiffness, swelling, heat, redness, giving way, lack of endurance, and locking of his left wrist. He reported pain after use of his left hand which radiated to the arm. Pain could be reduced by rest, medication, and hot and cold compresses. At the time of pain he could function with medication. The Veteran reported that his wrist cracked and he had tingling and loss of strength in his left hand. The treatment was physical therapy. The Veteran reported that his wrist got worse over the past several years and had gotten progressively weaker. He reported that his left wrist disability affected his work and hobbies. Examination of the left wrist showed edema and effusion. There were no signs of weakness, tenderness, redness, heat, and guarding of movement. There was no subluxation. Range of motion of the left wrist was 70 degrees of dorsiflexion, 80 degrees of palmar flexion, 20 degrees of radial deviation, and 45 degrees of ulnar deviation. This was the same as on the right side. There were additional limitations due to pain, fatigue, weakness, lack of endurance, incoordination, and pain. However, this did not result in reduced range of motion. The Veteran testified at a hearing in July 2010. The Veteran testified that he had reduced grip strength in his left hand. He had difficulty opening jars. He could not lift weights the way he used to. He felt that his wrist was stiff. He thought that he had arthritis. Sometimes his wrist swelled from overexertion. He knew how to take care of his wrist so he rarely aggravated it to the point that he could not do anything with it. He used over-the-counter pain medication to treat his left wrist pain. He estimated that he had a flare up of wrist pain about once per week. The Veteran's left wrist was re-examined on August 25, 2011. He reported that he had chronic left wrist pain daily. He reported noticing stiffness, cracking, and weakness. The symptoms were triggered by use of the left hand and wrist with pulling, pushing, lifting, and twisting. He had difficulty opening jars. He took over-the-counter pain medication which helped somewhat. He avoided activities that caused flare-ups of left wrist pain. The Veteran had 50 degrees of palmar flexion and dorsiflexion with pain essentially throughout the range of motion (beginning at 5 degrees). The Veteran lost 5 degrees of dorsiflexion after repetition. Functional limitations related to the left wrist were less movement than normal, weakened movement, and pain with movement. Strength was normal. There was no ankylosis. He had not had a joint replacement. He had scars for which he is separately service connected. X-rays showed arthritis of the left wrist. At work, the Veteran had difficulty lacing hoses, maintaining his grip to tie brakes, and climbing on box cars. He reported having some difficulty doing yard work and household chores due to his left wrist disability. However, he was able to perform his activities of daily living independently. The Board finds that a10 percent rating is warranted throughout the appeal period for the Veteran's left wrist fracture. Specifically, he has complained of pain in that wrist since he first filed his claim. Furthermore, while a diagnosis was not rendered during the July 2005 VA examination, no x-rays were taken at that time. A subsequent diagnosis was rendered on a more thorough examination. Therefore, the Board finds that the evidence is at last in equipoise as to whether the Veteran manifested periarticular pathology productive of painful motion of the left wrist throughout the appeal period. As such, he is entitled to the minimum compensable evaluation for this joint, which is 10 percent. 38 C.F.R. § 4.59. However, at no time during the appeal period does his disability warrant a rating in excess of 10 percent. A higher scheduler rating for the left wrist disability would require ankylosis of the left wrist, which was not shown or even suggested here. To the extent that the Veteran has described his symptomatology, he is certainly competent to do so, and his comments are considered credible and have been applied in determining the appropriate ratings. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, to the extent that they conflict with the notations contained on the examinations, the Board finds that the objective findings of a medical professional are more probative in determining the severity of the Veteran's disabilities than the Veteran's lay statements. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). The 10 percent rating for the Veteran's left wrist disability contemplates all of the symptoms attributable to the disability. The Veteran was not hospitalized after service for his left wrist disability, and while it reportedly causes him some difficulties at work he is nonetheless able to successfully perform his job requirements. C. Right knee (DJD and instability). The Veteran is rated 10 percent disabled for arthritis of the right knee and 10 percent disabled for instability of the right knee. Beginning August 25, 2011, the Veteran also has a separate 20 percent rating for dislocated semilunar cartilage. However, that rating is not on appeal before the Board. Arthritis of any joint is rated pursuant Diagnostic Code 5003. Arthritis is rated on the basis of the limitation of motion of the affected joint. When the limitation of motion of the affected joint is noncompensable under the appropriate diagnostic code, a rating of 10 percent is applied to each affected major joint or group of minor joints. In the absence of limitation of range of motion, a 10 percent evaluation is assigned for x-ray evidence of the involvement or 2 more major joints or 2 or more minor joint groups, and a 20 percent evaluation is assigned where such x-ray findings are accompanied by occasional incapacitating exacerbations. A 10 percent rating can also be assigned where there is limitation of motion that is noncompensable under the schedular criteria. See 38 C.F.R. § 4.71(a), Diagnostic Code 5003. The diagnostic codes addressing limited motion of the knee are 5260 (limitation of flexion) and 5261 (limitation of extension). Pursuant to diagnostic code 5260, a 10 percent rating is applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees. A 30 percent rating applies when flexion is limited to 15 degrees. Pursuant to Diagnostic Code 5261, a 10 percent evaluation is assigned for extension that is limited to 10 degrees. A 20 percent evaluation is assigned for extension that is limited to 15 degrees. A 30 percent evaluation is assigned for extension that is limited to 20 degrees. A 40 percent evaluation is assigned for extension that is limited to30 degrees. A 50 percent evaluation is assigned for extension that is limited to 45 degrees or greater. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202, 205-206 (1995). 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. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Instability of the knee is rated pursuant to diagnostic code 5257. A rating of 10 percent applies for slight recurrent subluxation or lateral instability. A rating of 20 percent applies when there is moderate subluxation or lateral instability. A rating of 30 percent applies when subluxation or lateral instability is severe. The VA General Counsel held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9- 98, 63 Fed. Reg. 56,704 (1998). Also, separate rating may be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same knee, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). The Veteran's right knee was first examined after service in July 2005. He reported having a meniscal tear with right anterior cruciate ligament reconstruction. He complained of constant swelling and locking of the knee. He reported that he was incapacitated by knee pain for nine days over the last year. There was no current treatment. There was no prosthetic implant. Functional impairment was difficulty standing and walking for prolonged periods of time and difficulty running. He did not lose any time off of work due to his right knee. The Veteran's gait was normal. The general appearance of his right knee was normal. There was crepitus. There was no recurrent subluxation, locking pain, or joint effusion. It was not ankylosed. The Veteran had flexion limited to 80 degrees by pain. He had full extension of the right knee. Pain had the major functional impact, but there was also fatigue, weakness, lack of endurance, and incoordination. However, the examiner was unable to quantify any additional limitation in degrees. Drawer and McMurray's signs were within normal limits. In a letter received by VA in December 2005 the Veteran related that he felt that he did have swelling and instability of his right knee. He felt that his motion was significantly reduced when his knee was swollen. He believed he had unusually good range of motion on the day that he was examined. He explained that he had been cross trained in the military because of his right knee disability. On his VA Form 9 dated in August 2007, the Veteran reiterated that his knee was feeling unusually well on the date of his VA examination. He felt that his employment opportunities were limited by his right knee disability. The Veteran's right knee was re-examined in November 2008. At that time, the Veteran reported weakness, stiffness, swelling, heat, redness, giving way, lack of endurance, locking, fatigability, and pain which he described as constant. The pain is elicited by physical activity and relieved by pain medication. The Veteran could function with pain medication. He claimed that sometimes his knees would give way when he was walking. He reported prior surgeries and physical therapy for his right knee. He did not have a joint replacement. He reported that his right knee disability got progressively worse. He reported that he could not exercise as well as in the past and that his job and daily life were affected. Inspection of the right knee showed edema, effusion, tenderness, and guarding of movement. There were no signs of weakness, redness, heat, or subluxation. There was crepitus. There was no genu recurvatum or locking pain. Range of motion was 135 degrees of flexion with pain at 130 degrees and full extension. There was additional functional limitation due to pain, fatigue, weakness, lack of endurance, and incoordination. However, this did not result in reduced range of motion. The anterior and posterior cruciate ligament stability test was within normal limits. There was slight instability of the medial and collateral ligaments. There was no evidence of peripheral nerve involvement. The Veteran testified at a July 2010 hearing. The Veteran testified that he felt that his knee had become less stable over the years. He often wore a brace. He lost range of motion due to swelling. Using stairs could make his knee come out of place and he would be incapacitated by pain for a day. He estimated that the knee gave out approximately twice per month, more often if he used stairs. He used heat and cold compresses to keep the swelling down. Moderate activity caused his knee to swell. He usually treated his knee with over the counter pain medication. He had fallen in the past but was careful now. He had several surgeries on his knee while he was in service but none after separation. He was no longer able to run or ride a bicycle due to knee pain. The Veteran was re-examined on August 25, 2011. It is noted that the Veteran was granted a separate 20 percent rating for dislocated semilunar cartilage effective August 25, 2011. At that time, the Veteran reported constant right knee pain. He reported swelling, warmth, stiffness, cracking, weakness, and instability. The Veteran reported that his symptoms occurred after using stairs or prolonged standing and walking. He used an ace bandage and occasionally a brace. He took over the counter medication which partially relieved the pain but caused an upset stomach if he did not eat. He reported flare-ups consisting of worse pain and swelling every other day. During these times, he has difficulty walking and lies down and elevates his leg and uses cold compresses. The Veteran had 110 degrees of flexion, with pain essentially throughout the entire range of motion (beginning at 10 degrees). There was no limitation of extension. Range of motion did not change after three repetitions. Functional impairment of the right knee consisted of less movement than normal, weakened movement, pain on movement, and disturbance of locomotion. The knee was tender to palpation. The Veteran had normal strength in his right knee. Anterior and posterior stability was normal. The examiner was unable to test medial-lateral stability. The Veteran had a prior history of subluxation or dislocation with these types of movements and was afraid to undergo the test. Review of the records seemed to show slight instability. There was a history of slight recurrent patellar subluxation or dislocation. The Veteran had a meniscal tear with frequent episodes of locking, pain, and joint effusion. He had a menisectomy. He did not have a joint replacement. X-rays showed arthritis of the right knee. The Veteran reported that at work he had difficulty walking on rocks, climbing on box cars at the railroad, and bending and stooping but continued to work as he did not want to lose his job. He was on disability leave related to a non-service connected problem. He was able to perform activities of daily living independently and was able to walk about three blocks before having to rest due to knee pain. The evidence does not show that the Veteran meets the criteria for a rating in excess of 10 percent for arthritis of the right knee. Range of motion testing always showed full extension of the knee. The Veteran always had flexion to greater than 30 degrees, although at his most recent examination he had pain beginning at 10 degrees. A 20 percent rating applies when flexion is to 30 degrees or less. While the Veteran had weakness and pain, he had a noncompensable range of motion under the diagnostic codes pertaining to flexion (greater than 45 degrees) and extension of the knee. Even though pain was shown to begin at 10 degrees, the functional impairment of the knee was greater than that required for a disability rating in excess of 10 percent. Therefore, a 10 percent rating for arthritis with limited or painful motion was properly applied. For a higher rating based on range of motion, there would have to be the functional equivalent of flexion limited to 30 degrees or extension limited to 15 degrees. Neither factor is present in this case. Similarly, the evidence shows that the Veteran does not meet the criteria for a rating in excess of 10 percent for his right knee instability. Stability testing, when conducted, showed normal or slight instability. Medial-collateral stability could not be tested at the most recent VA examination, but the examiner opined that based on prior records the Veteran appeared to have mild instability as well as mild recurrent subluxation or dislocation. This is consistent with the currently assigned 10 percent rating. The evidence showed no moderate instability or moderate subluxation/dislocation as is required for a higher rating for this disability. To the extent that the Veteran has described his symptomatology, he is certainly competent to do so, and his comments are considered credible and have been applied in determining the appropriate ratings. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, to the extent that they conflict with the notations contained on the examinations, the Board finds that the objective findings of a medical professional are more probative in determining the severity of the Veteran's disabilities than the Veteran's lay statements. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). Symptoms including painful, limited motion, instability, and mild subluxation/dislocation are expressly contemplated by the rating schedule in the ratings assigned. While the most recent VA examination identified other symptoms such as effusion and locking pain, the Veteran was assigned a separate 20 percent rating that addressed those symptoms. ORDER A rating of 20 percent for the Veteran's right pectoral muscle disability for the period prior to November 4, 2008 is granted, subject to the laws and regulations governing the payment of VA benefits. A rating in excess of 20 percent for the Veteran's right pectoral muscle disability for the period from November 4, 2008 to August 24, 2011 is denied. A rating in excess of 40 percent for the Veteran's right pectoral muscle disability for the period beginning August 25, 2011 is denied. A rating of 10 percent for the Veteran's left wrist disability prior to November 4, 2008 is granted, subject to the laws and regulations governing the payment of VA benefits. A rating in excess of 10 percent for the Veteran's left wrist disability beginning November 4, 2008 is denied. A rating in excess of 10 percent for DJD of the right knee is denied. A rating in excess of 10 percent for instability of the right knee is denied. ____________________________________________ REBECCA FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs