Citation Nr: 1325992 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 07-17 318A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to an increased rating for residuals of a left knee chondroplasty and post traumatic arthritis of the left knee, rated 10 percent disabling on the basis of symptomatic semilunar cartilage removal and 10 percent disabling on the basis of traumatic arthritis with noncompensable limitation of motion. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from November 1968 to August 1971. He received the Combat Action Ribbon. This matter comes before the Board Veterans' Appeals (Board) from an August 2006 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In that decision, the RO denied entitlement to an increased rating in excess of 10 percent for residuals of a left knee chondroplasty and an increased rating in excess of 10 percent for traumatic arthritis of the left knee. In December 2009, the RO granted a total disability rating based on individual unemployability (TDIU) that is effective November 2006. The appeal was remanded in June 2011, and January 2013. FINDINGS OF FACT 1. From March 26, 2008 to August 19, 2009 the Veteran's left knee disability was manifested by limitation of extension to approximately 15 degrees. 2. For the remainder of the appeal period, the Veteran's service-connected residuals of a left knee chondroplasty and post traumatic arthritis of the left knee have been manifested by leg flexion limited to at most 110 degrees; and leg extension limited to at most 5 degrees; without ankylosis of the knee; or malunion of the tibia and fibula. 3. During the entire appeal period the Veteran has had removal of the semilunar cartilage without subluxation or instability. CONCLUSIONS OF LAW 1. The criteria for a 20 percent rating for residuals of a left knee chondroplasty and post traumatic arthritis of the left knee on the basis of limitation of extension, were met from March 26, 2008 to August 19, 2009. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected residuals of a left knee chondroplasty and post traumatic arthritis of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, Diagnostic Codes 5010, 5256, 5260, 5261, 5262 (2012). 2. The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected residuals of a left knee chondroplasty and post traumatic arthritis of the left knee on the basis of removal of the semilunar cartilage have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7 and Codes 5257-5259 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the Veteran was sent a letter in June 2006 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports. Additionally, the Veteran was afforded VA examinations in July 2007, March 2008, August 2009, and August 2011 with an addendum in February 2013. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. The Board's 2011 remand was to afford the Veteran a current and adequate VA examination. The Veteran was afforded that examination in August 2011; but the examination report did not include the findings needed to rate the disability on the basis of functional impairment. See 38 C.F.R. §§ 4.40, 4.45 (2012). The Board's 2013 remand was to obtain clarification. That clarification was provided in the February 2013 review and addendum. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Ratings Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under Diagnostic Code 5010, arthritis due to trauma, established by X-ray findings will be rated under Diagnostic Code 5003 (governing degenerative arthritis). Under Diagnostic Code 5003, degenerative arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, 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 major joint or groups of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. NOTE (2): The 20 percent and 10 percent ratings based on X-ray findings will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a. Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260, a 10 percent rating is warranted for leg flexion limited to 45 degrees. A 20 percent rating is warranted for leg flexion limited to 30 degrees. A 30 percent rating is warranted for leg flexion limited to 15 degrees. Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5261, a 10 percent rating is warranted for leg extension limited to 10 degrees. A 20 percent rating is warranted for leg extension limited to 15 degrees. A 30 percent rating is warranted for leg extension limited to 20 degrees. A 40 percent rating is warranted for leg extension limited to 30 degrees. A 50 percent rating is warranted for leg extension limited to 45 degrees. Separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension), both codified at 38 C.F.R. §4.71a, may be assigned for disability of the same joint. See VAOPGCPREC 9- 2004. In addition, ankylosis of the knee will be rated as 60 percent disabling if at an extremely unfavorable angle, in flexion at an angle of 45 degrees or more. A 50 percent rating will be assigned if the knee is in flexion between 20 degrees and 45 degrees. The disability will be rated at 40 percent if it is in flexion between 10 degrees and 20 degrees. A 30 percent rating will be assigned if there is ankylosis at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Removal of the semilunar cartilage warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Dislocation of the semilunar cartilabe with frequent episodes of locking and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.7a, Diagnostic Code 5258 (2012). Impairment of the tibia and fibula will be rated as 40 percent disabling where there is a nonunion, with loose motion, requiring brace. A malunion of the tibia and fibula will be rated as 30 percent disabling if there is marked knee or ankle disability, 20 percent disabling if there is moderate knee or ankle disability, and 10 percent disabling if there is slight knee or ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The law permits separate ratings for arthritis and instability of a knee. Specifically, the VA General Counsel has held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257 because the arthritis would be considered an additional disability warranting a separate evaluation even if the limitation of motion was not compensable. See VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997). Likewise, the VA General Counsel has also held that, when x- ray findings of arthritis are present and a Veteran's knee disability is evaluated under Code 5257, the Veteran would be entitled to a separate compensable evaluation under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98 (Aug. 14, 1998). Pursuant to 38 C.F.R. § 4.71a (Diagnostic Code 5257), a rating of 10 percent is warranted when the Veteran experiences slight subluxation or lateral instability. A rating of 20 percent is warranted when the Veteran experiences moderate subluxation or lateral instability. A rating of 30 percent is warranted when the Veteran experiences severe subluxation or lateral instability. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flareups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet.App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2006). The Veteran underwent numerous VA examinations. In response to the Veteran's May 2006 claim, he underwent a VA examination in July 2007. The Veteran stated that with prolonged standing or sitting, or with changes in the weather, pain in the left knee rated a 3-4 on a scale of 1-10. He reported no pain in the knee while at rest. He did report some sensations of stiffness that required ambulation. He denied any instability or giving out of the knee. He reported that pain was minimal (1-2 on a scale of 1-10) with distance ambulation (more than 1/2 mile). He stated that he took Etodolac for arthritis pain. Upon examination, there was restricted range of active motion. There was -5 degrees loss of knee extension. He achieved flexion from 5-130 degrees. There was crepitation on active range of motion. Deep tendon reflexes were 1+. With repetitive range of motion, there was a loss of 5 degrees of full flexion (from -5-125 degrees) with no complaints of discomfort at extreme range of motion. There was no medial lateral instability. Drawer sign was negative. The Veteran ambulated with a normal gait. He used no assistive devices. He denied any incapacitating episodes in the past 12 months. The examiner stated that "Deluca criteria could not be evaluated with medical certainty." At the examination, the examiner did not see any poor endurance with repetitive motion. There was no incoordination noted; and the examiner stated that fatigue was a subjective symptom. The Veteran underwent another VA examination on March 26, 2008. The examiner reviewed the claims file in conjunction with the examination. The Veteran complained of pain, stiffness, swelling, instability, giving way, grinding, and popping. He denied weakness, heat, redness, locking, fatigability, and lack of endurance. He reported flare-ups of pain occurring 1-10 times per day, which lasted for hours, and which included pain of 6-7 (out of 10) severity. Flare-ups were precipitated by excessive, repetitive, or prolonged use. He reported that the flare-ups caused severe additional limitation of motion and severe functional impairment. He reported that he used a left knee brace and a cane. He denied episodes of dislocation or recurrent subluxation. He reported that the left knee caused a moderate to severe effect on his activities of daily living. Upon examination, the left knee showed objective evidence of painful motion and abnormal movement. There was no left knee edema, effusion, instability, weakness, tenderness, redness, heat, guarding of movement, or abnormalities of gait. There were no callosities, breakdown, or unusual shoe wear patterns. There was no ankylosis, or evidence of inflammatory arthritis. There was no evidence of medial/lateral collateral ligament instability, or anterior/posterior cruciate instability. The Veteran achieved extension of the left knee from -14 to -4 degrees with pain throughout. He achieved passive range of extension from -14 to -2 degrees. Following repetition of motion, he achieved extension to +1 degrees, with no additional limitation of motion due to pain, fatigue, weakness, or lack of endurance. He achieved active left knee flexion from 0-119 degrees, with pain from 117-119 degrees. He achieved passive range of motion from 0-127 degrees, with pain occurring from 117-127 degrees. There was no additional limitation of motion due to pain, fatigue, weakness, or lack of endurance. X-rays revealed mild patellofemoral arthritis with mild spurring of the patella; very mild chondrocalcinosis which could represent calcium pyrophosphate dihydrate deposition disease arthroplasty; with joint spaces largely preserved, with no visible joint effusions, fractures, or deformities. The Veteran underwent another VA examination in August 2009. The examiner reviewed the claims file in conjunction with the examination. The Veteran denied constitutional symptoms of arthritis and incapacitating episodes of arthritis. He did not report any functional limitations on walking. He reported intermittently using a knee brace. Upon examination, the Veteran's gait was normal. There was no evidence of abnormal weight bearing, inflammatory arthritis, or instability. There was crepitus and tenderness, as well as suprapatellar tenderness. He achieved flexion from 0-120 degrees and extension to 0 degrees. There was objective evidence of pain with active range of motion; but the examiner did not state at what point pain began. There was no additional limitation of motion following repetitive motion. X-rays revealed chondrocalcinosis in the medial and lateral compartments. There were mild lateral compartment and mild to moderate patellofemoral and medial compartment degenerative changes of the left knee. The examiner determined that the disability had no significant effects on employment. It prevented the Veteran from playing sports. It had a moderate effect on his ability to exercise. It had a mild effect on his ability to do chores, shop, travel, and participate in recreational activities. The Veteran underwent a VA examination in August 2011. He complained that the left knee was sore and stiff. He reported that he experienced "on and off" pain in the summer time; but that the pain was continuous during the winter. The pain varied from a 5-8 on a scale of 1-10. He stated that when he went up steps, he felt like the knee was going to give way; but it never has (and he has not had any falls). He stated that the pain increased to a 7/10 after walking or standing for 30 minutes. He reported that he noticed slight swelling on occasion; but that it went away following rest and elevation of the leg. He stated that he had to rest after walking for 10-15 minutes. He lived alone and was able to do all sorts of chores including mowing the lawn which is more than 1/2 acre. He stated that he had a riding lawnmower and a push mower; but that much more of the work was done with the push mower. He could not give any other instances in which he could not perform day to day activities as a result of the left knee disability. He reported that the right knee disability is much worse. Upon examination, the Veteran did not appear to be in any discomfort; and he did not appear to have any difficulty getting in and out of his chair. There was no evidence of any varus/valgus deformity while standing. Gait was normal without any antalgic pattern. Balance on the left lower extremity was normal. He was only able to squat 50 percent of the way due to difficulty bending the knees (left and right) any further. He complained of mild to moderate discomfort in the left knee. He did not have any loss of balance while walking around the examination room. Examination of the left knee revealed no tenderness, swelling, or effusion. He denied any pain upon palpation; however, he appeared to be in mild discomfort during palpation of the medial joint line. Drawer sign and Lachman's test were negative. Medial and lateral stress tests did not indicate any evidence of instability. Active range of motion in extension was 0 degrees without discomfort. Passive and repetitive range of motion remained the same without pain. Active flexion was to 100 degrees without pain. He stated that he had moderate discomfort at 110 degrees. He achieved passive range of motion to 120 degrees; but he complained of pain from 110-120 degrees. Repetitive range of motion remained at 100 degrees of active flexion and 120 degrees of passive flexion with pain between 110-120 degrees. There was no atrophy of the muscles. The examiner noted that the Veteran was independent in activities of daily living. The Veteran reported occasionally using a knee sleeve when performing household chores or for walking prolonged periods of time. Regarding DeLuca criteria, the examiner stated that they cannot be clearly-delineated with any medical certainty. It would all depend on the severity of pain, presence (or absence) of swelling, and the activities that the Veteran was performing. However, he stated that at the examination, there was an obvious loss of an additional 10 degrees of flexion due to pain on repetitive testing. There was no evidence of incoordination or atrophy or weakness. He stated that fatigue is a subjective complaint; but that the Veteran did not appear tired at the end of the examination. Pursuant to the Board's January 2013 remand, the RO obtained an addendum to the August 2011 examination report. A physician's assistant who reviewed the claims file found that the Veteran experienced an additional loss of 10 degrees of flexion without subjective reports of discomfort during repetitive motion testing and no complaints of fatigue or degradation of range of motion. He also found no demonstration at any time of decreased coordination, weakness or consistent pattern of flare-ups other than mentioned above. There were no flare-ups reported during examinations; and there was no reported pain other than during palpation of the medial joint line. There was no tenderness reported at the beginning of the exam and none reported at the conclusion of the exam. Analysis The Veteran's service-connected left knee chondroplasty and post traumatic arthritis of the left knee has been rated by the RO under the provisions of Diagnostic Code 5010 (for arthritis with limitation of motion) and Diagnostic Code 5259 (for loss of the semilunar cartilage). The Veteran has undergone four VA examinations. None of them have shown ankylosis of the left knee. Nor have they shown malunion of the tibia and fibula resulting in a moderate knee or ankle disability. Regarding range of motion, the Veteran achieved forward flexion of the knee to 130 degrees (July 2007), 119 degrees (with pain at 117 degrees at his March 2008 examination), 120 degrees (August 2009), and 120 degrees (with pain at 110 degrees at his August 2011 examination). Although the 2007 examiner stated that DeLuca factors could not be measured with "medical certainty," that examiner essentially reported that such factors were not shown on examination. The August 2011 examiner noted that with repetitive range of motion exercises, there was an additional 10 degrees of limitation of motion. Therefore, with repetitive motion, the examiner deemed that the Veteran would still be able to achieve flexion to 110 degrees (with pain in the last 10 degrees worth of motion). At no time has the Veteran's knee disability, even with consideration of functional impairment, been shown to have been manifested by leg flexion limited to 30 degrees. Consequently, a rating in excess of 10 percent is not warranted under Diagnostic Code 5260. In order to warrant a rating in excess of 10 percent under Diagnostic Code 5261 (for limitation of extension), the Veteran's disability would have to be manifested by leg extension limited to approximately 15 degrees. At the four VA examinations, the Veteran achieved leg extension to 5 degrees (July 2007), 14 degrees (March 2008), 0 degrees (August 2009), and 0 degrees without discomfort (August 2011). In the absence leg extension limited to 15 degrees, a rating in excess of 10 percent is not warranted under Diagnostic Code 5261. The limitation of extension to 14 degrees approximates the criteria for a 20 percent rating for limitation of extension. 38 C.F.R. §§ 4.7, 4.21. The evidence shows that this limitation of motion was shown on the March 26, 2008, examination, but not on the August 20, 2009 examination. Accordingly, a 20 percent rating was warranted for limitation of extension from March 26, 2008 to August 19, 2009. There is no medical evidence to show that there is any additional loss of motion of left knee due to pain or flare-ups of pain, supported by objective findings, or due to excess fatigability, weakness or incoordination, to a degree that supports a rating in excess of 10 percent other than from March 26, 2008 to August 19, 2009. The Veteran's is in receipt of the maximum rating for removal of the semilunar cartilage under Diagnostic Code 5259. There have been no reports of dislocated semilunar cartilage, which is consistent with the finding that it has been removed. Hence, a 20 percent rating is not warranted under Diagnostic Code 5258. Consequently, in order to warrant a rating in excess of 10 percent, the Veteran's left knee disability has to be manifested by moderate subluxation or lateral instability (Diagnostic Code 5257); or dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint (Diagnostic Code 5258). At the July 2007 VA examination, the Veteran specifically denied any instability or giving out of the knee. Moreover, upon examination, there was no medial lateral instability. At the Veteran's March 2008 VA examination, he complained of pain, stiffness, swelling, instability, giving way, grinding, and popping. He denied weakness, heat, redness, locking, fatigability, and lack of endurance. However, upon examination, the examiner found no objective evidence of instability or weakness. Specifically, the examiner commented that there was no evidence of medial/lateral collateral ligament instability, or anterior/posterior cruciate instability. At his August 2009 VA examination, the Veteran reported intermittently using a knee brace. Once again, upon examination, there was no evidence of abnormal weight bearing, inflammatory arthritis, or instability. Finally, at his August 2011 VA examination, the Veteran stated that when he went up steps, he felt like the knee was going to give way; but it never has (and he has not had any falls). Upon examination, the examiner noted that balance on the left lower extremity was normal. Drawer sign and Lachman's test were negative. Medial and lateral stress tests did not indicate any evidence of instability. The Board recognizes the Veteran's report that when he went up steps, the knee felt like it was going to give way. The Board also recognizes the Veteran's statements that he experiences instability. The Veteran is competent to describe symptoms as he experiences them. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). His reports of instability are not deemed credible in light of the consistent findings on examination that there is no instability and ligaments are intact Consequently, the evidence is against a separate rating under Diagnostic Code 5257. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a rating in excess of 10 percent for residuals of a left knee chondroplasty and post traumatic arthritis of the left knee, manifested by instability and symptomatic semilunar cartilage removal must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). The potential application of various provisions of Title 38 of the Code of Federal Regulations have also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). However, as discussed above, the record in this case persuasively shows that the Veteran's symptoms squarely match the type and degree of the examples set forth under the criteria for the current 10 percent schedular ratings. Consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is not appropriate in such a case where the rating criteria reasonably describe the Veteran's disability level and symptomatology. See generally Thun v. Peak, 22 Vet.App. 111 (2008). The Board therefore finds that referral for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is not warranted in this case. ORDER Entitlement to a separate 20 percent rating for limitation of extension is granted from March 26, 2008 to August 19, 2009. An increased ratings for residuals of a left knee chondroplasty and post traumatic arthritis of the left knee is otherwise denied. ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs