Citation Nr: 1326218 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 09-42 524 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a disability evaluation in excess of 20 percent for post-operative residuals of a left knee injury. 2. Entitlement to a disability evaluation in excess of 10 percent for patellofemoral degenerative changes of the right knee. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from August 1981 to August 1985 and November 1985 to March 1993. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama which denied the benefits sought on appeal. The Veteran testified before the undersigned Veterans Law Judge at a March 2013 videoconference hearing, and a transcript of this hearing is of record. FINDINGS OF FACT 1. The Veteran's service connected post-operative residuals of a left knee injury results in severe subluxation or dislocation of the patella and grade 4 changes to the patella and trochlear groove, as well as pain, swelling, stiffness, weakness, and giving way. 2. The Veteran's service connected patellofemoral degenerative changes of the right knee results in moderate subluxation or dislocation of the patella, as well as subjective reports of pain, swelling, stiffness, weakness, and giving way. As of October 25, 2011, extension of the Veteran's right leg was limited to at least 10 degrees. 3. The Veteran's service connected disabilities do not prevent him from finding and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability evaluation of 30 percent for post-operative residuals of a left knee injury have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Code 5257 (2012). 2. Prior to October 25, 2011, the criteria for entitlement to a disability evaluation of 20 percent for patellofemoral degenerative changes of the right knee have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Code 5257 (2012). 3. As of October 25, 2011, the criteria for entitlement to an additional 10 percent disability rating based on limitation of extension of the right knee have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5261 (2012). 4. The criteria for entitlement to a total disability rating based on individual unemployability have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R., Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. The Veteran filed the increased rating currently on appeal in October 2007. At that time, the Veteran was service-connected for post-operative residuals of a left knee injury, assigned a 20 evaluation under Diagnostic Code 5262, and for patellofemoral degenerative changes of the right knee, assigned a 10 percent rating under Diagnostic Code 5010. These ratings remained in effect until July 2008, when the Veteran underwent a right knee arthroscopy. Following this surgery, the Veteran was assigned a temporary total (100 percent) disability rating until December 2008, after which his disability rating was reduced and rating was assigned essentially as directed by the rating schedule. See 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). In October 2009, the Veteran was again assigned a temporary total disability rating following a left knee arthroscopic debridement and chondroplasty. This rating remained in effect until December 2009. In May 2012, the RO assigned an additional non-compensable (0 percent) disability rating for limitation of extension of the left knee, effective October 2011 The Veteran has not appealed any matters related to the temporary total disability evaluation or assignment of an additional disability rating for limitation of motion of the left knee. Degenerative joint disease of the knee is rated under Diagnostic Code 5010. 38 C.F.R. § 4.71a. Diagnostic Code 5010 directs that traumatic arthritis substantiated by x-ray findings should be rated as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is non-compensable, 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. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5257, which rates impairment based on recurrent subluxation or lateral instability of the knee, a 10 percent rating will be assigned with evidence of slight recurrent subluxation or lateral instability; 20 percent rating will be assigned with evidence of moderate recurrent subluxation or lateral instability; and a 30 percent rating will be assigned with evidence of severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint will be rated as 20 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, removal of semilunar cartilage that is symptomatic will be assigned a 10 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, a 10 percent rating will be assigned for limitation of flexion of the knee to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the knee to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the knee to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent rating is assigned for extension limited to 10 degrees; a 20 percent disability rating is assigned for extension limited to 15 degrees; a 30 percent disability rating is assigned for extension limited to 20 degrees; a 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Full range of motion of the knee is from 0 degrees to 140 degrees in extension and flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5262, malunion of the tibia and fibula with moderate knee or ankle disability will be assigned a 20 percent disability rating, malunion of the tibia and fibula with marked knee or ankle disability will be assigned a 30 percent disability rating, and nonunion of the tibia and fibula with loose motion, requiring a brace, will be assigned a 40 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The VA Office of General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Codes 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). In this opinion, 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 is based upon additional disability. Subsequently, in VAOPGCPREC 9-98 (Aug. 14, 1998), the VA General Counsel further explained that if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. See also VAOPGCPREC 9-04 (Sept. 17, 2004) (which finds that separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg may be assigned for disability of the same joint). The VA Office of General Counsel has also stated that Diagnostic Code 5259, removal of semilunar cartilage, may result in complications producing loss of motion. As such, limitation of motion is a relevant consideration under Diagnostic Code 5259. VAOPGCPREC 9-98 (Aug. 14, 1998). Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology, and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, painful movement, swelling, deformity, or disuse atrophy. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In a December 2007 letter, a VA orthopedic surgical resident, Dr. B.S. described the Veteran as suffering from advanced arthritis in both knees which is so severe that the Veteran needs bilateral total knee replacement surgery. Dr. B.S. strongly recommended that the Veteran either find sedentary employment or retire, as he was no longer capable of performing the manual labor demanded by his current employment with the United States Postal Service. The Veteran was afforded a VA examination in January 2008. At that time, the Veteran described a history of multiple injuries and surgeries to the left knee, as well current bilateral knee pain. However, he reported that he was able to stand, walk, and sit during his eight hour shift at his place of employment. The Veteran was observed to get in and out of a chair and on and off the examining table with minimal difficulty. His gait was somewhat slow and antalgic. On examination, range of motion of the left knee was from 0 to 100 degrees. There was evidence of moderate patella alta. He had Grade I to II medical collateral laxity, as well as tenderness in the medial joint line. However, there was no effusion or evidence of lateral instability of the patella. Range of motion of the left knee was from 0 to 110 degrees. There was no effusion or instability of the tendons or patella. McMurray's test was positive. There was no increased limitation of motion due to fatigue, weakness, or incoordination following repetitive testing. X-rays of the knee showed mild degenerative arthrosis of both knees. An October 2007 MRI of the left knee showed possible tears to the patella tendon, the posterior horn of the medial meniscus, and the ACL. An August 2007 MRI of the right knee showed tears to the proximal patellar tendon and distal patella tendon, as well as medial tibial condyle marrow edema, and possible tear of the posterior horn the medial meniscus. In August 2008, the Veteran underwent a right knee arthroscopy. Following this surgery, the Veteran suffered from severe pain, difficulty ambulating, and significant limitation of motion, as noted in VA Orthopedic Clinic Notes from the months following his surgery. As the Board noted above, the Veteran was assigned a temporary total disability rating during his period of convalescence. At a January 2009 VA Orthopedic Clinic appointment, the Veteran complained of bilateral knee pain, left worse than right, with catching, locking, and stiffness of the left knee. On examination, range of motion of the left knee was from 0 to 95 degrees. Range of motion of the left knee was from 0 to 130 degrees. There was crepitus with range of motion and tenderness to palpation. In January 2009, the Veteran was afforded a VA examination of his right knee. At that time, he described daily, constant moderate to severe aching, throbbing pain, with intermittent sharp pain and giving way. He also complained of instability, stiffness, weakness, locking, and effusion. He reported using a cane and knee brace on a daily basis. He reported being unable to stand for more than three hours or walk more than a quarter mile. On examination, there was bony joint enlargement, crepitus, effusion, tenderness, guarding, and patella alta. There was no instability. Range of motion of the right knee was from 0 to 105 degrees. Range of motion of the left knee was from 0 to 108 degrees. There was objective evidence of painful motion, but no additional limitation of motion following repetitive testing. The Veteran was diagnosed with patellofemoral degenerative changes of the right knee. In August 2009, the Veteran was afforded another VA examination. The Veteran complained of bilateral knee pain, left worse than right. He also described subjective complaints of instability, giving way, weakness, and stiffness. He reported that he had retired from his job at the post office in April 2008 and had worked at a pro shop from October 2008 to May 2009 before quitting this job as well because he is unable to stand for long periods of time. He was currently unemployed and treating his symptoms with pain and bracing. On examination, the Veteran had crepitus, edema, effusion, and tenderness to palpation. There was no objective evidence of instability. Range of motion of the left knee was from 0 to 90 degrees. Range of motion of the right knee was from 0 to 110 degrees. There was objective evidence of pain with active motion, but no additional limitation of motion following repetitive testing. There was no joint ankylosis. An x-ray showed mild degenerative knee arthrosis more marked in the patellofemoral compartment, patella alta, and patellar tendinopathy. The examiner concluded that due to the condition of his knees, the Veteran would be capable of sedentary employment, but not physical labor. At a September 2009 Orthopedic Clinic appointment, the Veteran complained of left knee pain with popping and crepitus with range of motion. On examination, the Veteran's range of motion of the left knee was from 0 to 100 degrees, limited by pain. He had tenderness to palpation of the parapatellar region, with some audible crepitus and clicking. He was diagnosed with left knee patellofemoral chondromalacia and scheduled for a left knee arthroscopy. In October 2009, the Veteran underwent a left knee arthroscopy with a post-operative diagnosis of patellofemoral osteoarthritis with grade 4 changes on both the patella and the trochlear groove, as well as patellar tendonitis at the inferior pole. A December 2009 VA Orthopedic Clinic Note shows that the Veteran is recovering well from his surgery, although he has continuing pain and wears a knee brace. The knee was stable with no effusion and range of motion from 0 to 110 degrees. At a February 2010 VA Orthopedic Clinic Note again reflects that the Veteran is recovering well from his left knee arthroscopy. He had range of motion in the left knee from 0 to 120 degrees and no instability. It was noted that the Veteran's long-term prognosis was poor and that he would have to have a total knee replacement at some point. However, the Veteran reported that he was able to get around very well despite his pain, he was very active around his farm ,and he was able to do all the activities he wants to do. At a February 2011 VA Orthopedic Clinic appointment, the Veteran complained of significant bilateral knee pain and buckling. He continued to wear his knee braces. On examination, he had tenderness to palpation, mostly around the patella. He had crepitus bilaterally with range of motion and positive patellar grind bilaterally. Range of motion was approximately 0 to 110 degrees bilaterally. There was no objective evidence of instability. In May 2011, the Veteran complained to his primary care provider that his knee braces did not seem to be providing adequate support. At an August 2011 VA Orthopedic Clinic appointment, the Veteran continued to complain of bilateral knee pain, but noted that it did not significantly limit him. On examination, the Veteran had range of motion in the left knee from 0 to 120 degrees. Range of motion in the right knee was from 0 to 110 degrees. The Veteran had full muscle strength in his lower extremities and was stable to valus/varus testing. An x-ray of his knee shows moderate bilateral osteoarthritis. In October 2011, the Veteran was afforded another VA examination of his knee joints. The Veteran reported the constant use of knee braces and a cane to assist his ambulation. On examination, the Veteran had range of motion of the right knee from 10 degrees of extension to 70 degrees of flexion, with pain at 55 degrees of flexion. Range of motion of the left knee was from 5 degrees of extension to 80 degrees of flexion with pain at 65 degrees of flexion. The Veteran was unable to perform repetitive testing. The Veteran had tenderness to palpation and diminished muscle strength. There was no evidence of instability. The Veteran had recurrent patellar subluxation or dislocation, described as severe in the left knee and moderate in the right knee. He had no shin splints, stress fracture, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. He did not have any meniscal condition. At his March 2013 hearing and in various statements to VA, the Veteran has complained of pain and swelling of the knees with prolonged standing and walking. He also complained of locking and giving way, particularly when going up and down stairs. He alleged that he is unemployable due to his bilateral knee disability. Based on all the above evidence, the Board finds that the Veteran is entitled a higher disability rating for both his left and right knee disabilities, but not under the diagnostic codes these disabilities are currently rated under. The Veteran's left knee disability is currently assigned a 20 percent disability rating under Diagnostic Code 5262, which rates malunion of the tibia or fibula. However, the Veteran's October 2011 VA examination specifically found that the Veteran did not presently nor did he ever suffer from an impairment of the tibia or fibula and there is no evidence of record of any impairment of the tibia or fibula. If there were no other diagnostic code that accurately reflected the Veteran's left knee disability, the Board would consider rating the Veteran's disability by analogy under Diagnostic Code 5262; however, the evidence of record shows that the Veteran has been diagnosed with severe recurrent subluxation or dislocation of the left patella. Thus, the Board finds that the Veteran is most appropriately assigned a 30 percent disability rating for severe recurrent subluxation or lateral instability under Diagnostic Code 5257, which rates other impairment of the knee. This is the maximum schedular rating under Diagnostic Code 5257. The Board has considered whether a separate disability rating could be assigned based on limitation of motion of the left knee, but neither extension nor flexion has been sufficiently limited during the period on appeal to warrant a compensable rating under Diagnostic Code 5260 or 5261. Additionally, as there is no evidence that the Veteran's suffers from ankylosis of the knee, dislocated or removed semilunar cartilage, genu recurvatum, or malunion of the tibia or fibula, a higher disability rating cannot be assigned under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263. In conclusion, the Board finds that entitlement to a disability rating of 30 percent under Diagnostic Code 5257, but no greater is warranted for the Veteran's service connected post-operative residuals of a left knee injury for the entire period on appeal. The Board also finds that the Veteran's right knee disability is most appropriately assigned a 20 percent disability rating under Diagnostic Code 5257 for moderate recurrent dislocation or subluxation of the patella. The Veteran's right knee disability has consistently been less severe than the Veteran's left knee disability, and the October 2011 VA examiner characterized the Veteran's right patella subluxation as moderate, rather than severe. Accordingly, the Board finds that a disability rating in excess of 20 percent is not warranted under Diagnostic Code 5257. Additionally, the Board notes that on the October 2011 VA examination, the Veteran's extension of the right knee was limited to 10 degrees. Per the GC opinion, the Veteran can be assigned a separate disability rating for limitation of extension of the right leg as of October 25, 2011, in addition to the 20 percent disability rating assigned under Diagnostic Code 5257 for instability. There is no earlier evidence (prior to October 2011) of compensable limitation of motion of the right knee. As there is no evidence that the Veteran suffers from ankylosis of the right knee, dislocated or removed semilunar cartilage, flexion limited to at least 45 degrees, non-union or malunion of the tibia or fibula, or genu recurvatum, a disability rating under Diagnostic Codes 5256, 5258, 5259, 5260, 5262, or 5263 is not appropriate. Again, the Board has considered that the Veteran reports wearing braces on both knees constantly, but it appears from all the evidence of record that he does so based on his own subjective perception of instability and weakness, as well as subluxation of the patella, rather than because of any impairment of the tibia or fibula. In conclusion, the Veteran's service connected patellofemoral degenerative changes are assigned a disability rating of 20 percent under Diagnostic Code 5257 for the period on appeal and a disability rating of 10 percent under Diagnostic Code 5261 as of October 25, 2011, but no greater. Finally, the Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that the schedular rating criteria reasonably reflect the Veteran's disability levels and symptomatology. The Veteran's reported difficulties, including pain, limitation of motion, swelling, and giving way are not so exceptional or unusual a disability picture as to render impractical application of regular schedular standards. Therefore, no referral for extraschedular consideration is required and no further analysis is in order. For all the above reasons, entitlement to a disability evaluation of 30 percent under Diagnostic Code 5257 for service connected post-operative residuals of a left knee disability for the entire period on appeal is granted. Entitlement to a disability evaluation of 20 percent for service connected patellofemoral degenerative changes of the right knee under Diagnostic Code 5257 is granted for the entire period on appeal. Entitlement to an additional 10 percent disability for service connected patellofemoral degenerative changes of the right knee under Diagnostic Code 5261 is granted from October 2011. A higher disability rating cannot be granted for either disability for any period on appeal. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). TDIU The Veteran is also seeking entitlement to a total disability rating, alleging that he is unable to work due to his service connected disabilities. Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). Here, the Veteran does not meet this criteria. However, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reasons of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation and Pension Service, for extra-schedular consideration of all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). The rating board will include a full statement as to the veteran's service-connected disabilities, employment history, educations and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). The veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran is currently service connected for a right knee disability, a left knee disability, asthma, and hypertension. The Veteran's bilateral knee disability has been discussed in detail above. As previously noted, in a December 2007 letter, Dr. B.S. opined that the Veteran was no longer capable of performing physically demanding labor, but he did not preclude sedentary employment. At an August 2009 VA examination, the VA examiner opined that the Veteran's bilateral knee disability would not preclude sedentary employment, but would prevent the Veteran from performing physical labor. In August 2009, the Veteran was also afforded an examination of his service connected asthma. The VA examiner opined that the Veteran's asthma had only mild impairment on his activities of daily living and would not prevent him from engaging in either sedentary or physical labor. At a February 2010 VA Orthopedic Clinic appointment, the Veteran reported that he was able to get around very well despite in spite his pain, he was very active around his farm, and he was able to do all the activities he wants to do. At an August 2011 VA Orthopedic Clinic appointment, the Veteran continued to complain of bilateral knee pain, but noted that it did not significantly limit him. The Veteran was afforded another VA examination of his asthma in June 2012. The examiner opined that the Veteran's asthma would preclude physical labor, but not sedentary. At his hearing, as well as in statements to VA, the Veteran has asserted that he is no longer able to work because of his service connected disabilities. In particular, the Veteran complained that he had to retire from his job as a mail handler, as well as his job at the pro shop, because he is not able to stand for long periods of time or lift heavy objects because of his knee disabilities. At his March 2013 hearing, the Veteran also reported that in 2000, he underwent vocational training to become a computer repair technician, but he claimed that he was also unable to physically perform this work because "I can't stoop and stand or lift 25 pounds so I can't get down on my knees." Based on all the above evidence, the Board finds that entitlement to TDIU is not warranted. While there is sufficient evidence of records to conclude that the Veteran is no longer able to perform physically demanding labor, such as his past job as a mail handler, due to his service connected disabilities, multiple VA examiners have opined that the Veteran is able to perform sedentary employment. In light of the Veteran's own statements to his VA treatment providers that he remains active on his farm and that his disabilities do not physically limit him, the Board has no difficulty concluding that the Veteran is physically capable of performing sedentary employment. Additionally, while the Veteran's last two jobs appear to have involved mostly physical labor, the Veteran has testified that he has received technical training in the past. Thus, he appears qualified to perform more than just manual labor. Rather, he has training in the field of computers, which is largely a sedentary job. In conclusion, the Board finds that the Veteran is not precluded from finding and maintaining employment solely due to his service connected disabilities. Accordingly, entitlement to TDIU is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board notes that in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the United States Court of Appeals for Veterans Claims (Veterans Court) clarified VA's notice obligations in increased rating claims. The Federal Circuit recently reversed the Veterans Court's decision in Vazquez-Flores, finding that VA is not required to tailor § 5103(a) notice to individual Veterans or to notify them that they may present evidence showing the effect that worsening of a service-connected disability has on their employment and daily life for proper claims adjudication. For an increased rating claim, section § 5103(a) now requires that the Secretary notify claimants generally that, to substantiate a claim, they must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd sub. nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (holding that notice specific to individual Veterans is no longer required in increased compensation claims). Here, the VCAA duty to notify was satisfied by a letter sent to the Veteran in January 2008. This letter informed the Veteran of what evidence was required to substantiate his claims, as well as of VA and the Veteran's respective duties for obtaining evidence. The Veteran was also informed of how VA assigns disability ratings and effective dates. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical 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 RO has obtained the Veteran's service treatment records, as well as VA treatment records. At his March 2013 videoconference hearing, the Veteran claimed that he received vocational training in 2000. It appears that this was through VA, although that is not entirely clear. The Board has considered whether a remand is required to obtain those records; however, it has been more than a decade since the Veteran received his vocational rehabilitation training and any evaluations performed in 2000 are unlikely to reflect the current status of the Veteran's disabilities. The Veteran submitted private medical records, and was provided an opportunity to set forth his contentions during the March 2013 videoconference hearing before the undersigned Veterans Law Judge. In this regard, the Board notes that in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that there are two duties imposed by 38 C.F.R. § 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked are not impacted by the Veteran's receipt of letter that complies with VA's duty to notify. In this case, during the Board hearing, testimony was elicited regarding the elements that were lacking to substantiate the claim and the Veteran and his representative demonstrated actual knowledge of this information. The representative's questions specifically elicited responses designed to show that the Veteran's understood the criteria necessary to substantiate his claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). Further, a review of the record also reveals no assertion, by the Veteran or his representative, that VA or the undersigned failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any other prejudice in the conduct of the Board hearing. Accordingly, the Veteran is not shown to be prejudiced on this basis. The appellant was afforded VA medical examinations in January 2008, January 2009, August 2009, November 2009, October 2011, and June 2012. These examinations are based upon review of the claims folder and thoroughly discuss the nature and severity of the Veteran's disabilities as well as the functional impairments resulting therefrom. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, 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). ORDER Entitlement to a disability evaluation of 30 percent for post-operative residuals of a left knee disability is granted. Entitlement to a disability evaluation of 20 percent for patellofemoral degenerative changes of the right knee is granted. Entitlement to an additional 10 percent disability evaluation for limitation of extension of the right knee as of October 25, 2011 is granted Entitlement to a total disability rating based on individual unemployability is denied. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs