Citation Nr: 1327310 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 04-28 721 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4, and facet joints at L4-L5, including as secondary to service-connected disabilities 2. Entitlement to an initial disability rating in excess of 40 percent for myofascial strain of the paraspinal muscles of the back. 3. Entitlement to a disability rating in excess of 20 percent for osteochondritis dissecans, lateral femoral condyle, left knee, with degenerative joint disease. 4. Entitlement to an initial disability rating in excess of 10 percent for left knee instability. 5. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the right knee. 6. Entitlement to a total disability rating, for compensation purposes, based on individual unemployability (TDIU) for the interval from February 15, 2001 to January 27, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from July 1976 to August 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied service connection for right knee and low back disorders as well as an increased rating for a left knee disorder. The Veteran provided testimony before an RO hearing officer in June 2003. A transcript of that hearing is associated with the claims file. In April 2007, the Board denied the Veteran's claims of service connection for right knee and low back disorders as well as an increased rating for the left knee disorder. He appealed to the United States Court of Appeals for Veterans Claims (Court). A May 2008 Order approved a Joint Motion for Remand (May 2008 Joint Motion) vacating the April 2007 Board decision. The Board in August 2008 issued a remand consistent with the directives of the May 2008 Joint Motion. In an April 2010 rating decision, the Appeals Management Center (AMC) granted service connection for left knee instability and assigned a 10 percent initial evaluation for that disorder effective from February 3, 2009; and granted service connection for right knee degenerative joint disease and assigned a 10 percent initial evaluation for that disorder effective from January 15, 2001. In a May 2010 rating decision, the AMC granted service connection for myofascial pain syndrome of the paraspinal muscles of the back and assigning a 10 percent initial rating for that disorder effective from February 15, 2001. At the same time, the AMC denied service connection for hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4 and facet joints at L4-L5. Also in the May 2010 decision, the AMC corrected the assigned effective date for service connection for right knee degenerative joint disease to February 15, 2001. In May 2011, the Board remanded claims for higher initial ratings for left knee instability, right knee arthritis, and myofascial strain of the paraspinal muscles of the back as well as the appealed claim (for an increased rating for osteochondritis dissecans, lateral femoral condyle, left knee, with degenerative joint disease. The Board also then recognized the implicated claim for TDIU including due to the service-connected disabilities the subject of appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (a TDIU claim is part of an increased rating claim when the issue incapacity for substantially gainful employment due to claimed disabilities is raised by the record). At the same time, in May 2011, the Board reopened and denied the claim for service connection for hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4, and facet joints at L4-L5. However, the Veteran appealed that denial and the Court by a March 2012 Order approved a Joint Motion for Remand (March 2012 Joint Motion) vacating that Board denial and remanding the case for action consistent with the March 2012 Joint Motion. By a signed November 2011 submission the Veteran withdrew a prior request for a Board videoconference hearing. In a December 2011 rating decision, the RO granted a 40 percent initial rating for myofascial strain of the paraspinal muscles of the back effective from the February 15, 2001. Also by that December 2011 rating action the RO granted TDIU effective from January 28, 2008. The Veteran by a VA Form 9 submitted in December 2011 perfected his appeal of his claims for higher initial ratings for left knee instability, right knee arthritis, and myofascial strain of the paraspinal muscles of the back, and for TDIU. Because the Veteran has only been granted TDIU effective from January 28, 2008, and his appealed increased rating claims giving rise to the TDIU claim date as far back as February 15, 2001, the issue of entitlement to TDIU for the interval from February 15, 2001 to January 28, 2008 remains on appeal. In August 2012, the Board remanded all issues for further development. As development has been completed, these matters are once again before the Board. The RO in Milwaukee, Wisconsin, currently has jurisdiction over the Veteran's VA claims folder. In a March 2013 rating decision, the RO proposed to discontinue entitlement to TDIU. In July 2013, the RO decided to continue a TDIU. The issue of entitlement to a TDIU for the appeal period from February 15, 2001 to January 28, 2008 is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4, and facet joints at L4-L5 was not manifested during the Veteran's active duty service, within the first post service year, or was not otherwise related to such service, and was not causally related to or aggravated by the Veteran's service-connected lumbar spine disability. 2. Throughout the appeal period, the Veteran's myofascial strain of the paraspinal muscles of the back has been manifested by pain and severe limitation of motion or forward flexion of 30 degrees or less; unfavorable ankylosis or intervertebral disc syndrome have not been shown. 3. The Veteran's left knee disability is manifested by a moderate disability with extension limited to not more than 10 degrees; a marked left knee or ankle disability, flexion limited to 45 degrees or less, or ankylosis have not been not shown. 4. Prior to February 3, 2009, the service-connected left knee disability was not manifested by recurrent subluxation or lateral instability. 5. From February 3, 2009, the service-connected left knee disability is manifested by mild instability. 6. Prior to December 7, 2012, the Veteran's left knee scar is superficial, measures 1 inch by .25 inch, is not tender or painful on examination, is not poorly nourished and does not produce any impairment of function. 7. From December 7, 2012, the Veteran's left knee scar is painful, unstable, and exceeds an area of 6 square inches (39 sq. cm); limitation of function or an area exceeding 12 square inches (465 sq. cm.) has not been shown. 8. The Veteran's right knee disability is manifested by a slight disability; a moderate right knee or ankle disability, extension limited to 10 degrees or more, flexion limited to 45 degrees or less, or ankylosis have not been not shown. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4, and facet joints at L4-L5 have not been met. 38 U.S.C.A. §§ 1101, 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for an initial disability rating in excess of 40 percent for myofascial strain of the paraspinal muscles of the back have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.71a, Diagnostic Codes 5289, 5292, 5293, 5295 (as effective prior to September 23, 2002); Diagnostic Code 5293 (as effective prior to September 26, 2003); Diagnostic Codes 5235-5243 (2012). 3. The criteria for a disability rating in excess of 20 percent for osteochondritis dissecans, lateral femoral condyle, left knee, with degenerative joint disease have not been met. 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256, 5258, 5259, 5260, 5261 (2012). 4. The criteria for a compensable rating for left knee instability prior to February 3, 2009, and a rating in excess of 10 percent from that date, have not been met. 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2012). 5. Prior to December 7, 2012, the criteria for a separate compensable rating for left knee scars have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 4.118, Diagnostic Codes (Codes) 7803, 7804, 7805 (in effect prior to August 30, 2002); Codes 7801-7805 (in effect from August 30, 2002). 6. From December 7, 2012, the criteria for a separate 10 percent disability rating, but no higher, for left knee scars have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. § 4.118, Diagnostic Codes (Codes) 7803, 7804, 7805 (in effect prior to August 30, 2002); Codes 7801-7805 (in effect from August 30, 2002). 7. The criteria for a rating in excess of 10 percent for degenerative joint disease of the right knee have not been met. 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5256, 5258, 5259, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In regards to service connection for hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4, and facet joints at L4-L5 (hereinafter degenerative disc disease/degenerative joint disease (DDD/DJD) of the lumbar spine). In February and June 2001 letters (prior to the initial adjudication of the claim) as well as November 2003, and March 2004, April 2008, and November 2009 letters, VA informed the Veteran of the evidence and information necessary to substantiate the claim, the information required of him to enable VA to obtain evidence in support of the claim, the assistance that VA would provide to obtain evidence and information in support of the claim, and the evidence that he should submit if he did not desire VA to obtain such evidence on her behalf. The April 2008 letter provided additional notice regarding disability ratings and effective dates of awards. The claim was readjudicated in August 2010 and February 2013 supplemental statements of the case (SSOC). 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) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). 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, 1277 (2009). In November 2003, November 2009, and July 2011 the RO notified the Veteran of the evidence needed to substantiate his claims for increased ratings for his service connected bilateral knee and back disabilities. This letters also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran has substantiated his status as a Veteran. He was notified of all other elements of the Dingess notice, including the disability-rating and effective-date elements of his claims, in the July 2011 letter. The claims were readjudicated in a February 2013 SSOC. See Mayfield, supra; see also Prickett, supra. The Veteran is represented and has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained service treatment records all of the identified VA and private treatment records as well as records considered in the Veteran's claim for Social Security Administration (SSA) disability benefits. The Veteran was afforded multiple VA examinations to determine whether his hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine was related to service and to assess the severity of his service-connected myofascial strain of the paraspinal muscles, and bilateral knee disabilities and such are found to be adequate, as the examiner reviewed the record and accurately reported the Veteran's history, along with all pertinent current findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Cf. Stegall v. West, 11 Vet App 268 (1998). In a February 2013 statement, the Veteran indicated that he was not seen by a physician with specialist knowledge in disabilities of the spine as requested in the August 2012 Board remand. However, a notation dated in January 2013, on the November 2012 VA examination report, stated that the VA examiner was a physician who specialized in physical medicine and rehabilitation, which was a specialty that dealt intensively with the spine and spinal cord issues. The Appeals Management Center thereby complied with these remand instructions. Cf. Stegall, supra. The Veteran has not reported and the evidence does not otherwise reflect any outstanding medical evidence. A review of Virtual VA does not reveal any additional documents pertinent to the present appeal. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. II. Service Connection for DDD/DJD of the Lumbar Spine The Veteran seeks service connection for degenerative disc disease of the lumbar spine. Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). The Veteran's service treatment records reveal that no spine abnormalities were noted when he was examined for service in June 1976. In September 1976, he complained of having low back pain after falling. In November 1976, he complained of having had back pain for the past 6 weeks. He also reported that he would get stiff after physical training or any prolonged period of standing. He also complained of chronic chest pain and difficulty breathing. There were no abnormal findings. A back strain was diagnosed. There was a normal range of motion and no abnormal curvature. Medication, heat and liniment were recommended. He was seen several times in November 1976 for his back complaints. A note dated in December 1976 shows the Veteran reported having had a back ache in the lumbar region since basic training. His back had good alignment. There was no edema or erythema. There was tenderness in the lumbar region. There were no further back complaints in service. The report of the separation examination is not in the file. Despite the numerous complaints of low back pain, the service treatment records are absent a diagnosis of degenerative disc disease, degenerative joint disease, or arthritis during service. As noted above, the Veteran's low back pain was assessed as a back strain. Service connection for myofascial pain syndrome of the paraspinal muscles of the back was granted effective from February 15, 2001. As for statutory presumptions, service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1112, 1131 and 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). Arthritis can be service-connected on such a basis. The Board notes that the Veteran has been diagnosed with DDD/DJD affecting the lumbar vertebrae and intervertebral disks. However, there is no evidence of arthritis within the year following the Veteran's discharge from service. Although the Veteran was examined by VA in September 1979, he was diagnosed with a history of traumatic injury, lower back with no objective evidence of orthopedic residuals, attributable to said injury found at this time, periodically mildly symptomatic. An X-ray study of the lumbosacral spine showed no abnormality. Therefore, service connection on a presumptive basis is not warranted. When a disease is first diagnosed after service, service connection can still be granted for that condition if the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). Under 38 C.F.R. § 3.310(b), secondary service connection may be warranted for disabilities aggravated by a service connected disability. Briefly, the Board observes that the Veteran filed his claim prior to October 10, 2006, and the revised criteria of establishing a baseline prior to aggravation is not applicable as it has retroactive effects. Allen v. Brown, 7 Vet. App. 439 (1995); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Rodriguez v. Peake, 511 F.3d 1147 (Fed. Cir. 2008);71 Fed. Reg. 52,744-52,747 (2006) (codified at 38 C.F.R. § 3.310 (2012)); VAOPGCPREC 7-2003. In Allen, the Court held that the term "disability", as used in 38 U.S.C.A. § 1110, refers to impairment of earning capacity and that such definition mandates that any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, shall be service-connected. Thus, pursuant to 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.310(a), when aggravation of a Veteran's nonservice-connected disorder is proximately due to or the result of a service-connected disability, such Veteran shall be compensated for the degree of disability, but only that degree over and above the degree of disability existing prior to the aggravation. In this case, the appellant clearly has a current disability; the Veteran has been diagnosed with mild to moderate hypertrophic degenerative disease involving lateral vertebral body margins at L2-3 and L3-4 and facet joints as L4-5; lumbosacral degenerative joint disease and disc disease with left L4 radiculopathy. The remaining question, therefore, is whether there is medical evidence of a relationship between the current disability and military service or between the current disability and a service-connected disability. On review of the claims file, there is no competent medical evidence linking any lumbar spine disorder to active service or a service-connected disability. On October 2001 VA joints examination, the examiner stated that there was no evidence of a significant change in the Veteran's gait that would affect his low back. Therefore, the examiner opined that it was unlikely that the left knee condition caused or significantly aggravated his back condition. The examiner added that the mild degenerative changes in the Veteran's back should be considered a result of aging. On February 2009 VA examination, the examiner opined that the Veteran's back disorder was not secondary to his left knee disability. The examiner opined that the Veteran's degenerative changes and radiculopathy were more likely than not related to an injury to the back and aging rather than from the left knee disability and less likely than not related to service. The examiner noted that the Veteran had further back injuries post service. The Veteran's radiating discomfort did not occur until the past few years and the Veteran reported that he did not have radiation of pain to the lower extremities in service. Therefore, the examiner opined that the diagnosis of degenerative changes with radiculopathy was not related to service. A VA examiner opined, in November 2012, that the Veteran's degenerative disease of the lumbar spine was not caused by or permanently aggravated by the service connected conditions of the knees, myofascial strain, left toe arthritis or a scar about the right foot. The examiner reasoned that the right foot scar was not visible and that the left toe arthritis did not alter gait or cause stress to the spine. The examiner stated that the Veteran's myofascial strain did not cause or aggravate the lumbar spine degenerative disease. The examiner reasoned that the myofascial strain in addition to the degenerative changes limited movement of the spine, but did not place additional stress to the spine. While the Veteran's gait was altered by knee condition, in the examiner's opinion, this caused additional stress to the paraspinal muscles temporarily aggravating the strain, however the Veteran was limited in ambulation and this did not cause permanent aggravation to myofascial strain. The examiner stated that there was no significant stress by limited altered gait to cause or permanently aggravate degenerative disease of the lumbar spine. Although VA treatment records showed treatment in the pain clinic for back pain, for which the Veteran noted was aggravated by standing or walking for prolonged periods, the records did not show that the Veteran's DDD/DJD was related to service or a service-connected disability. The Board has considered the Veteran's beliefs that his current DDD/DJD of the lumbar spine is related to service or to a service-connected disability. In this regard, the Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. During his June 2003 hearing, the Veteran testified that clinicians at a VA medical facility had informed him that the disability was secondary to his service-connected left knee disorder. However, no such opinion appears in the medical records assembled for the Board's review. Moreover, the Court has held that a lay person's account of what a medical professional purportedly said is simply too attenuated and inherently unreliable to constitute medical evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995). Thus, this testimony is not entitled to probative value in the instant case. While the file lacks competent evidence relating current DDD/DJD of the lumbar spine disorder to active service, the Board notes that service connection could still be established on a direct basis upon a showing of continuity of symptomatology. On this point, the Board finds it significant that the first post-service documentation of back stiffness since an in-service injury was in September 1979, however, on examination, the Veteran had normal walking and posture. The examiner found nothing orthopedically significant. The back had a full, normal range of motion with curvatures preserved. The muscles were symmetrical, strong and of normal tone. Straight leg raising was negative. The diagnosis was history of traumatic injury, lower back with no objective evidence of orthopedic residuals, attributable to said injury found at this time, periodically mildly symptomatic. X-rays of the lumbosacral spine showed no abnormality. It was not until October 2001, that x-rays showed mild degenerative changes in the lumbosacral spine, approximately 22 years post service. Thus there is no supporting medical evidence of a continuity of pertinent symptomatology based on documented treatment. In this regard, a lengthy period without evidence of treatment (for DDD/DJD of the lumbar spine) may also be viewed as evidence weighing against the Veteran's claim. See generally Maxson v. Gober, 230 F.3d 1330 (Fed.Cir. 2000). However, the absence of contemporaneous medical evidence does not in itself preclude a grant of service connection. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Indeed, the Veteran's own statements that his lay-observable symptomatology has been continuous can overcome an absence of medical evidence showing such continuity. Regardless, although the appellant reports continuity of post-service symptoms, the Board finds his allegations to be of no probative value because they lack credibility. During his October 2001 VA examination, the Veteran did not suggest that he had continuous back pain since service. Rather, it was not until the February 2009 VA examination, that the Veteran reported that he had low back pain since service. More significantly, on the February 2009 VA examination, the examiner noted that the Veteran had further back injuries post service. The examiner reported that the Veteran's radiating discomfort did not occur until the past few years and the Veteran reported that he did not have radiation of pain to the lower extremities in service. Based on the Veteran's reported history, the examiner opined that the diagnosis of degenerative changes with radiculopathy was not related to service. Having said that, one must also keep in mind that the Veteran's back pain, which he has complained about as a residual of an in-service injury, already has been conceded to be a consequence with the granting of service connection for myofascial strain of the paraspinal muscles of the back. And he resultantly already is receiving compensation for this consequent disability, currently at the 40-percent level. In conclusion, a preponderance of the evidence is against the claim for service connection for hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4, and facet joints at L4-L5 under a direct and secondary basis. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). III. Increased Rating Legal Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2012). However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2012). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected knee and back disabilities are deemed competent evidence. However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria in order to assess their credibility. The Court has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. The Court has recently held that 'pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain may result in functional loss, but only if it limits the ability 'to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance.' Id., quoting 38 C.F.R. § 4.40. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A disability may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1 (2012). Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). A. Myofascial Strain of the Paraspinal Muscles of the Back At the outset, it is noteworthy that the portion of VA's Ratings Schedule pertaining to evaluation of diseases and injuries of the spine has changed twice, effective on September 23, 2002, and on September 26, 2003. See 38 C.F.R. § 4.71a (Diagnostic Codes 5285-95) (2002); 38 C.F.R. § 4.71a (Diagnostic Code 5293) (2003); 38 C.F.R. § 4.71a (Diagnostic Codes 5235, 5236, 5237, 5238, 5239, 5240, 5241, 5242, 5243) (2012). VA's General Counsel has held that, where a law or regulation changes during the pendency of a claim for an increased rating, VA should first determine whether the revised version is more favorable to the Veteran. In so doing, it may be necessary for VA to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, however, the retroactive reach of the new regulation under 38 U.S.C.A. § 5110(g) can be no earlier than the effective date of the change. See VAOPGCPREC 3-2000 (Apr. 10, 2000); see also 38 C.F.R. § 3.114. The Board notes that a readjustment in the rating schedule may not be used to reduce a Veteran's disability rating unless an improvement in the disability is shown to have occurred. 38 U.S.C.A. § 1155. As an initial matter, the Veteran has not been diagnosed with intervertebral disc syndrome. On October 2012 VA examination, the examiner specifically found that the Veteran did not have intervertebral disc syndrome. Therefore, he is not shown to have pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. Additionally, he is not shown to have "incapacitating episodes" as defined as DC 5293 from September 23, 2002 until September 26, 2003 and DC 5243 from September 26, 2003 to warrant a higher 60 percent evaluation. On February 2009 VA examination, the Veteran reported that he had not been placed on bedrest within the past year. Under the criteria in effect prior to September 26, 2003, lumbosacral strain was evaluated under 38 C.F.R. § 4.71a, Code 5295 (2003). Lumbosacral strain warrants a 40 percent rating for severe lumbosacral strain with listing of the whole spine to the opposite side; positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Code 5295 (2003). Under the criteria in effect prior to September 26, 2003, limitation of motion of the lumbar spine warrants a 40 percent rating if it is severe. 38 C.F.R. § 4.71a, Code 5292 (2003). Under the criteria in effect prior to September 26, 2003, ankylosis of the lumbar spine warrants a 40 percent evaluation if it is favorable or a 50 percent evaluation if unfavorable. 38 C.F.R. § 4.71a, Code 5289 (2003). Complete bony fixation (ankylosis) of the spine at an unfavorable angle with marked deformity and ankylosis of major joints or without other joint involvement warrants a 100 percent rating. 38 C.F.R. § 4.71a, Code 5286 (2003). Under the general rating formula for rating diseases and injuries of the spine, effective September 26, 2003, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. There are several notes set out after the diagnostic criteria, which provide the following: First, associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 140 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurological disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Note five provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Note six provides that disabilities of the thoracolumbar and cervical spine segments shall be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 On review of the evidence of record, the Board finds that the criteria for an evaluation in excess of 40 percent the Veteran's service-connected myofascial strain have not been met. On October 2001 VA joints examination, flexion to 90 degrees, lateral flexion to 25 degrees, bilaterally, and extension to 20 degrees. He had complaints of pain with motion of the back and with palpation of the back. There was no evidence of tightness or spasm in the paraspinal musculature. Functionally, he was able to reach down to the floor easily and grab a newspaper off of the floor without complaints of pain. VA treatment records show ongoing complaints of back pain since 2001, with periods of increased pain and stiffness noted. The Veteran underwent physical therapy for the back in 2002 and 2003. The records show limitation of lateral flexion and rotation to fifty percent of normal in March 2002 and June 2003. On February 2009 VA examination, physical examination did not reveal any muscle atrophy or ankylosis of the thoracolumbar spine. There was evidence of spasm and tenderness with light palpation diffusely through the lumbar paraspinal muscles as well as the trigger points. The trigger points radiated pain locally and not distal to the lower extremity. There was objective evidence of painful motion of the lumbosacral spine; however, there was no evidence of additional limitation of joint function or range of motion after repetitive movement. Range of motion testing revealed that extension was to 5 degrees, left and right lateral flexion was to 20 degrees, and left and right rotation was to 10 degrees. The examiner noted that the Veteran reported pain with lateral flexion. The combined range of motion and forward flexion were not able to be calculated as the Veteran reported that he was not able to forward flex and he did not do this because he stated that it increased his back symptoms. On July 2011 VA general examination, the Veteran was unable to do rotation secondary to subjective back pain and was unwilling to do forward flexion secondary to subjective pain. An additional VA examination was conducted in August 2011. At the examination, the Veteran described continued low back pain with muscle spasms. He reported that during muscle spasms, he had difficulty with reaching to open the door to his refrigerator or his apartment. Muscle spasm occurred three times a week. During spasms, his back froze up. He reported generalized stiffness of the back, weakness, and limited motion. No bowel or bladder complaints were reported. He felt unsteady due to his knee and back and could walk half of a block. He did not have any hospitalizations or surgery for his back. He reported that he was assisted for lower body dressing/putting on shoes due to his back condition. On physical examination, his stance/posture was lateral bending to the left. He supported his weight on his cane and forward flexed posture of 10 degrees. When extending the spine, he stood with 5 degrees of flexion. He reported that he was not able to move forward or backwards due to pain and therefore no flexion or extension range of motion testing was performed. Lateral motion was to 10 degrees on each side times three, with the Veteran reporting low back pain as limiting. Rotation was to 15 degrees to the left and 20 degrees to the right with the Veteran reporting low back pain as limiting. These motions were maintained times three. The examiner indicated that the Veteran's range of motion was limited by pain. He had lower extremity weakness due to knee and toe condition. There was tenderness on palpation to both the central and paraspinal muscles, bilaterally. There was mild spasm. Asymmetric posture was present. There was no asymmetry due to muscle spasm, but rather by the Veteran supporting his weight on the cane due to the left knee condition. He had forward flexed posture between 5 to 10 degrees. On October 2012 VA examination, the Veteran reported that in the past year, he needed more help from his son and used a walker more due to his back condition. He indicated the he used ibuprofen and heat, which temporarily provided relief. He described flare-ups, noting that sitting caused stiffness and pain. On physical examination, flexion was limited to 20 degrees with pain at 20 degrees, extension was limited to 5 degrees with pain at 5 degrees, right lateral flexion was limited to 15 degrees with pain at 10 degrees, left lateral flexion was limited to 0 degrees with no objective evidence of pain, and rotation was limited to 0 degrees with no objective evidence of pain, bilaterally. The examiner indicated that the Veteran was able to repeat flexion, extension, and lateral bending twice, with pain limiting further attempts. He did not attempt repeated repetition due to increased pain, and requested to stop range of motion testing. The examiner noted functional loss due to less movement than normal, pain on movement and interference with sitting, standing, and/or weight bearing. There was tenderness to palpation of the left sacroiliac joint and paraspinal muscles, with the left trigger points radiating tingling to the left lower extremity. The Veteran had guarding or muscle spasm of the thoracolumbar spine that resulted in abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. The examiner indicated that the Veteran used a brace and a walker for both knee and back conditions. The Veteran did not have intervertebral disc syndrome. The examiner identified tenderness to the left sacroiliac joint. The Veteran did not have a vertebral fracture. The examiner continued the diagnosis of myofascial strain and indicated that the condition would not impact the Veteran's ability to work. In November 2012, the VA examiner opined that the Veteran's myofascial strain in addition to the degenerative changes limited movement of the spine and did not place additional stress to the spine. While the veteran's gait is altered by knee condition in the examiner's opinion this caused additional stress to the paraspinal muscles temporarily aggravating strain, however he was limited in ambulation and this did not cause permanent aggravation to myofascial strain. Service connection has not been granted for degenerative changes of the lumbar spine and has been denied herein. However, to the extent supported by the evidence of record, the Board will consider and discuss symptoms attributable to the Veteran's service-connected myofascial strain, and include overlapping degenerative changes of the lumbar spine symptoms that have not been specifically disassociated from the Veteran's myofascial strain. See Mittleider v. Brown, 11 Vet App 181 (1998) (standing for the proposition that where non-service-connected symptoms cannot be separated from service-connected symptoms, all of the symptoms are treated as service-connected). In that regard, on February 2009 VA examination, the examiner noted that the Veteran's symptoms related to lumbosacral pain, stiffness, and limited range of motion were attributable to both the non-service connected lumbosacral degenerative joint disease and disc disease with left L4 radiculopathy and the service connected myofascial strain of the paraspinal muscles of the back. The Veteran's symptoms of diffuse tenderness of the paraspinal muscles as well as the trigger points were noted to be due to his service connected myofascial strain. Symptoms relating to radiculopathy, sharp radiating pain to the left lower extremity, weakness of the left lower extremity, and positive straight leg raise were attributed to the non-service connected lumbosacral degenerative joint disease and disc disease with left L4 radiculopathy. On August 2011 VA examination, the examiner stated that the Veteran's nonservice-connected lumbar spine degenerative changes also contributed to limitation in sitting and walking tolerance, however, the paraspinal muscles would limited prolonged sitting, which would be required in a sedentary position of employment. The Veteran took Tylenol #3 for his knees and back, which had sedating side effects and limited him from driving. The examiner opined that the muscle spasms and tenderness were related to the myofascial strain, while the central low back pain and limited range of motion are related to the non-service connected degenerative disease. In a September 2011 addendum, the VA examiner stated that based on her review of the August 2011 VA examination, it was her opinion that the Veteran's reported symptoms of muscle spasms and examination findings of tenderness and mild spasm of the lumbar paraspinal muscles were related to the condition of myofascial strain. Symptoms related to the diagnosis of DJD/degenerative disc disease (DDD) were central low back pain and pain radiating to the lower extremities and limited range of motion of the lumbar spine on examination. As the limited range of motion was attributable to both the non-service connected lumbosacral degenerative joint disease and disc disease with left L4 radiculopathy and the service connected myofascial strain of the paraspinal muscles of the Veteran was entitled to the maximum schedular rating for loss of range of motion under the "old" and "new" criteria (Codes 5292, 5237, 5242, and 5243). Even considering any complaints of weakness, fatigability, or loss of function due to pain, a higher disability may not be assigned. See Johnston v. Brown, 10 Vet. App. 80 (1997) (if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable). Also, x-rays demonstrated that there was no vertebral fracture to warrant an extra 10 percent rating for demonstrable deformity of a vertebral body from fracture. As a 40 percent rating is the maximum rating for chronic lumbosacral strain under the "old" criteria (Code 5295), consideration of this Code would provide no greater benefit to the Veteran. As the Veteran is not entitled a rating for intervertebral disc syndrome, therefore, the only means by which a higher rating could be assigned would be if there is evidence unfavorable ankylosis of the entire thoracolumbar spine. The Board acknowledges that on February 2009 VA examination, the Veteran reported that he was not able to forward flex because of his back symptoms. On July 2011 VA general examination, the Veteran was unable to do rotation secondary to subjective back pain and was unwilling to do forward flexion secondary to subjective pain. On August 2011 VA examination, he had forward flexed posture between 5 to 10 degrees. He reported that he was not able to move forward or backwards due to pain and therefore no flexion or extension range of motion testing was performed. The Board has considered whether a rating higher than 40 percent is warranted, but finds that unfavorable ankylosis of the thoracolumbar spine or the entire spine is neither shown nor more nearly approximated than favorable ankylosis of the thoracolumbar spine for any period. Regarding the attributes of unfavorable ankylosis set out above, although a segment of the thoracolumbar spine is fixed in flexion, the entire thoracolumbar spine is not fixed in flexion. Ankylosis is immobility and consolidation of a joint due to disease, injury, surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465(1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Moreover, the ankylosis of a segment of the spine does not result in difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching. The clinical evidence does not demonstrate such symptoms, and the Veteran does not assert that he has such symptoms. A higher disability evaluation under the "old" Diagnostic Code 5289 or "new" Diagnostic Code 5240 would therefore be inappropriate The Board has also considered the Veteran's statements that his disability is worse than the 40 percent rating he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is not, however, competent to identify a specific level of disability of his low back disability according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's myofascial strain has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and clinical records) directly address the criteria under which this disability is evaluated. There being no other potentially applicable Diagnostic Codes, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 40 percent for his service-connected lumbar spine. As such, the preponderance of the evidence is unfavorable. B. Left Knee Disabilities The record reflects that a November 1979 rating decision granted service connection for a left knee osteochondritis dissecans, lateral femoral condyle and assigned a 10 percent disability rating under Diagnostic Codes 5099-5003, effective August 2, 1979. In September 2000, the Veteran filed a claim for an increased rating for the left knee and a January 2001 rating decision, increased the assigned rating to 20 percent disabling, effective June 30, 2000, under Diagnostic Codes 5003-5262. In a May 2001 rating decision, the RO granted an earlier effective date of January 18, 2000 for the assignment of the 20 percent disability rating. A June 2002 rating decision continued the 20 percent rating under Diagnostic Codes 5010-5262. The Veteran disagreed and subsequently perfected this appeal. Furthermore, in an April 2010 rating decision, the AMC assigned a separate 10 percent disability rating Diagnostic Code 5257 for left knee instability, effective February 3, 2009, which is also currently on appeal. Regulations provide that, when the disability being rated is not specifically provided for in the rating schedule, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Further, the provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and "99." Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. In regards to the Veteran's disability rating under Diagnostic Codes 5003 and 5010, disabilities associated with traumatic arthritis are evaluated under Diagnostic Code 5010. Further, the Schedule for Rating Disabilities directs that disabilities involving traumatic arthritis are to be evaluated as degenerative arthritis under Diagnostic Code 5003. See 38 C.F.R. § 4.71a. Degenerative arthritis established by X- ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (which in this case would be Diagnostic Codes 5260 (limitation of flexion of the leg) and 5261 (limitation of extension of the leg).). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, however, arthritis is rated as 10 percent disabling when shown by x-ray evidence of the involvement of two or more major joint or two or more minor joint groups, or as 20 percent disabling when shown by x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Diagnostic Code 5260 provides for a zero percent evaluation where flexion of the leg is limited to 60 degrees. For a 10 percent evaluation, flexion must be limited to 45 degrees. A 20 percent evaluation is warranted where flexion is limited to 30 degrees. A 30 percent evaluation may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent evaluation where extension of the leg is limited to 5 degrees. A 10 percent evaluation requires extension limited to 10 degrees. A 20 percent evaluation is warranted where extension is limited to 15 degrees. A 30 percent evaluation may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent evaluation, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees a 50 percent evaluation may be assigned. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The Board notes that separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. The Veteran's current 20 percent disability rating has been evaluated, in part, as being analogous to for malunion of the tibia and fibula with moderate disability of the knee under Diagnostic Code 5262. In order to warrant a higher rating under this code a marked left knee or ankle disability would be necessary. On reviewing the evidence, on October 2001 VA examination, the examiner noted that X-rays were obtained of both knees in August 2000, which revealed minor degenerative changes. Both the October 2001 and April 2004 VA examiners noted that the veteran's gait was normal. The October 2001 examiner found no evidence of swelling, effusion, or erythema. The Veteran was able to get up from the examining chair without evidence of weakness or disability. He ambulated comfortably and there was no significant asymmetry noted in his gait. However, the Veteran had complaints of pain over the lateral joint line on the left knee. The examiner reported the neurological testing failed to reveal any evidence of weakness. Deep tendon reflexes were equal and symmetrical in the lower extremities. The Veteran complained of pain when he attempted to walk on his feet and toes; he was able to do minimal walking on his heels. Vocationally, he reported that was able to stand for up to seven to eight hours of work. He worked on an assembly line and was required to work up to 11 hours. He reported that as he was unable to tolerate the last couple of hours of work, he stopped working altogether. He felt that he would have been able to continue to work if he was limited to standing seven to eight hours a day. On April 2004 VA examination, the Veteran reported that his knee locked-up or was stiff. On examination, there was no recurrent dislocation, inflammatory arthritis, or constitutional symptoms. Deep tendon reflexes were 2+, with sensation intact. On February 2009 VA examination, the Veteran described weakness, stiffness, and swelling of the knee. There was occasional warmth and redness in the left knee. On examination, there was tenderness with light palpation along the medial and lateral joint line. Strength was decreased to 3/5 in extension and to 4/5 in flexion. Due to the left knee condition, the Veteran shifted his weight over the right knee. His gait was antalgic and slow with cane in right hand. He reported that he last worked in 2009 and had difficulty driving his forklift due to the amount of time he stood along with increased weight on his knee, which was painful. The examiner opined that the left knee condition did not require frequent hospitalization, noting a history of hospitalization once for three days because of knee surgery. The examiner further opined that because of the left knee, the Veteran was limited to sedentary occupations, as he was not able to participate in prolonged standing or walking. He used a cane to ambulate and therefore was unable to carry items. He could not bend or climb. He could pursue only sedentary activity related to the left knee condition. The examiner noted that the Veteran took Motrin for his left knee, which did not limit employment. In a December 2009 medical opinion regarding the Veteran's physical capacity for work, the physician reported that the Veteran could participate in full-time sedentary work. The examiner indicated that the Veteran's knee and back conditions would likely result in the Veteran being absent from work due to impairment or treatment two days per month. On August 2011 VA examination, the Veteran described continuing problems with bilateral knee pain, weakness, stiffness, and instability. The examiner reported that there were no incapacitating exacerbations that required prescribed bedrest noted in the record. There also were no noted constitutional symptoms. On physical examination of the left knee, there was tenderness to palpation at the distal patella and mediolateral joint line. There was mild effusion. Strength was decreased to 3/5. The knee condition affected the Veteran's daily activities in that he was limited to standing 10 to 15 minutes at a time and could only walk half a block. He did not go up and down stairs. The examiner found that due to a combination of the impairments caused by the Veteran's knee and back disabilities, he was not capable of gainful employment. VA treatment records showed ongoing treatment for left knee pain. In May 2003, the Veteran was seen for complaints of pain and a buckling and locking sensation for the past six months in his left knee. He had full range of motion in both knees. In January 2010, a corticosteroid injection was performed on the left knee. August 2010 radiographs of the knees revealed osteoarthritis and small suprapatellar effusion of the left knee and negative findings on the right knee. An April 2011 MRI showed increasing tricompartmental degenerative changes, now moderate; new tear of the lateral meniscus; progression of cartilage loss of the patellofemoral joint(with now near complete absence involving the mid lateral facet with severe thinking elsewhere), the medial joint space compartment (mid thinning of the tibial plateau), and the lateral joint space compartment (near complete loss of cartilage of the posterior femoral condyle and tibial plateaus); increasing joint effusions; new mild sprain of the MCL; and mild tendonosis at the insertion of the patellar tendon. Treatment records dated in November 2011 indicated that the Veteran was eligible for a left total knee replacement surgery; however, in June 2012, he reported that swimming improved his knee motion. He planned to consider surgery again in 2013. See November 2011 VA treatment records and November 2012 VA examination report. To date, there was no evidence that the Veteran had this procedure. Records associated with the award of Social Security Administration (SSA) disability benefits showed that the Veteran was found disabled for SSA purposes due to both his back and knee conditions. On December 2012 VA examination, the Veteran was diagnosed with osteochondritis desiccans, lateral femoral condyle, DJD and instability of the left knee and DJD of the right knee. The Veteran reported that he had flare-ups that impacted the function of the knee and/or lower leg. There was tenderness to palpation and strength was reduced in knee flexion (3/5) and extension (3/5). The examiner noted a history of left knee meniscectomy and meniscal tear, with residuals of frequent episodes of joint "locking", pain, and effusion. The medical evidence along with the Veteran's complaints show no more than moderate left knee impairment throughout the appeal period. The left knee osteochondritis dissecans, lateral femoral condyle, with degenerative joint disease causes pain, limitation of motion, an altered gait, decreased strength, limitations in standing, walking, and sitting for long periods of time, an inability to carry items due to use of a cane, the inability to climb steps or ladders, crawl, or bend to the floor. Additionally, the evidence suggests that the Veteran's left knee disability has an impact on the type of employment the Veteran would be able to engage in as well as the number of hours he would be able to work and would likely contribute to him missing work twice a month. Based on consideration of the medical evidence as well as the Veteran's complaints, no more than a moderate left knee disability has been shown and a 20 percent rating is appropriate under DC 5262. At no point has tibia and fibula impairment with a marked knee disability been shown to warrant a higher, 30 percent, disability rating. Based on a review of the medical evidence, the Board acknowledges that the point at which pain began was not reported during range of motion testing on multiple VA examinations; however, as held in Mitchell, pain alone does not rise to the level of functional loss. On October 2001 VA examination, range of motion was from 0 to 120 degrees with significant reports of pain. In regards to functional impairment, the Veteran reported that his right knee locked occasionally, he had increased pain with standing, and difficulty with walking long distances. He took anti-inflammatories for pain. Heat and or sitting down also decreased the pain. On April 2004 VA examination, range of motion was from 0 to 120 degrees. He reported that there was no functional impairment with flare-ups. He was able to perform all activities of daily living, even with his pain. He was able to sit and stand for one hour and able to walk a mile. Moreover, the examiner commented that the Veteran had no functional loss due to the left knee at rest and minimal (less than 5 percent) disability during flares. On February 2009 VA examination, extension was to 5 degrees, which decreased to 10 degrees after repetition. Flexion was to 90 degrees and did not decrease after repetition. The Veteran reported pain with motion. In regards to functional impairment, he reported that he had flare-ups with cold weather and walking. He reported that the knee condition affected his daily activities. On August 2011 VA examination, extension was limited to -5 degrees and flexion was limited to 70 degrees, which did not decrease upon repetition. The Veteran reported pain though all joint range of motion, and motion was done slowly and with hesitation. The examiner noted that pain and weakness limited motion. The knee condition affected the Veteran's daily activities in that he was limited to standing 10 to 15 minutes at a time and walked half a block. He did not go up and down stairs. The Veteran also reported that his knee had lack of endurance with swelling, intermittent redness, and tenderness present at all times. Flare-ups were associated with walking and cold weather, which limited his activity. On December 2012 VA examination, flexion was to 70 degrees with pain at 45 degrees and extension was to 10 degrees with pain at 10 degrees. Range of motion did not change after repetitive motion of the bilateral knees. The examiner noted that the Veteran had functional loss/functional impairment after repetitive use due to decreased movement, weakened movement, pain on movement, swelling, and disturbances in locomotion, bilaterally. The left knee had additional excess fatigability, deformity, and interference with sittings, standing, and weight-bearing. Overall, even considering the Veteran's additional functional loss due to pain, there was no evidence that flexion was limited to 45 degrees to warrant a 10 percent rating under Code 5260. Furthermore, there was no evidence the flexion was limited to 30 or 15 degrees to warrant higher 20 or 30 percent disability ratings, respectively under Diagnostic Code 5260. The most restrictive extension documented was 10 degrees after repetition on February 2009 VA examination and 10 degrees with pain at 10 degrees at the December 2012 VA examination, with no additional limitation of motion after repetition. Therefore, the highest rating warranted based on limitation of extension would be 10 percent under Diagnostic Code 5261. There was no evidence that extension was 15, 20, 30, or 45 degrees to warrant 20, 30 40, 05 50 percent disability ratings, respectively under Diagnostic Code 5261. Additionally, the Board has considered VA treatment records and SSA records and there are no additional functional factors present to serve as a basis for an evaluation in excess of the Veteran's currently assigned 20 percent on the basis of limitation of extension and/or flexion. The Board recognizes the Veteran's statements attesting to his knee pain, stiffness, weakness, lack of endurance, tenderness, redness, and flare-ups. The Board notes that lay persons can attest to observable symptomatology. In addition, the Veteran's statements describing his symptoms are considered to be competent evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), Layno v. Brown, 6 Vet. App. 465, 469 (1994), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). His credibility also is undisputed because no reason is found to doubt him and his statements have been consistent with the evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995); Macarubbo v. Gober, 10 Vet. App. 388 (1997) The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased disability rating for the Veteran's left knee disability is not warranted on the basis of functional loss due to pain in this case as the Veteran's symptoms are supported by pathology consistent with the assigned 20 percent rating, and no higher. The Board observes that the Veteran's competent and credible reports of knee pain, stiffness, weakness, lack of endurance, tenderness, redness, and flare-ups. The Board recognizes that he has had limited range of motion due to pain. Even so, the Board finds that the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish pain, weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased rating based on limitation of motion. Based on ranges of motion referenced above, ankylosis (defined as a fixation of the joint) has neither been alleged nor shown. Therefore, there is no basis for a higher (30 percent) rating under DC 5256. VAOPGCPREC 23-97 held that a claimant who has both arthritis and instability of the knee may receive two separate disability ratings under Diagnostic Codes 5003-5010 and Diagnostic Code 5257 without violating the prohibition of pyramiding of ratings. 38 C.F.R. § 4.14. It was specified that, for a knee disorder already rated under Diagnostic Code 5257, a claimant would have additional disability justifying a separate rating if there is limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261. A the Veteran's current 20 percent disability rating has been assigned under Diagnostic Codes 5003-5262 and a separate 10 percent disability rating has been assigned under Diagnostic Code 5257, effective February 3, 2009, the Board will determine whether or not the Veteran is entitled to a separate disability evaluation prior to February 3, 2009 and an increased disability evaluation from that date. Diagnostic Code 5257 provides ratings for impairment of the knee when there is evidence of slight (10 percent), moderate (20 percent), or severe (30 percent) recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. For the appeal period prior to February 3, 2009, the Board finds that the service-connected left knee disorder was not manifested by recurrent subluxation or lateral instability. For example, the October 2001 VA examiner found that physical examination of the knee revealed no evidence of swelling, effusion, or erythema. The examiner noted that there was no significant crepitus and there was no evidence of significant valgus or varus laxity. McMurray's test was negative. The Veteran had pain with patellar compression. Neurological testing failed to reveal any evidence of weakness. May 2003 VA treatment records showed complaints of pain and a buckling and locking sensation for the past six months in his left knee. On April 2004 VA examination, the Veteran reported that his knee gave way many times, however, the examiner specifically stated that there was no recurrent dislocation, subluxation, inflammatory arthritis, or constitutional symptoms. He did not wear a knee brace. There was evidence of crepitus in the left knee. Lachman's and McMurray's were negative. There was no evidence of varus or valgus in neutral position. His gait was normal. Although the Veteran reported that his knee had a buckling sensation or gave way many times, and crepitus has been found on examination, Lachman's and McMurray's tests were negative, there was no evidence of significant valgus or varus laxity, the Veteran did not wear a knee brace or use a cane, and the VA examiner specifically found that there was no recurrent dislocation, subluxation. Therefore, a separate rating under DC 5257 for instability for the appeal period prior to February 3, 2009 is not warranted. In regards to whether a rating in excess of 10 percent is warranted from February 3, 2009, on February 2009 VA examination, the Veteran reported that he used a cane due to both his left knee and back conditions. Crepitus was noted with motion. There was mild mediolateral instability with pain. There was negative anterior-posterior drawer, and negative McMurray. The knee was in good alignment. On August 2011 VA examination, he had a brace for his left knee and used a cane and a walker. There was mild mediolateral instability, negative drawer, and negative McMurray with limited testing due to the Veteran's joint position. On December 2012 VA examination, there was slight medial-lateral instability of the left knee. For the appeal period from February 3, 2009, the Veteran's left knee disability has been described as mild or slight. As moderate subluxation or instability of the left knee has not been alleged or shown, a rating in excess of 10 percent is not warranted from February 3, 2009 un Diagnostic Code 5257. As Diagnostic Codes 5258 (dislocated semilunar cartilage), 5259 (removal of semilunar cartilage), and 5263(genu recurvatum) include ratings of 20 percent or less, these codes do not need to be addressed during this appeal period as they could not serve as the basis for an increased rating. Finally, the Board has considered whether the Veteran is entitled to a separate compensable rating for his left knee scars. Separate ratings for scars are permitted as long as the rules of pyramiding are not violated. Pyramiding, rating the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14 (2012). A Veteran, however, may be entitled to separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). A claimant should not be compensated twice for the same symptomatology as such a result would overcompensate the claimant for the actual impairment of his earning capacity. Brady v. Brown, 4 Vet. App. 203, 206 (1993). During the pendency of the appeal, VA's Schedule for Rating Disabilities has been revised with respect to the regulations pertaining to evaluations of disorders of the skin. 38 C.F.R. § 4.118 was amended, effective August 30, 2002, and the revised criteria includes criteria for rating non-facial scars, found at Codes 7800 - 7805. 38 C.F.R. § 4.118. Prior to August 30, 2002, consideration of the rating for the Veteran's left knee scar must include Codes 7803 (10 percent for scars that are superficial, poorly nourished with repeated ulceration), 7804 (10 percent for scars that are superficial, tender and painful on objective demonstration), and 7805 (scars rated based on limitation of function of affected part). 38 C.F.R. § 4.118 (in effect prior to August 30 2002). Under the criteria effective August 30, 2002, consideration must be given to Codes: 7801 (for scars -not on head , face, or neck- that are deep and cause limited motion, ranging from 10 to 40 percent, with 10 percent warranted if the area exceeds 6 square inches or 39 sq. cms.); 7802 (for superficial scars that do not cause limited motion, 10 percent if the area exceeds 144 sq, inches or 929 sq. cms); 7803 (10 percent for scars that are superficial, unstable); and 7804 (10 percent for scars that are superficial, painful on examination). 38 C.F.R. § 4.118 (effective August 30, 2002). There were no changes specific to Code 7805, which provides that scars may be rated on the basis of any related limitation of function of the body part which they affect. 38 C.F.R. § 4.118 (in effect prior to and from August 30, 2002). The criteria for rating scars under 38 C.F.R. § 4.118 were revised again effective October 23, 2008. Application of the new criteria is limited to claims filed on or after October 23, 2008. Here, the Veteran's claims were received prior to October 23, 2008, and he has not requested a review under the new criteria. Accordingly, the revised schedular rating criteria are not applicable in this case and those in effect prior to October 23, 2008, must be applied. Prior to the December 7, 2012 VA examination, the Board finds that assignment of an initial compensable rating for the left knee scars is not warranted. In this regard, there is simply no medical evidence indicating that these scars resulted in limitation of function; rather, the August 2011 VA examiner specifically reported that the left knee scars that did not limit function across the knee joint. Thus, the criteria for an initial compensable rating pursuant to Diagnostic Code 7805 are not met. The evidence also does not reflect that the Veteran's left knee scars are poorly nourished, with repeated ulceration. Rather, the scar has been consistently described as a well-healed surgical scar on the medial aspect of his left knee or a well-healed linear scar as well as a small scar less than 1 cm on the left knee. See October 2001, February 2009, and August 2011 VA examination reports. Thus, an initial compensable rating pursuant to Diagnostic Code 7803, as in effect prior to August 30, 2002, is not warranted. This scar has also not been shown to be tender or painful on examination. In this regard, on February 2009 VA examination both left knee scars were nonadherent and nontender with light palpation in the area of the scars. Thus, an initial compensable rating pursuant to Diagnostic Code 7804, as in effect prior to and as revised August 30, 2002, is not warranted. The evidence of record prior to December 7, 2012, also does not demonstrate that the Veteran's left knee scar is deep or causes limited motion and exceeds an area of 6 square inches or is unstable. Thus, the criteria for an initial compensable rating pursuant to Diagnostic Codes 7801, 7802, and 7803, as revised August 30, 2002, are not met. Under these circumstances, the Board finds that the criteria for assignment of an initial compensable rating for the Veteran's left knee scars, prior to December 7, 2012, are not met. On VA examination dated December 7, 2012, the examiner reported that the Veteran had painful and/or unstable scars, or the total area of all related scars was more than 39 square centimeters (6 square inches). The examiner clarified that there was a left knee curved linear scar 12.0 x 1.0 cm intact, nontender, altered sensation along scar. There was also a left knee 2.0 x 0.5 cm linear scar that was intact and nontender. Considering the pertinent evidence of record in light of the noted legal authority above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the record presents a basis to award an initial 10 percent rating for the left knee scars, effective December 7, 2012, under Diagnostic Codes 7801, 7803, and 7804 as revised August 30, 2002. As a 10 percent rating is the maximum evaluation provided under Diagnostic Codes 7802, 7803, and 7804 (as in effect prior and as revised August 30, 2002) the Board turns to other potentially applicable codes. As limitation of function has not been shown a higher rating under DC 7805, as in effect prior and as revised August 30, 2002, is not warranted. Finally as an area exceeding 12 square inches (465 sq. cm), has not been shown a rating under DC 7801 is not warranted. C. Right Knee Disability The record reflects that an April 2010 rating decision granted service connection for right knee degenerative joint disease and assigned a 10 percent disability evaluation under Diagnostic Codes 5260-5003, effective February 3, 2009. Based on a review of the medical evidence, the Board acknowledges that the point at which pain began was not reported during range of motion testing on multiple VA examinations; however, as held in Mitchell, pain alone does not rise to the level of functional loss. On October 2001 VA examination, range of motion on this examination was from 0 to 120 degrees. On April 2004 VA examination, range of motion was from 0 to 140 degrees. The Veteran reported that there was no functional impairment with flare-ups. On February 2009 VA examination, range of motion was from 0 to 110 degrees times three. The Veteran reported pain during the ranges of motion and there was increasing discomfort after the third attempt. On August 2011 VA examination, range of motion was -5 to 90 degrees. There was hesitation and pain during motion, and his motion was at a slower pace on the third repetition. The examiner noted that pain and weakness limited motion. On December 2012 VA examination, the Veteran reported that he had flare-ups that impacted the function of the knee and/or lower leg. His stated that his right knee was worse at times, but he always had severe pain in his left knee. Range of motions studies revealed that the Veteran had flexion to 90 degrees with pain at 45; extension to 5 degrees with pain at 5 degrees of the right knee. The Veteran did not have additional limitation of motion after repetition. The examiner noted that the Veteran had functional loss/functional impairment after repetitive use due to decreased movement, weakened movement, pain on movement, swelling, and disturbances in locomotion. Overall, even considering the Veteran's additional functional loss due to pain, there was no evidence that flexion was limited to 45 degrees to warrant a 10 percent rating under Code 5260. Furthermore, there was no evidence the flexion was limited to 30 or 15 degrees to warrant higher 20 or 30 percent disability ratings, respectively under Diagnostic Code 5260. The most restrictive extension documented was 5 degrees with pain at 5 degrees of the right knee and no additional limitation of motion after repetition on December 2012 VA examination. However, even considering that the Veteran had functional loss/functional impairment after repetitive use due to decreased movement, weakened movement, pain on movement, swelling, and disturbances in locomotion, the highest rating warranted based on limitation of extension would be 0 percent under Diagnostic Code 5261. There was no evidence that extension was 10, 15, 20, 30, or 45 degrees to warrant 10, 20, 30, 40, or 50 percent disability ratings, respectively under Diagnostic Code 5261. Additionally, the Board has considered VA treatment records and SSA records and there are no additional functional factors present to serve as a basis for an evaluation in excess of the Veteran's currently assigned 10 percent on the basis of limitation of extension and/or flexion. Therefore, the Veteran's right knee disability has been appropriately assigned a 10 percent disability rating under Diagnostic Code 5003 on the basis of arthritis with painful limitation of motion that is noncompensable under Diagnostic Codes 5260 and 5261. As there is no x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, a higher, 20 percent, disability rating is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Based on ranges of motion referenced above, ankylosis (defined as a fixation of the joint) is not shown. Therefore, there is no basis for a higher (30 percent) rating under DC 5256. VAOPGCPREC 23-97 held that a claimant who has both arthritis and instability of the knee may receive two separate disability ratings under Diagnostic Codes 5003-5010 and Diagnostic Code 5257 without violating the prohibition of pyramiding of ratings. 38 C.F.R. § 4.14. It was specified that, for a knee disorder already rated under Diagnostic Code 5257, a claimant would have additional disability justifying a separate rating if there is limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261. The Board finds that the service-connected right knee disorder was not manifested by recurrent subluxation or lateral instability. On October 2001 VA examination, there was no evidence of instability of the right knee. While, there was mild crepitus with range of motion, the examiner noted that there was no evidence of significant valgus or varus laxity. Also, McMurray's test was negative. On April 2004 VA examination, the examiner noted that the Veteran did not wear a knee brace. On examination, there was no evidence of varus or valgus in neutral position. Lachman's and McMurray's tests were negative. His gait was normal. On February 2009 VA examination, there was no mediolateral instability. There was negative anterior posterior drawer and McMurray's tests and the right knee was in good alignment. On August 2011 VA examination, here was no evidence of ligament laxity or knee instability and anterior posterior drawer and McMurray tests were negative. Therefore, a separate rating under DC 5257 for instability is not warranted Diagnostic Code 5258 provides a 20 percent rating for dislocation of the semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2012). On October 2001 VA examination, the Veteran reported that his right knee locked occasionally, however, on examination there was no evidence of swelling, effusion, or erythema. On February 2009 VA examination, no edema was noted. On August 2011 VA examination, he also reported that both knees had lack of endurance with swelling, intermittent redness, and tenderness present at all times. While the Veteran has reported pain and locking, and tenderness has been shown on October 2001, February 2009, August 2011, and December 2012 VA examinations, the knee disability is not manifested by most of the symptoms needed for a 20 percent rating under Diagnostic Code 5258. 38 C.F.R. § 4.7, 4.21. Diagnostic Code 5258 provides a 20 percent rating for malunion of the tibia and fibula with a moderate knee or ankle disability. Here, however, the Veteran's right knee disability is no more than slight. On October 2001 VA examination, the examiner noted that X-rays were obtained in August 2000, which revealed minor degenerative changes. The Veteran reported that his right knee locked occasionally. He noted increased pain with standing. Vocationally, he reported that was able to stand for up to seven to eight hours of work. He worked on an assembly line. He was required to work up to 11 hours. He reported that he was unable to tolerate the last couple of hours of work, so he stopped working. He felt that he would have been able to continue to work if he was limited to seven to eight hours of standing a day. He took anti-inflammatories for pain. Heat and or sitting down also decreased the pain. He reported that he had difficulty walking long distances. Physical examination revealed that the Veteran was able to get up from the examining chair without evidence of weakness or disability. He ambulated comfortably and there was no significant asymmetry noted in his gait. Further examination failed to reveal an antalgic gait. There was no evidence of swelling, effusion, or erythema. He also had complaints of tenderness in the joint line, particularly on the medial aspect of the right knee. He had pain with patellar compression, bilaterally. The examiner reported the neurological testing failed to reveal any evidence of weakness. Deep tendon reflexes were equal and symmetrical in the lower extremities. The Veteran complained of pain when he attempted to walk on his feet and toes; he was able to do minimal walking on his heels, bilaterally. On April 2004 VA examination, the Veteran reported that he currently worked full-time with no lost time. On examination, his gait was normal. Physical examination of the knee revealed that deep tendon reflexes were 2+, with sensation intact. On February 2009 VA examination, there was tenderness to palpation along the lateral joint line. No edema was noted. Strength was 4/5. His gait was antalgic and slow with cane in right hand. VA treatment records included August 2010 radiographs of the knees that revealed negative findings of the right knee. On August 2011 VA examination, the Veteran described continuing problems with bilateral knee pain, weakness, stiffness, and instability. He also reported that both knees had lack of endurance with swelling, intermittent redness, and tenderness present at all times. There were no hospitalizations, surgery, or further injury to either knee since his last VA examination. On physical examination of the right knee, there was tenderness to the medial patella. Strength was 4/5. On December 2012 VA examination, the Veteran was diagnosed with DJD of the right knee. The Veteran reported that he had flare-ups that impacted the function of the knee and/or lower leg. His right knee was worse at times, but he always had severe pain in his left knee. There was tenderness to palpation and strength was reduced in right knee flexion (4/5) and extension (3/5) and left knee flexion (3/5) and extension (3/5). Based on consideration of the medical evidence as well as the Veteran's complaints, no more than a slight right knee disability has been shown and a 10 percent rating is appropriate under Diagnostic Code 5262. Additionally, x-ray studies in this case have shown no malunion or nonunion of the tibia and fibula and a moderate right knee disability has not been demonstrated to warrant a higher, 20 percent, rating under Diagnostic Code 5262. As Diagnostic Codes (removal of semilunar cartilage), and 5263(genu recurvatum) include ratings of 10 percent or less, these codes do not need to be addressed during this appeal period as they could not serve as the basis for an increased rating. The Board has considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran, as required by the holding in Schafrath. The Board has found no section that provides a basis upon which to assign a higher disability rating throughout the appeal period. E. Extraschedular Considerations Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The Veteran's myofascial strain of the paraspinal muscles of the back has been manifested by pain and severe limitation of motion or forward flexion of 30 degrees or less. His left knee disability has been manifested by pain, limited extension, instability, tenderness, antalgic gait, and effusion. His left knee scar has been painful, unstable, and exceeds an area of 6 square inches. His right knee disability has been manifested by painful and weakened motion. During the pendency of the appeal, the Veteran reported that his back and knee conditions interfered with his ability to drive a forklift, lift more than 20 pounds, and stand for prolonged periods of time. Additionally, on August 2011 VA examination, the examiner opined that the Veteran was not able to sustain gainful employment due to the service-connected conditions of the bilateral knee and myofascial strain. The rating criteria are intended to compensate for considerable time lost from work consistent with the percentage rating. 38 C.F.R. § 4.1 (2012). The rating criteria also take into account the pain, limitation of function and effects on employment reported in the record. Hence, referral for consideration of extraschedular ratings is not warranted. Thun, 22 Vet. App. 114-15. ORDER Entitlement to service connection for hypertrophic degenerative disease involving lateral vertebral body margins, lumbar spine, at L2-L3 and L3-L4, and facet joints at L4-L5, is denied. Entitlement to an initial disability rating in excess of 40 percent for myofascial strain of the paraspinal muscles of the back, is denied. Entitlement to a disability rating in excess of 20 percent for osteochondritis dissecans, lateral femoral condoyle, left knee, with degenerative joint disease, is denied. Entitlement to a compensable rating for left knee instability prior to February 3, 2009, and a rating in excess of 10 percent from that date, is denied. Entitlement to a separate compensable rating for left knee scars prior to December 7, 2012, is denied. Entitlement to a separate 10 percent disability rating for left knee scars from December 7, 2012, is granted. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee, is denied. REMAND The Court has held that entitlement to a TDIU is an element of initial ratings. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). February 2009 and August 2011 VA examinations noted the Veteran's prior work history and reflect that the Veteran had multiple jobs, including a driving a forklift and worked through a temporary agency until 2008. The Veteran reported that it was difficult for him to drive forklifts because of his back and knee conditions. He reported that he was placed on a 20 pound weightlifting restriction in the past. Although he filed a VA Form 21-8940 in July 2011, information surrounding the Veteran's employment prior to April 27, 2004 and from November 20, 2006 to November 2, 2007 is unclear and relevant to the appeal period in question from February 15, 2001 to January 28, 2008. On October 2001 VA examination, he reported that it was difficult for him to stand during the last couple of hours of work on an assembly line due to his knee disability, so he stopped working altogether. Given his limited education and history of labor intensive occupations, and apparent interference with his work related to his service-connected disabilities, the Veteran should be asked to clarify whether he was able to engage in gainful employment from February 15, 2001 to January 27, 2008. Rice; Roberson. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to clarify if he engaged in gainful employment (employment paying wages above the poverty line for a single person), from February 15, 2001 to January 28, 2008, to submit supporting employment records, and any other evidence showing when he ceased such employment. 2. Adjudicate the Veteran's entitlement to TDIU from February 15, 2001 to January 28, 2008. 3. If any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then return the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J.A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs