Citation Nr: 1327475 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 07-24 483A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to an increased rating for right knee disability status post meniscectomy with arthritis, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from July 1973 to February 1975. This matter comes before the Board of Veterans' Appeals (Board) from a May 2006 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in New York, New York. This matter was most recently before the Board in March 2013 and was remanded for further development. It has now returned to the Board for further appellate consideration. As is discussed in further detail below, the Board finds that the RO has substantially complied with the mandates of the March 2013 remand, and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's right knee disability has been manifested by complaints of swelling, pain, limitation of motion, and instability; but objectively the Veteran has flexion which is not limited to 60 degrees or worse, and extension which is not limited to 10 degrees or worse. 2. The Veteran has no more than slight laxity of the knee which is already assigned a separate rating from his traumatic arthritis of the right knee. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent from right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, and 5256 - 5263 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in March 2006, August 2006, and April 2009. The claims file includes medical records, and the statements of the Veteran in support of his claim. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a duty to obtain. VA examinations/opinions were obtained in March 2006, September 2006, January 2007, May 2009, March 2012, and June 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that, taken as a whole, the Veteran has been afforded adequate VA examinations/opinions. The reports include clinical examinations, diagnostic testing, and the Veteran's reported symptoms. The reports provide findings relevant to the criteria for rating the disability at issue. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). The Veteran has reported that, at times, he has flare-ups of increased pain and swelling. The June 2013 VA examiner stated that there is no medical manner to answer whether additional loss of range of motion occurs during flare-ups or with repetitive use from pain, fatigue, or weakened movement, except to examine the Veteran during a flareup or after such repetitive use. The Veteran has been examined on numerous occasions, which has included repetitive use testing; findings with regard to limitation of motion were noted after testing. Based on the record as a whole, the Board finds that there is sufficient evidence of record to make findings with regard to the severity of the Veteran's disability, and that an additional VA examination is not necessary. In this regard the Board notes that the Veteran's claim has now been pending for more than seven years and he has been examined on six occasions. The Veteran has had examinations in various seasons and at various times of the day. He has been examined in cold weather seasons and warm weather seasons; thus, any increases in his disability due to temperature changes or seasonally activities would be reasonably noted in the examination reports. He also has been examined in the mornings (i.e. 10:00 a.m.) and the late afternoon (i.e. 3:00 a.m.); thus, reflecting his disability severity prior to daily activities and after daily activities. The claims file also includes VA clinical records which reflect the Veteran's complaints. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claim. Essentially, all available evidence that could substantiate the claim has been obtained. Legal Criteria Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating 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 is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating musculoskeletal disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40 and 4.45 (2012), see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. Id. § 4.45. Pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Flexion and Limitation of the Lower extremity DC 5260 provides a noncompensable rating when flexion is limited to 60 degrees or more. A 10 percent rating is warranted for leg flexion limited to 45 degrees. A 20 percent evaluation is for leg flexion limited to 30 degrees. A 30 percent evaluation is for leg flexion limited to 15 degrees. DC 5261 provides a noncompensable rating when extension is limited to 5 degrees or less. A 10 percent rating is warranted for leg extension limited to 10 degrees. A 20 percent evaluation is for leg extension limited to 15 degrees. A 30 percent evaluation is for leg extension limited to 20 degrees. A 40 percent evaluation is for leg extension limited to 30 degrees. A 50 percent evaluation is for leg extension limited to 45 degrees. In VAOPGCPREC 9 - 2004 (Sept. 17, 2004), it was held that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. As such, if the evidence of record reflects compensable loss of both flexion and extension of either leg, the Veteran would be entitled to the combined evaluation under Diagnostic Codes 5260 and 5261, per the combined ratings table in 38 C.F.R. § 4.25. Instability of the knee Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code (DC 5257), without violating the prohibition on pyramiding. See VAOPGCPREC 23-97. DC 5257 is predicated on instability, rather than limitation of motion, therefore, an analysis under DeLuca does not apply. See Johnson v. Brown, 9 Vet. App. 7 (1996). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claim on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran is service connected for right knee status post meniscectomy, currently evaluated as 10 percent disabling. In February 2006, the Veteran submitted a claim for an increased rating, asserting that his disability had worsened. As the Veteran's claim was received by VA in February 2006, the rating period on appeal may be from February 2005, one year prior to the date of receipt of the increased rating claim, provided that the evidence reflects a worsening of the disability during that one year time period. 38 C.F.R. § 3.400(o)(2) (2012). See also Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010). However, in accordance with 38 C.F.R. §§ 4.1 and 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the history of the disability is for consideration in rating a disability. The Veteran is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010 for traumatic arthritis of the right knee. Under Diagnostic Code 5010, traumatic arthritis is rated as degenerative arthritis (established by X-ray) under Diagnostic Code 5003, which in turn, is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Diagnostic Code 5200, etc.). See 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. During the pendency of the appeal, the RO, in a February 2007 rating decision, granted a 10 percent rating for laxity of the right knee, effective from January 8, 2007. A subsequent July 2009 rating decision granted an earlier effective date of September 5, 2006 for the separate 10 percent rating for laxity of the right knee. The Board has considered the Veteran's subjective complaints and the pertinent medical records, as summarized below. The evidence reflects that in approximately December 2004, the Veteran had an increase in knee symptoms, and subsequently had knee surgery in April 2005. A December 6, 2004 emergency department note reflects that the Veteran had complaints of right knee swelling and discomfort with extension for the past two days. He reported a similar problem one week earlier, but said that the swelling had resolved spontaneously. Upon examination, the Veteran had right pre-patellar swelling with no warmth and mild tenderness. He had active and passive range of motion. The diagnosis was pre-petallar aspetic bursitis. A January 26, 2005 VA record reflects that the Veteran presented with right knee pain. He reported that he had a similar episode which occurred the previous month. He reported that he does not do any strenuous physical activity. He further reported that he works at a desk. Upon clinical examination, the examiner noted that the Veteran had a right knee with serous effusion, and tenderness to palpation on lateral and medial aspects of the knee. The Veteran was unable to extend the leg completely. The physician also noted that x-rays done in December 2004 showed mild arthritic changes and effusion. An MRI reviewed in February 2004 showed a complete maceration of the medial meniscus, a severe sprain of the ACL and subchondral edema of the tibial plateau, and possible diffuse chondromalacia. A February 14, 2005 VA clinical record reflects that the Veteran's right knee had tenderness over the medial aspect of his joint line. An MRI of the right knee revealed a complete maceration of the medial meniscus, a severe sprain of the ACL and subchondral edema of the tibial plateau, possible diffuse chondromalacia. The assessment was right knee arthritis. The Veteran had 1+ anterior drawer test but was stable to the posterior drawer test, and to varus and valgus testing. A February 15, 2005 VA clinical record reflects that the Veteran reported complaints of right knee pain for a "couple of months". The Veteran stated that his right knee was swollen and that he could not walk without a crutch. He also reported that prescription medication was not helping. A March 2005 record noted a diagnosis of right knee arthritis and indicated that non-operative procedures had been exhausted. The Veteran reported that he has significant pain that is off and on and that his knee swells on him causing worse pain. An April 2005 record showed crepitus on range of motion, with full extension and up to 110 degrees of flexion. There was no evidence of varus or valgus instability; Lachmans, and posterior and anterior drawer tests were all negative. Upon examination, there was considerable moderate effusion of the right knee, and crepitus of range of motion. The Veteran underwent right knee arthroscopy in April 2005. An April 2005 post-operative follow-up record showed that after right knee arthroscopy, the Veteran had moderate effusion over the right knee with extension to +5 degrees and flexion to 100 degrees. Varus and valgus motions were stable, and anterior and posterior drawer tests were negative. A May 2005 follow-up record indicated full extension to 110 degrees of flexion, with mild effusion, and well-healing incisions. A June 2005 VA orthopedic clinic note reflects that the Veteran had continuing swelling of his knee and continued to walk on the right knee, rather than using crutches. The examiner noted that the "knee itself does not demonstrate any crepitus but does have a moderate amount of fluid in the joint. He has no evidence of calf swelling. He has no evidence of any neurological deficit. Indeed, he has 100 degrees of easy flexion and virtually full extension except for the hydraulic effect of the fluid." The examiner noted that the Veteran could help himself "a lot" if he would begin using the crutches. The examiner also noted that the Veteran was "gainfully employed as a computer operator. He does not do heavy labor" The examiner noted that if the Veteran cooperated with use of crutches and methods for managing his knee problems, " there is every reason to believe that he can do an awful lot to contribute to the resolution of his continuing symptoms and the objective swelling." A January 2006 history and physical VA note reflects that there was no edema of the extremities. It was noted that the Veteran was employed. The Veteran was afforded a VA examination in March 2006. The Veteran complained of pain, stiffness, swelling, heat and redness in the right knee. There was no locking, but there were complaints of fatigability, and lack of endurance. He did not use any crutches, braces, cane, or corrective shoes. The Veteran reported that he could not bend, push, pull, climb or squat on the right knee. Upon physical examination, there was crepitus on movement of the right knee. Range of motion testing revealed flexion ranging from 115 to 120 degrees with pain and extension to 0 degrees without pain. There was no evidence of fatigue, weakness, lack of endurance, or incoordination after repetitive use. There was also no evidence of instability, weakness, tenderness, redness, heat or abnormal movement however, there was guarding of movement. There were no flare-ups, gait was normal, and there were no callosities, abnormal weight bearing, or unusual shoe wear pattern. The examiner also noted that there was no additional limitation following repetitive use and no flare-ups. There was no instability of the knee. The examiner noted that the Veteran can do the daily living however, there are restrictions to the occupation as noted by the Veteran (e.g. cannot do prolonged weight bearing due to pain, he cannot bend, push, pull, climb, or squat on the right knee). The Veteran was afforded another VA examination in September 2006. The Veteran complained of pain, stiffness, intermittent swelling, and weakness. He denied symptoms of instability, giving way or locking. The Veteran reported flare-ups occurring approximately once or twice per week precipitated by any increased or prolonged activity, especially descending stairs, and lasting from one to two days. The Veteran reported that he had not missed any work due to flare-ups in the past year, however, he stated that "he is nearing retirement and is, therefore, very hesitant to miss any work." The Veteran also reported that he had been employed for 22 years as an engineering technician. The Veteran reported that "this work should normally require a fair amount of 'field work' which involves getting out into field and observing projects. However, for the past 3 to 4 years, due to his worsening knee he has been unable to do any field work and has strictly being doing sedentary work." The Veteran did not use any canes, crutches, braces or corrective shoes. Physical examination revealed a mildly antalgic gait on level ground due to some decreased flexion of the knee. Descending stairs showed some moderate discomfort, especially with weight bearing. There was no erythema, effusion, increased warmth, or abnormal shoe wear pattern. Range of motion testing revealed full extension and flexion limited to 95 degrees, with pain at the last 10 degrees of extension and flexion. Repeated flexion and extension caused discomfort after several repetitions. Repeated movement also caused fatigue, weakness, and lack of endurance. The Board acknowledges the Veteran's statement to the September 2006 examiner that he had been unable to do field work and had been limited to sedentary work for the past three to four years due to his worsening knee symptoms; however the clinical evidence of record reflects that his knee did not worsen until approximately December 2004, less than two years earlier. At that time, the Veteran's work was described as desk work. The Veteran was afforded another VA examination in January 2007. The Veteran complained of daily pain in the right knee, with giving way (buckling) but no locking. The Veteran reported no recent recurrent swelling and denied wearing a brace. Examination of the right knee indicated medial joint line tenderness and mild bony hypertrophy medially in the right knee. There was no effusion but patellar compression was painful. Range of motion testing showed flexion to 130 degrees with pain and full extension. McMurrays testing was painful; there was mild laxity with varus-valgus testing, and 1+ laxity on anterior drawer testing. There was also mild patellofemoral crepitus on range of motion testing. A diagnosis of degenerative arthritis of the right knee, status post medial meniscectomy in 1973 and arthroscopy in 2005 was provided. VA treatment records dated January 2008 primarily reflect that the Veteran reported continued complaints of right knee pain. A December 31, 2008 history and physical record reflects that the Veteran's arthritis was controlled on Celebrex twice a day. No complaints were made specific to his knee other than stating that he had chronic knee and ankle pain which was a 3/10. The Board finds that the Veteran's description of pain as a 3 out of 10 is indicative that it was not so severe as to cause such additional functional loss so as to warrant a rating higher than 10 percent. The Veteran was provided with another VA examination in May 2009. The Veteran complained of knee pain after walking 100 to 200 yards, swelling after walking up two flights of stairs, and inability to play sports. He reported that he can do chores around the house, but no heavy lifting. He also reported that he can mow the lawn with a power mower. He reported that he has pain every day and that this knee loosens up in about 10 minutes in the morning with a hot shower. He reported that he takes Motrin most days. The Veteran reported right knee giving way, instability, pain, weakness, and decreased speed of joint motion. There were no episodes of dislocation or subluxation and no locking episodes. There were no effusions. Physical examination noted that the Veteran's gait had poor propulsion with no other evidence of abnormal weight bearing, loss of a bone, or inflammatory arthritis. There were objective findings of grinding and tender medial ligament of the knee with lateral pressure, but there was no evidence of crepitation, clicks or snaps, instability, patellar abnormality, or meniscus abnormality. Range of motion testing revealed flexion to 95 degrees and extension to 8 degrees, with pain on motion. There was no evidence of additional limitation of motion on repetitive use. McMurrays and drawer signs were negative, there was no laxity, no fluid, no bursal change, and no synovitis. There was no evidence of ankylosis. X-rays showed early degenerative osteoarthritic changes of the right knee. The Veteran was noted to be a CAD (computer aided design) operator. It was noted that he was employed full time. The examiner noted that the Veteran's right knee pain had significant effects on his occupation in terms of decreased mobility, problems with lifting and carrying, and decreased strength. The disability prevented sports, had a severe effect on exercise, had a moderate effect on chores and shopping, had a mild effect on recreation, and traveling, and had no effect on feeding, bathing, dressing, toileting, grooming, and driving. A March 2012 VA examination report (General Medical purposes) reflects that the Veteran reported that he had no new complaints since his last VA examination and his right knee was reported to be "relatively stable at present". The Veteran reported that his "right knee becomes swollen with increased pain on occasion." He also reported frequent episodes of joint pain and joint effusion. His right knee flexion was 90 degrees with objective evidence of painful motion beginning at 90 degrees. He had full extension with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing and his post-test flexion ended at 90 degrees. He again had full extension. The examiner found that the Veteran did not have additional limitation in range of motion of the knee following repetitive use testing. The examiner found that after repetitive use, the Veteran does have less movement than normal, weakened movement, excess fatigability, incoordination, swelling, and disturbance of locomotion. He also had tenderness or pain to palpation for joint line or soft tissues. He had normal strength of knee flexion and extension. He had normal anterial instability and posterial stability and medial-lateral instability. There was no history or evidence of recurrent patellar subluxation/dislocation. He was noted to use crutches occasionally. The Veteran's functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The March 2012 VA examination opined as follows: Veteran is currently retired but would have limitation on physical activity at work. Restrictions would be walking more than 100 feet and inability to stand for long periods of time. Veteran able to sit without limitations. There would be no limitation on sedentary activity at work. The Veteran was provided with the most recent VA examination in June 2013. The Veteran reported that he has periods of increased pain and swelling of the right knee which occur "right out of the blue" and during which he uses his crutches for a few days. Upon clinical examination, right knee flexion was to 120 degrees. Objective evidence of painful motion began at 100 degrees. He had no limitation of right knee extension and no objective evidence of painful motion. The Veteran was able to perform repetitive use testing. After testing, his flexion was to 110 degrees and he still had full extension. The examiner noted that he had functional loss of the knee and lower leg which consisted of less movement than normal, excess fatigability, pain on movement, swelling, and interference with sitting, standing and weight bearing. He also had tenderness or pain on palpation. With regard to strength, the Veteran had full strength of right knee flexion and extension, which was a 5/5. The Veteran had anterior instability and medial-lateral instability of the right knee, but had normal posterior stability. There was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran had meniscectomy residuals of swelling and pain. The Veteran had a scar related to the meniscectomy but it was not painful and/or unstable or of a total area greater than 39 square cm (6 square inches). The Veteran used crutches occasionally when the right knee swelled up severely. The June 2013 VA examiner also stated as follows: As far as additional loss of [range of motion] during flare-ups or with repetitive use of the [right] knee from pain, fatigue, or weakened movement there is no medical manner to answer such a change in the exam other than to examine the patient during such a flareup or after such repetitive use. Thus to state what that change in [range of motion] might be without the benefit of such as additional exam would have no medical foundation and would be completely speculative. The Board has considered the Veteran's subjective complaints and the objective findings on examination. As noted above, the Veteran is currently rated at 10 percent for his right knee disability under 38 C.F.R. § 4.71a, Diagnostic Code 5010 for traumatic arthritis. Traumatic arthritis of the right knee is rated based on limitation of flexion and extension. If arthritis is confirmed by X-ray, such as in this case, a 10 percent rating is assigned if limitation of motion of the joint involved is noncompensable under the corresponding Diagnostic Codes. Here, during the appeal period, ranges of motion studies have not shown limitation of extension or flexion to a compensable degree. Under DC 5260, the Veteran would be entitled to a 20 percent rating if he had flexion limited to 30 degrees. The evidence is against such a finding. In sum, the Veteran had flexion to 110 degrees (April 2005), 100 degrees (April 2005), 110 degrees (May 2005), 100 degrees (June 2005), 115 degrees (March 2006), 95 degrees with pain at last ten degrees (September 2006), 130 degrees (January 2007), 95 degrees (May 2009), 90 degrees with pain beginning at 90 degrees (March 2012), and 120 degrees with pain beginning at 100 degrees (June 2013). In sum, his flexion, routinely has been greater than 30 degrees, even when limited by pain and after repetitive use, which would account for limitation due to fatigability, weakness, and other factors. Under DC 5261, the Veteran would be entitled to a 10 percent rating if he had leg extension limited to 10 degrees. The evidence is against such a finding. In sum, the Veteran had full extension (April 2005), extension to +5 degrees (April 2005), full extension (May 2005), "virtually full extension" (June 2005), full extension without pain (March 2006), full extension with pain at last 10 degrees (September 2006), full extension (January 2007), extension to 8 degrees with pain on motion (May 2009), full extension, with no pain, even after repetitive testing(June 2013). In sum, his extension has not been limited to 10 degrees on a consistent basis, even when limited by pain and after repetitive use, which would account for limitation due to fatigability, weakness, and other factors Even considering additional functional limitation (i.e. Deluca factors), the evidence does not reflect that the Veteran has a disability which would be equivalent or greater than flexion limited to 30 degrees or extension limited to 10 degrees. The Board again notes that pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). The evidence shows that the Veteran does not experience such functional loss to a degree that would warrant a higher rating. In that regard, the Board notes that the Veteran has cited to a September 2006 VA examination report that he has frequent flare-ups which are incapacitating. The Veteran is competent to report how his knee feels to him and that he does not feel that he can use it at times; however, his subjective reports of incapacitation are not supported by the objective clinical records. The Veteran has been examined on numerous occasions, to include March 2006, September 2006, January 2007, May 2009, March 2012, and June 2013. The Veteran was able to perform range of motion testing on those occasions, to include repetitive use testing. Moreover, the clinical records are void of findings of chronic incapacitating episodes. The Board acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) However, in the present case, not only is there a lack of clinical records, but the numerous examination reports do not reflect incapacitating episodes upon clinical examination. The Board finds that an occasional flare-up which requires the use of crutches, as reported by the Veteran, is not so chronic or incapacitating so as to warrant a higher rating. The Board has also considered whether an increased rating for the right knee disability is warranted under any alternate diagnostic code. However, as the evidence fails to establish ankylosis, DC 5256 is not for application. Similarly, as the evidence fails to demonstrate malunion of the tibia and fibula, DC 5262 is not applicable. DC 5263 is inapplicable because there is no showing of genu recurvatum. The Veteran has been granted a separate 10 percent rating under DC 5257 for status post right meniscectomy with laxity of the right knee, which the Board finds is adequate; a higher rating is not warranted for the Veteran's slight knee impairment. Words such as "mild", "slight", "moderate", " marked ", and " severe " are not defined in the VA 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. The Board finds that the objective clinical findings are the most probative as to the severity of the Veteran's disability, and finds that the Veteran's right knee laxity disability is no more than slight. For example, the March 2006 records reflect that he had no instability and did not use assistive devices, the January 2007 record reflects mild laxity, the May 2009 record reflects that there was no laxity. The 2013 record reflects anterior and medial-lateral instability, but normal posterior stability and no evidence of recurrent patellar subluxation or dislocation. The anterior instability was 1+, and the medial-lateral instability was 1+. Such findings are consistent with a slight disability. In sum, the Board finds that the Veteran does not meet the requirements for compensable ratings based on limitation of extension and flexion, ankylosis, nonunion or malunion of tibia and fibula, or genu recurvatum. His functional loss due to such things as pain, weakness, decreased speed of joint motion, and fatigue are appropriately compensated under the current 10 percent rating. (Painful motion is considered limitation of motion to support a minimum compensable rating for arthritis under DC 5003 or 5010.) In addition, his laxity is appropriately rated separately. He is not entitled to a separate rating under DC 5259 (cartilage, semilunar, removal of, symptomatic) as this would constitute impermissible pyramiding. Moreover, the highest rating permissible rating under DC 5259 is 10 percent for symptoms. Thus, it would be potentially more beneficial for the Veteran to be separately rated for traumatic arthritis and laxity. A compensable rating for a scar is not warranted as the Veteran's scar was not painful and/or unstable or of a total area greater than 39 square cm (6 square inches). (38 C.F.R. § 4.118, DCs 7801-7804.) In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim. In making this determination, the Board considered the benefit-of-the-doubt doctrine but finds that it is inapplicable. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-schedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extra-schedular disability rating would be warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). The discussion above reflects that the rating criteria reasonably describe and contemplate the severity and symptomatology of the Veteran's service-connected right knee disability. In reaching this conclusion, the Board has considered the Veteran's contention that the rating criteria do not adequately address his symptoms of weakness, buckling, instability and decreased speed of motion. However, the symptoms experienced by the Veteran generally correspond to the symptoms contemplated by the applicable Diagnostic Codes. Regarding weakness and decreased speed, the criteria consider that there are varying levels of disability, that pain, fatigue, and other factors may cause limitation of motion. The Diagnostic Codes also allow for traumatic arthritis to be compensated even if the limitation of motion is not compensable under the diagnostic codes for flexion and extension limitations. The rating for arthritis of the knee was assigned on that basis. Regarding buckling and instability, the Board notes that the criteria address the fact that a knee may have instability or laxity. The Board is of the opinion that buckling is a type of instability. The rating criteria are broad enough to allow for symptoms of laxity to be considered as "slight", "moderate", or "severe". In addition, while there is some evidence that the Veteran sometimes has pain which prevents extended walking or standing, the Board is of the opinion that the compensable ratings for pain on motion and instability are ultimately sufficient for the purpose of compensating the Veteran for the type of impairment which he experiences when doing such activities as standing and walking. Pain on motion and pain on walking are essentially the same thing, so the argument that the rating for pain on motion fails to address impairment resulting from pain that occurs while walking is not convincing. Moreover, the evidence does not reflect that the Veteran's disability has caused frequent hospitalization or marked interference with work. Although the Veteran credibly reported that the knee disorder caused some limitation in his ability to carry out the duties of his employment by preventing him from going into the field, he nevertheless was able to continue his employment by engaging in sedentary work for the three to four years until he retired, and there is no indication that his missed significant amounts of time from work. Thus, while there was significant interference with work, it did not rise to the level of being marked interference. Therefore, referral for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). Total rating for compensation purposes based on individual unemployability (TDIU) Entitlement to an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) and a TDIU extra-schedular rating under 38 C.F.R. § 4.16(b), although similar, are based on different factors. See Kellar v. Brown, 6 Vet. App. 157 (1994). An extra-schedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran's disabilities. In addition, exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. In contrast, 38 C.F.R. § 4.16(b) merely requires a determination that a particular Veteran is rendered unable to secure or follow a substantially gainful occupation by reason of his or her service-connected disabilities. See VAOPGCPREC 6-96. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The evidence of record, as noted above, is against a finding that a claim for TDIU has been reasonably raised. The competent credible records are negative for a finding that the Veteran was unable to maintain substantial gainful employment due to his service-connected right knee disability. The record reflects that he reported in January 2005 that he works at a desk. A June 2005 VA orthopedic clinic note reflects that the Veteran was "gainfully employed as a computer operator... He does not do heavy labor". A January 2006 record reflects that the Veteran was employed. While the March 2006 VA examiner noted that the Veteran cannot do prolonged weight bearing due to pain, and cannot bend, push, pull, climb, or squat on the right knee, the record reflects that the Veteran was able to do his job, which was mostly desk work. The September 2006 record reflects that the Veteran reported that he had not missed any work due to flare-ups. The May 2009 record reflects that the Veteran was employed full time. The March 2012 record reflects that the Veteran's knee disability caused no limitation on sedentary activity at work. Based on the foregoing, the Board finds that a remand for RO consideration of entitlement to TDIU is not warranted. ORDER Entitlement to an increased rating for right knee disability status post meniscectomy with arthritis, currently evaluated as 10 percent disabling is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs