Citation Nr: 1327476 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 09-02 259 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for service-connected left knee disability manifested by subluxation. 2. Entitlement to an evaluation in excess of 10 percent for service-connected degenerative joint disease of the left knee. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served in the Army National Guard (ARNG) with an initial period of active duty training from March 28, 1976, to July 16, 1976, and periods of active duty for training from May 20, 1977, to June 4, 1977; June 16, 1978, to July 1, 1978; and July 13, 1979, to July 29, 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. On June 15, 2011, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. The instant matters were previously before the Board in January 2013 following a Joint Motion for Remand (JMR), which was granted by the United States Court of Appeals for Veterans Claims (Court) in June 2012. Upon remand from the Court, the matters were remanded to the agency of original jurisdiction (AOJ) for further development and readjudication. Upon completion of the requested development, the Veteran's claims for increased disability ratings for his left knee disabilities were readjudicated and denied via an April 2013 supplemental statement of the case (SSOC). The appeal was returned to the Board in June 2013. FINDINGS OF FACT 1. Objective findings of instability of the left knee have not been shown; any subluxation is no more than moderately disabling. 2. The Veteran's degenerative joint disease of the left knee is manifested by painful motion tantamount to flexion no worse than 60 degrees or extension no worse than 5 degrees. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for left knee disability manifested by subluxation have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). 2. The criteria for a disability rating in excess of 10 percent for degenerative joint disease of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See Quartuccio v. Principi, 16 Vet. App. 183 (2002) The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For increased rating claims, the VCAA requires only generic notice, that is, 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. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009); Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010). After receiving the Veteran's increased rating claims, the RO sent to him multiple letters notifying him of the evidence required to substantiate his claims. The letters advised the Veteran of the information already in VA's possession and the evidence that VA would obtain on his behalf, as well as of the evidence that he was responsible for providing to VA, to include private medical evidence. The RO further advised the Veteran of the need to submit evidence showing that his service-connected disability had worsened or increased in severity or evidence demonstrating the effect that the increase in disability had on his employment and daily life. The Veteran was also notified how VA determines disability ratings and effective dates. As determined by the Board in its October 2011 decision, the VCAA notice letters provided to the Veteran satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) and complied with the requirements of Vazquez-Flores, supra. Notably, the parties' JMR included no reference to the Board's findings in this regards, nor does the Court's order indicate vacatur of that portion of the Board's decision that found compliance with VA's duty to notify. Regarding the duty to assist, the Board finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claims. All available evidence pertaining to the Veteran's claim has been obtained. The evidence includes his STRs, VA treatment records, VA examination reports, and private medical evidence, as well as lay statements in support of his claim, to include his June 2011 hearing testimony. In this regard, the Board notes that the matters were previously remanded, in part, to obtain the Veteran's treatment records from the Jesse Brown VA Medical Center (VAMC) in Chicago, Illinois, dated from November 2010 to the present. A review of the record reveals that the AOJ requested all treatment records pertaining to treatment of the Veteran at the Jesse Brown VAMC from November 2010 forward. A review of the Veteran's Virtual VA file shows treatment records dated through December 2012. The Board notes that the Veteran's representative asserted that she was unable to determine whether the Veteran's recent treatment records had been associated with the claims folder because she did not have access to the Compensation and Pension Records Interchange (CAPRI). However, the Veteran's representative does have access to Virtual VA and a review of Virtual VA system shows that the Veteran's treatment records have been associated with his paperless claims folder. Further, the Veteran was afforded VA examinations in January 2007 and March 2011. The Board points out that it was previously determined that the January 2007 and March 2011 VA examinations were adequate, that the examiner's opinion was supported by the reasons stated therein, and that the March 2011 VA examiner's failure to review the claims folder was not prejudicial to the Veteran because the Veteran provided the examiner with a detailed history of his reported disability, to include his current symptomatology, and the examiner provided a full examination of the Veteran. Again, the parties' JMR includes no reference to the Board's findings in these regards, nor does the Court's order indicate vacatur of that portion of the Board's decision that found compliance with VA's duty to provide the Veteran with an adequate medical examination. Rather, the matters were remanded, in part for the Veteran to be afforded a new VA medical examination, not because of some deficiency in the report of either the January 2007 or the March 2011 VA examination, but because the Veteran's testimony during his June 2011 hearing regarding immobility of the left knee in the mornings suggested that his symptoms may have increased in severity since the March 2011 VA examination was conducted. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); 38 C.F.R. § 3.327(a) (2012) (duty to provide a thorough and contemporaneous examination is triggered when the 'evidence indicates there has been a material change in a disability or that the current rating may be incorrect"); see also Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994) (holding that "[w]here an increase in the disability rating is at issue, the present level of disability is of primary importance"). A review of the record shows that in March 2013, the Veteran was afforded a VA examination, which included a full examination of the Veteran, to include range-of-motion and joint stability testing. The examiner also documented the Veteran's current symptomatology, discussed the functional impact of his reported flare-ups and the occupational impact of his left knee disability, and provided an addendum that set forth specific reasons for his belief that the Veteran's recurrent subluxation was slight. The Board is also satisfied that the examination report contains sufficient evidence by which to evaluate the Veteran's service-connected left knee disabilities in the context of the rating criteria and during the relevant time period. Accordingly, the Board has properly assisted the Veteran by affording him adequate VA examinations. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Cox v. Nicholson, 20 Vet. App. 563 (2007). In this regard, the Board has considered the arguments raised by the Veteran's representative in her informal hearing presentation regarding the adequacy of the examination provided on remand. Although the representative questions whether the examiner reviewed the VA treatment records associated with the claims folder on remand, the Board notes that because the examination was conducted in connection with the Veteran's claim for increased ratings, it is the current findings that are most important. Thus, even if the examiner failed to review the treatment record, the Board does not find that such a failing would render deficient the examination because those records were dated during the years prior the examination and would not bear on the severity of the Veteran's disability at the time of the examination. See Nieves-Rodriguez v. Peake, 22 Vet. 295, 301 (2008) (noting that the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed); see also Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997) (review of claims file not required where it would not change objective and dispositive findings made during medical examination). The representative also alleges that the examiner did not fully address the factors required by DeLuca v. Brown, 8 Vet. App. 202, 206 (1995), as required by the Board's remand. Reviewing the examination report in consideration of the representative's assertions, the Board does not agree that the examination was in any way deficient. The examiner provided range-of-motion findings, discussed the DeLuca factors, noted the Veteran's subjective complaints, and provided an assessment of the Veteran's disability, to include functional and occupation impacts. It is not apparent to the Board that the examination report is missing any relevant information or that the information contained therein is in any way inaccurate or falsified. II. Analysis Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). "Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern." Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. For increased rating claims, staged ratings are appropriate 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, 509-10 (2007). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7 (2012). At the outset, the Board notes that the Veteran is currently in receipt of two separate ratings for his service-connected left knee, as it has been determined that he has both subluxation and arthritis of the left knee. See VAOPGCPREC 23-97 (a veteran who has arthritis and instability of the knee may be rated separately for arthritis and instability or subluxation of the knee, provided that a separate rating is based upon additional disability). Accordingly, the Board will address whether the Veteran is entitled to a higher rating under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257, on account of lateral instability or subluxation and whether the Veteran is entitled to a higher rating under 38 C.F.R. § 4.71a, DC 5010, for his left knee injury with degenerative joint disease. The evidence relevant to both issues is summarized as follows. VA medical records dated in 2005 and 2006 show treatment primarily related to the Veteran's right knee and right foot pain, neck pain, and back pain. On examination in January 2007, the Veteran described episodes of his left knee giving out accompanied by a sharp anterior knee pain, resolving after 30 minutes. He reported 3 to 5 episodes a month and stated that he took Naprosyn twice daily for pain. He reported having stiffness, generally related to cold or damp weather, and reported difficulty ascending and descending stairs and rising from a seated position. The Veteran denied locking and stated that he did not use a knee brace. Use of cane related to episodes of giving out rather than for pain was noted. Examination of the Veteran revealed a mild bilateral valgus deformity. His gait was observed to be reciprocal heel-to-toe without limp. The lateral tracking of the Veteran's left knee could be felt to reduce at about 45 degrees of flexion. Apprehension sign was positive. The patellar compression test was negative, but crepitations were noted. There was no tenderness over the medial or lateral facets. Patellar lift test was negative and there was no swelling or atrophy. The left knee was stable to varus and valgus stress at zero and 30 degrees. Anterior drawer, Lachman, and McMurray tests were negative, as were posterior drawer and reverse pivot tests. The Veteran's range of motion was recorded to be from 0 to 135 degrees. The motion arc was not painful when examined unloaded. However, deep knee bends produced pain beginning at about 30 degrees and continuing throughout the range of motion. Pain on the left was greater than the right. Repetitive knee bends did not increase pain or affect the measured range of motion. Weakness and incoordination were not noted to be factors. The examiner did indicate that it was likely that the Veteran experienced some additional functional impairment during flare-ups in that his physical activity was limited. X-rays demonstrated extensive patellofemoral arthritis of the left knee. The examiner indicated that the Veteran's left knee disability contributed significantly to his unemployment. An October 2008 VA treatment note shows complaints of left knee pain. Some crepitus with flexion and extension was noted. Erythema, swelling, and warmth were not observed. A January 2009 treatment entry for hypertension noted that the Veteran ambulated with a cane assist and had a steady gait. In March 2009, the Veteran reported difficulty walking on account of left knee pain. In June 2009, the Veteran presented to VA with complaints of his knee popping. Crepitus was noted in both knees. There was no edema and Lachman and McMurray test were negative. The claims folder also contains an initial physical therapy record dated in July 2009. The Veteran was given strengthening, stretching, and stability exercises. At the time, it was noted that the Veteran was able to ambulate independently without An October 2009 letter from a VA clinician noted that the Veteran had osteoarthritis that caused pain in both knees. Use of a cane, physical therapy, and medication were reported treatments. The clinician indicated that the Veteran would be unable to work full time in the capacity of his prior job as a housekeeper. In November 2009, the Veteran reported that his knee pain was controlled with Tylenol. VA treatment records dated in December 2010 show that the Veteran complained of popping in his knee. Lachman and McMurray tests were negative. The Veteran was afforded another VA examination in March 2011. The examiner noted that the Veteran's left knee had been treated with a cortisone injection in the past as well as with Naprosyn and a cane for ambulation. A knee replacement had been discussed, but the Veteran desired to hold off on that procedure. The Veteran complained of soreness and stiffness and reported difficulty walking more than 3 to 4 blocks at a time. He denied any specific gross instability, but reported his pain to be increasing in severity. Physical examination of the Veteran revealed a mild valgus deformity of the left lower extremity when compared to the right and a slight antalgic gait. His range of motion was recorded to be from 0 to 105 degrees, with pain at 105 degrees. His range of motion was the same during passive, active, and repetitive testing. No loss of joint function due to pain was noted, nor was there evidence of weakness, fatigability, incoordination, or flare-ups. There was some tenderness to palpation over the lateral joint line and some discomfort with the patellar compression testing. The Veteran appeared to have an end point varus and valgus stressing. The examiner found no evidence of neoplasms, subluxation, or instability. The Veteran did not report any incapacitating episodes. X-rays revealed left knee osteoarthritis of the lateral compartment with near bone-on-bone articulation with an old healed fracture of the medial aspect of the patella. In May 2011, the Veteran presented with complaints of left knee pain and swelling, which had persisted for one week. An aspiration and/or injection of the joint was performed to remove fluid. The Veteran underwent the same procedure again later that month, which was noted to be "grossly bloody." Effusion and crepitus of the left knee was noted. The Veteran was again seen in June 2011 for complaints pain and swelling in the left knee. At that time, he rated his knee pain as a 10 on a scale to 10. During his June 2011 hearing, the Veteran stated that he was unable to bend his knee that morning and that he had recently had fluid drawn off his knee. He reported trouble ascending and descending stairs, swelling in his left knee, and pain upon walking. The Veteran indicated that pain was more problematic that swelling. A July 2011 rheumatology clinic note indicated the Veteran had lower extremity edema, ambulated with a cane, and complained of severe left knee pain, which had increased in the last month. His range of motion was limited due to left knee pain and it was noted that a neoprene elastic knee brace would be obtained from prosthetics. The Veteran was next seen in February 2012, at which time he had no complaints. It was noted that he had changed his diet, exercised more, and had lost 18 percent of his body weight. The Veteran still used a cane to walk long distance. No swelling or tenderness was noted and the Veteran had a full range of motion. In November 2012, the Veteran reported knee pain on and off. Examination revealed a full range of motion and mild joint crepitus. The Veteran was afforded another VA examination in March 2013. Range-of-motion testing revealed left knee flexion to 120 degrees, with pain at 120 degrees, and full extension with no objective evidence of pain. Repetitive testing yielded the same results. The Veteran endorsed flare-ups and described the impact of those flare-ups as occasional pain. The examiner considered the Veteran's functional loss on account of such things as decreased motion, weakness, excess fatigability, incoordination, painful motion, swelling, deformity, interference with sitting, standing and weightbearing, and instability of station, and indicated that the Veteran experienced functional loss/functional impairment due to pain on movement. There was also evidence of tenderness or pain to palpation. Muscle strength testing was normal. Lachman, posterior drawer, and valgus and varus tests were all normal, indicating no anterior, posterior, or medial-lateral instability of the left knee, but the Veteran was noted to regularly use a knee brace. A history of left knee patellar subluxation/dislocation was noted and indicated to be slight. There was no evidence of shin splints, stress fractures, chronic exertional compartment syndrome, or other tibial or fibular impairment. The examiner considered the occupational impact of the Veteran's left knee disability and determined that the left knee disability would not impact the Veteran's ability to work. In an addendum provided in April 2013, the VA examiner provided an extended rationale for his opinion that the Veteran's left knee subluxation was slight, stating that his opinion in this regard was based on the facts that during a flare-up the Veteran reported only occasional pain, that the Veteran was able to achieve the same flexion for the left and right knee save for pain at the end point of flexion for the left knee, that repetitive testing produced no change in achieved flexion or extension, that knee strength as normal, that there was no instability, and that there was no abnormal gait. The examiner also noted that the Veteran's left knee disability would not impact his ability to work. A. Rating under 38 C.F.R. § 4.71a, DC 5257 The Veteran's service-connected disability manifested by subluxation is currently evaluated as 20 percent disability under DC 5257, which pertains to other impairments of the knee. The provisions of DC 5257 provide for a 10 percent rating when there is recurrent subluxation or lateral instability that is slight. A 20 percent rating is applicable where there is recurrent subluxation or lateral instability that is moderate. A 30 percent rating is for consideration where there is evidence of severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257 (2012). Here, the Board finds that evidence of record does not support a higher rating under DC 5257 as the relevant evidence of record fails to contain objective evidence of severe instability or subluxation during the pendency of the claim for increase. Neither the January 2007, May 2011, or March 2013 VA examination reports revealed evidence of severe subluxation or instability. Indeed, the March 2013 VA examiner specifically indicated that the Veteran's subluxation was only slight and provided numerous reasons for his stated opinion, which reasons are supported by the evidence of record. Although the Veteran has complained of pain, stiffness, swelling, and giving way, the evidence shows that his pain is managed by Naprosyn and Tylenol and that his stiffness and soreness were brought on by changes in the weather. (Limitations due to pain are contemplated by the rating for arthritis, as are any problems due to restricted motion. See discussion below; 38 C.F.R. §§ 4.40, 4.45, 4.71a (2012).) No VA examiner found instability, nor was subluxation demonstrated on examination in May 2011. Moreover, none of the Veteran's VA treatment reports contains evidence of severe subluxation or instability. While the evidence shows that the Veteran uses a knee brace and a cane, the Board does not find the use of these devices to indicate severe disability, especially in light of the VA examiner's opinion, as a medical professional, that the Veteran's disability manifested by subluxation is only slight in nature. In sum, the Board finds that the evidence of record does not support a 30 percent rating under DC 5257, as the evidence fails to demonstrate severe subluxation or instability. The Veteran's ligaments are intact such that there is no inability to maintain stability in that sense. Although there are complaints of giving way, it is unclear the cause of this. Further, there were no observations of guarded movement or incoordination. As to the Veteran's reported difficulty with stairs and giving way, the Board finds that those symptoms are accounted for by the 20 percent rating assigned for moderate subluxation or lateral instability of the knee. B. Rating under 38 C.F.R. § 4.71a, DC 5010 As noted above, the Veteran is in receipt of a separate 10 percent rating under DC 5010 rating for residuals of a left knee injury with degenerative joint disease. Pursuant to DC 5010, arthritis due to trauma substantiated by x-ray findings is to be rated as degenerative arthritis. Pursuant to DC 5003, 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. When, however, the limitation of motion of the specific joint involved is not compensably disabling under the appropriate diagnostic codes, a rating of 10 percent is assignable for each major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. See 38 C.F.R. § 4.71a; see also Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991) (painful motion of a major joint caused by arthritis is deemed to be limited motion and entitled to a minimum 10 percent rating even though there is no actual limitation). 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, the disability is to be rated as follows: with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, DC 5003. Limitation of knee motion is rated under DC 5260, pertaining to flexion, and DC 5261, pertaining to extension. Under DC 5260, a noncompensable rating is assigned when flexion of the knee is limited to 60 degrees; a 10 percent rating is warranted when flexion is limited to 45 degrees. A 20 percent rating is for consideration when flexion is limited to 30 degrees. A 30 percent rating is applicable where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating is warranted where extension is limited to 5 degrees. A 10 percent rating is assigned when extension of the knee is limited to 10 degrees. A 20 percent rating is applicable when extension is limited to 15 degrees. A 30 percent rating is warranted where extension is limited to 20 degrees. Finally, a 40 percent rating is assigned when extension is limited to 30 degrees. 38 C.F.R. § 4.71a, DC 5261. As noted above, the Veteran's left knee range of motion was recorded as 0 to 135 degrees in January 2007, as 0 to 105 degrees in March 2011, and as 0 to 120 degrees in March 2013. Based on these findings, the Veteran does not have motion limited to a compensable degree. See 38 C.F.R. § 4.71a, DCs 5260, 5261. Accordingly, a rating greater than 10 percent is not warranted based on actual limitation of motion caused by the Veteran's degenerative joint disease because the Veteran is able to achieve flexion and extension beyond that which would be considered even noncompensable. The Board notes that, when an evaluation of a disability is based on limitation of motion and/or arthritis, the Board must also consider, in conjunction with the otherwise applicable DC, any additional functional loss a veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012). DeLuca, supra. Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. On examination in January 2007, it was noted that deep knee bends produced pain beginning at about 30 degrees and continuing throughout the range of motion. Pain was also noted at 105 degrees of flexion on examination in March 2011 and at 120 degrees of flexion in March 2013. Further, the Veteran's VA treatment records are replete with references to knee pain. The Board finds, however, that the Veteran's painful motion is accounted for by his 10 percent disability evaluation and there is no basis upon which to assign a higher rating. See Lichtenfels, supra. Indeed, it appears that the Veteran's disability in this regard had been rated on the basis of painful motion, as the medical evidence of record demonstrates that the Veteran does not experience an objective compensable limitation of motion. See id. Notably, despite the point at which his pain sets in, the Veteran has consistently been able to achieve greater degree of motion than that which would be compensable. In this regard, the Court has affirmed that pain itself does not constitute functional loss and "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,' 38 C.F.R. § 4.40, in order to constitute functional loss." Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Thus, an evaluation in excess of the minimum compensable rating on account of pain must be based on demonstrated functional impairment. Given the Veteran's ability to achieve flexion to at least 105 degrees and extension to 0 degrees, it is clear that his pain does not result in a functional loss equivalent to that which would warrant a rating greater than the currently assigned 10 percent. Further, although the Veteran has indicated flare-ups, he has not described them as incapacitating, nor do any of the VA treatment records note such problems. Rather, the Veteran complains of occasional pain. Examination of the Veteran has also failed to reveal any additional weakness, fatigability, incoordination, restricted range of motion, or functional impairment with repetitive testing. From a functional standpoint, it has been noted that the Veteran has had pain on movement; however, he has clearly been able to achieve a greater range of motion than that required for a 20 percent disability rating, even taking into account the DeLuca factors, at all times during the claims period. As to the Veteran's testimony during his June 2011 hearing that he was unable to bend his knee that morning, the Board does not find that assertion warrants the assignment of a higher rating. If anything, it represented a temporary increase in symptomatology and not a chronic worsening of his disability. Accordingly, as the evidence fails to reveal flexion limited to 30 degrees or extension limited to 15 degrees, even with consideration of functional loss, the Board finds that a rating greater than the currently assigned 10 percent is not warranted under the under DC 5010. Even when considering the possibility of separate ratings for limitation of flexion and limitation of extension, there is no evidence that supports such an award. Both limitations are noncompensably disabling. The Board has also considered whether the Veteran may be entitled to a higher rating under the following DCs applicable to disabilities of the knee: (1) DC 5256 which pertains to disabilities involving ankylosis of the knee; (2) DC 5258 which provides for a 20 percent evaluation for dislocated semilunar cartilage "with frequent episodes of 'locking,' pain, and effusion into the joint"; and (3) DC 5262 which is used to evaluate impairments of the tibia and fibula. 38 C.F.R. § 4.71a, DCs 5256, 5258, 5262 (2012). There is no evidence of ankylosis of the left knee joint or any impairment of the tibia or fibula to allow for application of DCs 5256 or 5262. Further, although effusion has been noted, the evidence of record does not demonstrate any complaints of dislocated cartilage. Accordingly, the Board finds that the evidence does not support a rating under DC 5258. The Board has also considered whether referral for extraschedular consideration is warranted, but finds that it is not. In this regard, the Board finds that the symptoms of the Veteran's left knee disabilities are not so exceptional or unusual such that the schedular criteria do not adequately compensate for them. Here, the Veteran's main symptoms have been pain, flare-ups, decreased motion, and limitation of activities. The Board does not find that the Veteran's symptoms take his case outside the norm such that referral for consideration of a higher evaluation on an extraschedular basis is required. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); 38 C.F.R § 3.321(b)(1) (2012). Indeed, the rating schedule compensates for subluxation and limited motion. Although limitation of activities such as walking and use of a brace and/or cane are not specifically noted in the rating schedule, it is clear the Veteran's activities are limited due to his knee pain and decreased motion and that those assistive devices are used to alleviate the Veteran's symptoms, which are accounted for by the rating schedule. The Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that the issue of entitlement to a total rating based upon individual unemployability (TDIU) is part of an increased rating claim when that issue is raised by the record. Here, TDIU was previously denied in a November 2004 rating decision. A review of the evidence relevant to the current appeal contains no indication that the Veteran is unemployable solely on account of his left knee symptomatology, such that the issue of entitlement to TDIU has again been raised by the record in connection with the Veteran's claim for increased evaluations of his service-connected left knee disabilities. While his left knee disabilities may impact his ability to function occupationally on account of the fact that his walking is limited, there is no indication in the record that he is unable to work due to his left knee disabilities. Although it was noted in October 2009 that he was not able to work full time, such a statement does not raise an assertion that the Veteran was unable to maintain substantially gainful employment because of his knee. As such, the Board finds that the issue of entitlement to TDIU has not been raised by the evidence of record as part of the Veteran's increased rating claim. See Rice, supra; see also Comer v. Peake, 552 F.3d 1362, 1366 (Fed.Cir.2009) (holding that the issue of entitlement to TDIU is raised whenever there is "cogent evidence of unemployability, regardless of whether [the claimant] states specifically that he is seeking TDIU benefits."). ORDER Entitlement to an evaluation in excess of 20 percent for service-connected left knee disability manifested by subluxation is denied. Entitlement to an evaluation in excess of 10 percent for service-connected degenerative joint disease of the left knee is denied. ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs