Citation Nr: 1328077 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 08-19 867 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to a higher rating for service-connected left knee disability, rated as 10 percent disabling prior to March 22, 2013, and rated as 20 percent disabling from March 22, 2013 to the present. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran had active service from December 1987 to December 1991, from March 1992 to March 1994, and from June 1994 to April 1999. This case comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The claim was most recently before the Board in March 2013, at which time the case was remanded via the Appeals Management Center (AMC) for additional development in accordance with a September 2012 Joint Motion for Partial Remand (Joint Motion) and an October 2012 Order issued by the United States Court of Appeals for Veterans Claims (CAVC) that granted the Joint Motion. In a June 2013 rating decision, the RO increased the disability rating for the Veteran's left knee disability from 10 percent disabling to 20 percent disabling, effective from March 22, 2013. On a claim for an increased rating, a Veteran will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Since the rating assigned in the June 2013 rating action does not constitute a full grant of the benefit sought throughout the entire appeal period, and since the Veteran did not withdraw his claim of entitlement to a higher rating, the issue remains before the Board for appellate review. FINDINGS OF FACT 1. The evidence dated prior to March 22, 2013, does not show that the Veteran's left knee disability more closely approximated left knee flexion limited to 30 degrees or left knee extension limited to at least 15 degrees; there is also no x-ray evidence showing the involvement of 2 or more major joints or minor joint groups with occasional incapacitating exacerbations. 2. The evidence dated from March 2013, shows that the Veteran's left knee disability is primarily manifested by residuals of status post meniscectomy, to include a limitation of motion due to pain and reports of locking, swelling, and instability. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 10 percent for a left knee disability prior to March 22, 2013, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5262 (2012). 2. The criteria for a disability rating higher than 20 percent for a left knee disability from March 22, 2013, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Before addressing the merits of the claim, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. VA's duty to notify has been satisfied. The Veteran was notified via letters dated in December 2007 and July 2008 of the evidence needed to substantiate his claim and of his and VA's duties in this respect. See Dingess v. Hartman, 19 Vet. App. 473, 490-491 (2006) aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). He was also provided with information regarding the rating criteria for the diagnostic codes relevant to his disability. Although the December 2007 and July 2008 notice letters were provided after the initial adjudication of his claim, the claim was readjudicated with the most recent occurring in the June 2013 supplemental statement of the case. Nothing more is required. VA also has a duty to assist a Veteran in the development of his claim. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained available service treatment records and identified post-military treatment records. The Veteran also submitted written statements discussing his contentions. To date, neither the Veteran nor his representative has identified any outstanding evidence. The Veteran was also afforded VA examinations with respect to his claim. The Board finds the VA examination reports to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his service-connected disability under the applicable rating criteria. There is also no objective evidence indicating that there has been a material change in the severity of the Veteran's left knee disability since the most recent March 2013 VA examination. As noted above, the case was previously before the Board. In March 2013, the Board remanded the case so that the Veteran's outstanding VA medical records could be obtained and considered by the agency of original jurisdiction (AOJ) and so that he could be scheduled for a VA examination to determine the current severity and manifestations of his left knee disability. His VA records dated up until 2013 were obtained. The Veteran was afforded a VA examination for his claimed disability in March 2013. As explained above, the examination reports of record, including the March 2013 examination report, are adequate to decide the case. Indeed, the March 2013 VA examiner provided clinical findings and medical opinions applicable to the relevant diagnostic codes and addressed the ultimate question as to the appropriate rating for the Veteran's disability. Therefore, the Board finds that the AOJ has substantially complied with the prior remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West,13 Vet. App. 141, 146-47 (1999) (remand 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). Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F3d. 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. at 183. Legal Criteria for Increased Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Evaluation of a disability includes consideration of the Veteran's ability to engage in ordinary activities, including employment, and the effect of symptoms on functional abilities. 38 C.F.R. § 4.10. 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 portrays the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other 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. § 4.4. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Prior to March 22, 2013, the Veteran's service-connected left knee disability has been rated as 10 percent disabling under Diagnostic Code 5010-5261. In a June 2013 rating decision, the RO assigned an increased rating of 20 percent for the disability under a different diagnostic code, Diagnostic Code 5258. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5010 indicates that the disability should be rated like degenerative arthritis based on limitation of motion of the affected parts. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Diagnostic Code 5003 provides that 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. According to Diagnostic Code 5003, when limitation of motion would be noncompensable, i.e., zero percent, under a limitation-of-motion code, but there is at least some limitation of motion, VA assigns a 10 percent disability rating for each major joint so affected, to be combined, not added. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In the absence of any limitation of motion, involvement of 2 or more major joints or 2 or more minor joint groups warrants a 10 percent evaluation, and the same with occasional incapacitating exacerbations warrants a 20 percent evaluation. The knee is considered a major joint. 38 C.F.R. § 4.45(f). Diagnostic Code 5260, addresses limitation of motion with respect to flexion. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. A noncompensable evaluation is assigned for flexion limited to 60 degrees. Flexion limited to 45 degrees warrants a 10 percent evaluation. A 20 percent rating requires flexion limited to 30 degrees. The maximum rating of 30 percent is reserved for flexion limited to 15 degrees. Id. Diagnostic Code 5261 addresses limitation of motion with respect to extension. Extension limited to 5 degrees results in a noncompensable rating. Extension limited to 10 degrees merits a 10 percent evaluation. A 20 percent rating is reserved for extension limited to 15 degrees, while a 30 percent rating is reserved for extension limited to 20 degrees. Extension limited to 30 degrees warrants a 40 percent evaluation. The maximum 50 percent rating is awarded when there is extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5257 addresses other impairment of the knee. Slight impairment due to recurrent subluxation or lateral instability results in a 10 percent evaluation. Moderate impairment results in a 20 percent evaluation. Severe impairment results in the maximum 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5258 provides for a 20 percent disability rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. A 20 evaluation is the maximum rating under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 provides for a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Several other Diagnostic Codes under 38 C.F.R. § 4.71a pertain to knee disabilities in addition to those above. They include: Diagnostic Code 5256 for ankylosis of the knee; Diagnostic Code 5262 for impairment of the tibia and fibula; and Diagnostic Code 5263 for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). 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. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit evaluation 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 disorders is duplicative or overlapping with the symptomatology of the other disorder. Esteban v. Brown, 6 Vet. App. 259 (1994). Two examples are notable. First, separate disability evaluations are assigned where the Veteran has both a limitation of flexion and a limitation of extension of the same knee pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2004). Second, a Veteran may receive separate ratings for arthritis and instability of the same knee under 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5257 (or under Diagnostic Codes 5258 and 5259). See VAOPGCPREC 09-98 (August 14, 1998); VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); see also Esteban, 6 Vet. App. at 259; Licthenfels v. Derwinski, 1 Vet. App. 484 (1991). Although all the evidence has been reviewed, only the most salient and relevant evidence is set forth below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). Factual Background In June 2007, the Veteran filed a claim for a temporary 100 percent rating for his left knee after having undergone arthroscopic surgery and meniscectomy earlier that same month. In a July 2007 rating decision, the RO granted a 100 percent, temporary rating, effective from June 8, 2007, based on surgical or other treatment necessitating convalescence. A 10 percent rating was assigned effective from August 1, 2007. The Veteran appealed the 10 percent rating assigned effective from this date, which is the claim presently before the Board. As previously noted, the RO assigned a 20 percent rating for the disability effective from March 22, 2013. A May 2007 VA treatment record documents the Veteran's report of having left knee pain for over a year. He stated that his pain "comes and goes." Flare ups reportedly occurred and lasted four to six weeks. These episodes were associated with pain and swelling. The Veteran also described episodes of his knee giving out and a sensation that his knee had hyperextended backwards. He was noted to have significant pain on the medial aspect of his knee. The physical examination showed left knee range of motion from zero to 130 degrees. No specific tenderness was noted, although the Veteran experienced pain when going from flexion to extension. There was no evidence of varus or valgus instability, and Lachman's test was negative. McMurray's test was "mildly positive." An October 2007 VA orthopedic note shows that the Veteran was fourteen weeks post left knee surgery and that he continued to have some point tenderness over the needle portal of incision. He reported experiencing some slight improvement, and he stated that his pain was fairly constant, but not debilitating. The physical examination was negative for evidence of joint effusion. The Veteran demonstrated full flexion and extension of the left knee. The joint was stable to varus, valgus, and AP stresses. Lachman and McMurray's testing was negative. The examiner recommended the Veteran's continued use of over-the-counter pain medication, as need. The examiner determined that the Veteran was doing well from a mechanical standpoint. An August 2008 VA treatment record reflects the Veteran's report that his knee felt better and that he rode a bike to work approximately 15 miles. During a January 2009 VA primary care consultation, the Veteran reported that he ran regularly. A March 2009 VA examination report reflects the Veteran's report of daily left knee pain that was not helped with the use of medication. Flare ups of his symptoms reportedly occurred with weather changes, navigating stairs, and kneeling. His symptoms could last all day and were also accompanied by occasional swelling and frequent grinding. Functional impairments were identified as interference with some sports and activities. The Veteran's symptoms also included occasional locking, but no episodes of giving way. He denied that his left knee disability interfered with his job. The Veteran did not use any assistive devices and reported that he could walk 1/4 of a mile. On the physical examination, the Veteran walked with a minimally antalgic gait. Range of motion testing revealed left knee flexion from 3 to 100 degrees. Complete extension could not be performed. There was no evidence of soft tissue swelling, discoloration, or ligamentous laxity. Moderate crepitus was noted. Repetitive range of motion testing revealed additional limitation, as left knee flexion was from 3 to 90 degrees, with complaints of mild pain, mild weakness, and fatigue. There was no evidence of incoordination. Although the examination revealed mildly painful motion, there was no evidence of instability. The examiner identified the major functional impact as pain and fatigue with repetitive use. He was unable to determine any additional limitation following repetitive use during flare ups without resorting to speculation. The examiner noted his review of x-ray studies completed in 2007, which revealed degenerative changes in the left knee joint. The examination revealed a diagnosis of musculoligamentous strain of the left knee with previous partial meniscectomy. The examiner noted no significant effects on the Veteran's usual occupation due to his left knee disability, and moderate effects on his ability to participate in sports and exercise. A July 2010 VA joints examination report associated with an unrelated claim shows further assessment of the Veteran's left knee disability. The physical examination revealed left knee flexion to 130 degrees and left knee extension to zero degrees, without evidence of pain fatigue, weakness, lack of endurance, incoordination. There was no change in the range of motion on the fifth repetition and no additional loss noted. The examination was negative for objective evidence of painful motion, edema, effusion, instability, tenderness, redness, heat, abnormal movement, or guarding of movement for the left knee. Varus and valgus testing was normal, and McMurray's testing was negative. The examination revealed normal anterior cruciate and posterior cruciate ligaments. The examiner noted that the Veteran walked with a normal gait and that he did not have any functional limitations on stranding and walking. He reported occasionally using an ace wrap for his knee. As directed by the March 2013 Remand, the Veteran underwent a VA examination in March 2013. He reported experiencing pain, grinding, locking, and swelling under the left knee cap. He stated that he avoided climbing stairs and that he no longer ran due to his knee disability. The Veteran did participate in prolonged walking. Reportedly, flare ups of his symptomatology impacted his ability walk and climb stairs. The physical examination revealed left knee flexion to 125 degrees with objective evidence of pain at 120 degrees. Extension was to zero degrees and without pain. Following repetitive testing, left knee flexion was to 125 degrees and extension was to zero degrees. There was no additional limitation of the left knee range of motion following repetitive use. The examiner identified less movement than normal and pain on movement as functional loss or functional impairment due to the left knee disability. Tenderness was noted with palpation of the left knee. Posterior drawer and valgus/varus testing was normal. Lachman's test results were 1+ for the left knee and the examination showed slight subluxation/dislocation of the knee. The examiner responded "yes" to whether the Veteran has or has ever had a meniscus condition and identified the associated symptoms for the left knee as frequent episodes of locking, pain, and joint effusion. He noted the Veteran's history of left knee meniscectomy and identified diffuse knee pain as the residual symptom due to his surgery. The associated x-ray examination revealed soft tissue calcification and normal appearing bony structures of the knee. Based on the examination findings, the examiner rendered a diagnosis of residuals, status post meniscectomy. The examiner determined that the Veteran's knee disability did not affect the Veteran's desk job, although he may have some difficulty standing after prolonged sitting. He opined that the Veteran's left knee motion was at least as likely as not affected by pain, but it was less likely than not affected by weakness, fatigue, lack of endurance, or incoordination. As the rationale for this opinion, the examiner noted that the Veteran had just purchased a bike, participated in heart walks, and described patellar pain. The examiner further opined that there was no objective evidence of locking seen on examination. He opined that it was at least as likely as not that the Veteran's report of locking and instability were secondary to the condition of his patella and ACL. The examiner noted that there was significant evidence of crepitus over the left patella. He explained that with walking, the Veteran's pain may lead to a sensation of instability. Moreover, anterior drawer testing showed some mild laxity in the left knee, which was suggestive of ACL pathology. The examiner further highlighted that there was no evidence of medial or lateral instability. Given this, the examiner opined that the condition of the Veteran's left knee patella combined with his ACL condition likely gave him the sensation of instability of the left knee. The examiner characterized the Veteran's symptoms as mild. He further opined that the Veteran's symptoms were likely secondary to pathology of the left knee patella and laxity of the ACL. Analysis- Increased Rating Prior to March 22, 2013 Based on the above, a disability rating higher than 10 percent is not warranted for the Veteran's left knee disability prior to March 22, 2013. As noted above, the Veteran's left knee disability is rated under Diagnostic Codes 5010-5260 for this time period based on findings of degenerative changes and objective evidence of painful motion. The evidence dated prior to March 22, 2103, shows that the Veteran demonstrated flexion to at least 100 degrees and extension to at least 3 degrees, and he was noted to have pain with range of motion testing. The medical evidence, however, does not show that his limitation of flexion and extension, even considering pain and any additional limitations of function, warrant a compensable rating under Diagnostic Codes 5260 or 5261, let alone a rating in excess of 10 percent. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-07. Thus, a disability rating higher than 10 percent is not warranted for this time period based under the relevant diagnostic codes for a limitation of motion. Similarly, a higher rating is not warranted for arthritis under Diagnostic Code 5010 as there is no X-ray evidence of involvement of 2 or more major joints or 2 or more major joint groups with occasional incapacitating exacerbations. The Board has considered whether higher or separate disability ratings may be assigned for this time period under other relevant diagnostic codes. A higher or separate rating under Diagnostic Code 5257 for knee impairment with recurrent subluxation or lateral instability is also not warranted based on the evidence of record. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. While the Veteran has reported that his left knee would give way and was noted to have crepitus in the knee, there is no objective lateral instability or subluxation of the left knee prior to March 22, 2013. Indeed, the VA examinations and treatment records dated prior to March 22, 2013, overall, show that the stability testing of the Veteran's left knee (via varus, valgus, Lachman, McMurray's testing) were negative. The Board acknowledges that the May 2007 treatment record shows a "mildly positive" McMurray's test. However, the Boards notes that subsequent testing in October 2007 and March 2009 was negative for evidence of left knee instability. As there is no indication that the Veteran's left knee symptomatology more closely approximates recurrent subluxation or lateral instability, a higher or separate rating under Diagnostic Code 5257 is not warranted. A higher, 20 percent rating, is also not warranted under Diagnostic Code 5258 based upon dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Here, the Board acknowledges that the Veteran underwent surgery to repair a left meniscus tear and that he has reported experiencing pain, swelling during flare ups, and occasional locking. However, the objective evidence does not show that his left knee disability more closely approximates frequent episodes of locking, pain, and effusion into joint. Although he reportedly experienced swelling during flare ups, there is no objective evidence of effusion or edema into the joint. Moreover, given the Veteran's report of only occasional swelling and locking, it cannot be said that his left knee disability is manifested by frequent episodes of locking and effusion. As such, a higher, 20 percent rating is not warranted under Diagnostic Code 5258. The Board acknowledges that Diagnostic Code 5259, for symptomatic removal of cartilage, may be applicable in this case since the Veteran underwent a meniscectomy. Diagnostic Code 5259 provides that a separate 10 percent rating may be assigned when the knee remains symptomatic. In this case, the Veteran's symptoms primarily include pain. The Veteran's symptom is contemplated in the rating he receives based on findings of degenerative changes with a noncompensable limitation of motion. The Board concludes that to assign a separate rating under Diagnostic Code 5259 would constitute pyramiding as the Veteran would essentially be getting double ratings that compensate for his left knee pain and limitation of motion. See 38 C.F.R. § 4.14. That is, his current 10 percent rating under Diagnostic Code 5010-5261 has already awarded him for the limitation of motion due to pain. Because pyramiding is precluded by regulation, a separate rating under Diagnostic Code 5259 is not warranted. Analysis- Increased Rating From March 22, 2013 As noted above, the Veteran's left knee disability has been rated as 20 percent disabling under Diagnostic Code 5258 from March 22, 2013, to the present. The Board again highlights that a 20 percent evaluation is the maximum rating under this diagnostic code. As the Veteran is already in receipt of the highest rating under this diagnostic code, a higher rating may not be assigned under Diagnostic Code 5258. Thus, the Board will consider whether a higher rating is warranted under any other relevant diagnostic code. The evidence also does not show that a higher or separate rating is warranted based on a limitation of motion under Diagnostic Codes 5260 and 5261. As demonstrated during the March 2013 examination, the Veteran demonstrated limited flexion to 120 degrees and full extension to zero degrees. Thus, his range of motion, even considering his functional impairments, does not warrant a compensable rating under Diagnostic Codes 5260 or 5261. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 205-06. Moreover, the Veteran's left knee pain on flexion is contemplated by the 20 percent rating assigned under Diagnostic Code 5258, which is assigned, in part, for frequent episodes of pain. Therefore, to assign a separate rating based on painful motion (flexion) under Diagnostic Code 5260 would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. A higher or separate rating is also not warranted for left knee instability under Diagnostic Code 5257. The Board acknowledges the Veteran's March 2013 report of instability and the findings on the anterior drawer testing showing mild laxity. The March 2013 examiner highlighted, however, that there was no objective evidence of medical or lateral instability found on examination. Instead, the Veteran's left patella and ACL pathology likely gave him a "sensation" of mild instability. Given the examiner's probative opinion, a higher or separate rating under Diagnostic Code 5257 for recurrent subluxation or instability is not warranted. To the extent that the Veteran asserts that he should receive compensation for his reports of instability, his symptomatology has already been contemplated by the 20 percent rating assigned under Diagnostic Code 5258 for dislocated semilunar cartilage. Any additional compensation for instability would constitute pyramiding. See 38 C.F.R. § 4.14. A separate or higher rating is also not warranted under Diagnostic Code 5259 for removal of the semilunar cartilage, symptomatic. Here, the Board notes that the Veteran may not be assigned a higher rating under Diagnostic Code 5259, as this code only provides for a maximum 10 percent rating. Additionally, the Veteran may not be assigned a separate rating under Diagnostic Code 5259, as he is already been assigned a rating under Diagnostic Code 5258 for the residuals symptoms associated with his left knee meniscectomy. Thus, granting a separate rating for the same manifestations of the Veteran's left knee disability under Diagnostic Code 5259 would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. Conclusion In reaching the above determinations, the Board has also considered whether a higher rating may be assigned under any other diagnostic code relevant to knee disabilities. Diagnostic Code 5256, ankylosis, is not applicable in this case, as there is no evidence of ankylosis of the left knee. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Indeed, a higher disability rating is not warranted under this diagnostic code, as the Veteran has displayed an ability to flex and extend both his left knee as noted above. The Board finds that Diagnostic Code 5262 (impairment of the tibia and fibula) and Diagnostic Code 5263 (genu recurvatum) are not applicable here, as the medical evidence does not show that the Veteran has any of these disabilities. 38 C.F.R. § 4.71a, Diagnostic Codes 5262, 5263. Thus, a higher rating is not warranted under any other diagnostic code. Additionally, consideration has been given to whether any additional staged ratings are warranted in this case. However, at no time during the periods in question has the Veteran's disability warranted ratings higher than what has been assigned or upheld herein. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layman, to report on that as to which he has personal knowledge, such as his knee pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). As a layman, without the appropriate medical training and expertise, he is not competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his left knee disability in terms of the applicable rating criteria. On the other hand, such competent evidence concerning the nature and extent of the Veteran's disability 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) directly address the criteria under which his disability is evaluated. Consideration has also been given to whether a referral for extra-schedular rating is warranted for the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). 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. 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; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extra-schedular consideration referral). The schedular evaluation for the Veteran's left knee disability is adequate, despite the Veteran's disagreement with the disability ratings. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The Veteran does not have an "exceptional or unusual" disability; he merely disagrees with the assigned evaluations for his level of impairment. The available schedular evaluation for this service-connected disability is adequate. Thus, referral for extra-schedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extra-schedular consideration is moot. See Thun, 22 Vet. App. at 115. Finally, although the Veteran has submitted evidence of his medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable due to the disability. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to his service-connected left knee disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2011). ORDER A disability rating higher than 10 percent for a left knee disability prior to March 22, 2013 is denied. A disability rating higher than 20 percent for a left knee disability from March 22, 2013, is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs