Citation Nr: 1328541 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 07-00 033A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUE Entitlement to an initial rating in excess of 10 percent for residuals of reconstruction of the anterior cruciate ligament (ACL) of the left knee REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from October 1988 to April 1991, and from October 2006 to March 2007. The Veteran had additional service in the Navy Reserve and the Air Force Reserve. This appeal to the Board of Veterans' Appeals (Board) arose from an April 2006 rating decision in which the RO, inter alia, granted service connection and assigned a 10 percent rating for residuals of reconstruction of the ACL of the left knee, effective June 4, 2005.. The Veteran filed a notice of disagreement (NOD) with the initial disability rating assigned for the left knee in June 2006. A statement of the case (SOC) was issued in September 2006, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in January 2007. Because the appeal involves disagreement with the initial rating assigned following the grant of service connection for the left knee disability, the Board has characterized this matter in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). In the January 2007 substantive appeal, the Veteran requested a hearing before a Veterans Law Judge at the RO. The Veteran withdrew the request in writing in April 2007. In February 2009, the Board denied an initial rating in excess of 10 percent for residuals of reconstruction of the ACL of the left knee. The Veteran appealed the February 2009 Board decision to the United States Court of Appeals for Veterans Claims (Court). In an August 2011 decision, the Court vacated the Board's February 2009 decision and remanded the claim to the Board for further proceedings consistent with the decision. In May 2012, the Board remanded the claim on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further action, to include additional development of the evidence. After completing the requested development, the AMC continued to deny the claim as reflected in an April 2013 supplemental SOC (SSOC)) and returned the matter on appeal to the Board for further consideration. In addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are not relevant to the issue on appeal. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. For the period from June 4, 2005 to August 15, 2005, the Veteran's residuals of a left knee injury consisted of a cartilage tear with effusion, locking, and pain, but no clinical instability, limitation in range of motion, or imaging indications of arthritis. 3. For the periods from October 1, 2005 to October 15, 2006, and from March 20, 2007 and thereafter, the Veteran's residuals of reconstruction of the ACL of the left knee have included a noncompensable degree of limited motion due to pain and stiffness, necessitating use of support devices, and limitation of extended walking, sitting, and standing; but no clinical evidence of instability or unrepaired cartilage damage. CONCLUSIONS OF LAW 1. The criteria for an initial, 20 percent rating for residuals of left knee injury, for the period from June 4, 2005 to August 15, 2005, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, Diagnostic Codes 5003, 5014, 5257, 5258, 5260, 5261 (2012). 2. The criteria for a rating in excess of 10 percent for residuals of reconstruction of the ACL of the left knee, from October 1, 2005 to October 15, 2006, and from March 20, 2007 thereafter are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, Diagnostic Codes 5003, 5014, 5257, 5258, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2009). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (here, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. January 2006 and March 2006 pre-rating letters provided notice to the Veteran explaining what information and evidence was needed to substantiate what was then a claim for service connection for reconstruction of the anterior cruciate ligament of the left knee, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The March 2006 letter provides the Veteran with general information pertaining to VA's assignment of a disability rating and effective date-in the event service connection is granted-as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After the award of service connection and the filing of the Veteran's disagreement with the initial ratings assigned, the September 2006 SOC set forth the criteria for higher ratings for the left knee disability (the timing and form of which suffices, in part, for Dingess/Hartman). Although the record includes no notice letter specific to the claims for higher rating herein decided, , no such letter was required on the downstream issue of entitlement to a higher initial rating. See 38 U.S.C.A. § 5103A;VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004)). Moreover, in any event, and on these facts, the omission of such a letter is not shown to prejudice the Veteran. As noted, in addition to the notice provided in the September 2006, pertinent, pre-rating notice was provided in connection with what were then claims for service connection. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of service, VA and private treatment records, and the reports of January 2006, October 2006, and March 2013 VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran, as well as by her representative and three acquaintances, on her behalf. The Board finds that no additional RO action to further develop the record in connection with this claim, prior to appellate consideration, is required. In particular, the Board finds that there has been substantial compliance with the instructions in the May 2012 remand. Additional VA records were obtained. The Veteran was advised of the opportunity to submit additional evidence and did submit written statements describing her symptoms. The Veteran was provided an adequate examination. The examiner reviewed the entire history, performed a detailed clinical examination, and assessed the Veteran's reported symptoms and causes for loss of function loss. Also, the examiner provided clinical information appropriate to the application of the rating criteria. 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). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate the claim, the avenues through which she might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any of these claims. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Background The Veteran served as a U.S. Air Force Reserve noncommissioned security officer and retired at the rank of Staff Sergeant. Service personnel records show that the Veteran was on inactive duty for training in early June 2005 when she fell and injured her left knee while performing physical training. In July 2005, a magnetic resonance image revealed an ACL tear and torn anterior aspect of the lateral meniscus. The Veteran sought treatment immediately after the injury at a military clinic. An examiner noted the Veteran's reports of striking the ground with her knee, hearing a popping sound, and experiencing posterior knee pain. The examiner noted swelling. Other clinical tests were negative. The examiner diagnosed left knee strain and prescribed ice, an elastic sleeve, medication and restriction of the Veteran's duties. Later in June 2005, the Veteran again sought treatment for continued pain, swelling, locking, and buckling of the knee. An examiner noted tenderness, effusion, and a positive McMurray's test but a normal range of motion without medial or lateral instability. [ McMurray's test is used to detect a torn meniscus. Dorland's Illustrated Medical Dictionary, 1879 (30th Ed. 2003).] The examiner noted a preliminary diagnosis of meniscus tear but ordered imaging studies. In early July 2005, a magnetic resonance image showed a torn ACL and a torn anterior aspect of the lateral meniscus with a small amount of fluid in the joint. On August 16, 2005, the Veteran underwent arthroscopic left knee surgery including an ACL reconstruction. Military examiners continued to order no running, marching, or extended standing, but the records do not show that the Veteran was unable to drive, perform daily activities, or civilian employment duties as a loan officer. The Veteran underwent ACL reconstruction surgery on August 15, 2005. Following surgery, she participated in a program of physical therapy. By September 2005, the program included mini-squats and leg presses although she continued to report moderate post-surgical pain. Range of motion was 0 to 118 degrees. In January 2006, a military clinician noted that the Veteran's participation in therapy had been irregular since October with significant quadriceps atrophy. The Veteran had a normal gait and only trace effusion. The Veteran reported pain while walking, difficulty with stairs, and occasional giving way. The examiner did not note any positive clinical instability tests but continued to prohibit running, jumping and marching. The Veteran reported that she planned to start work as a substitute school teacher. The examiner advised exercises at the gym three times per week including leg presses and the use of an elliptical trainer. Later the same month, the Veteran underwent a VA general medical examination. A VA nurse practitioner (NP) noted the Veteran's reports of difficulty with extended standing, walking, and stair climbing because of the left knee and because of a chronic low back disorder with severe muscle spasms and right knee pain. Range of motion of the left knee was zero to 110 degrees passively and zero to 115 degrees actively with pain on motion In May 2006, a military examiner noted the Veteran's report of continued moderate left knee pain. However, on examination, the examiner noted no swelling or tenderness. Range of motion was normal without pain or instability. No additional imaging studies were obtained. In October 2006, a VA physician noted the Veteran's reports of continued aching left knee pain, occasional swelling, and a feeling of instability. The Veteran reported that she was unemployed because of an inability to find work and had been placed on a permanent military restriction from running. The Veteran reported that she was unable to perform security work because of difficulty standing but could perform daily activities. She used a knee brace and had "difficulty getting around" during flare-ups that occurred two to three times per month lasting one day. On examination, the range of motion was from 5 degrees extension to 90 degrees flexion with pain throughout the range but with no additional limitations on repetition caused by pain or structural defects. The McMurray test was normal with no clinical instability but with pain during the instability tests. The physician referred to X-rays that showed the residuals of the ACL reconstruction but no other abnormalities. Upon appeal in August 2011, the Court found that this examination was inadequate to rate the disability because the physician noted pain throughout the range of motion but made no initial finding of the degree of range of motion loss due to pain on use. It was unclear at what point during the range of motion that the limitation was due to pain. The physician also did not note whether any functional loss was attributable to flare-ups. Starting about one week after this examination, the Veteran entered active duty service from October 2006 to March 2007 as a security officer at a U.S. Air Force Base. She was provided a chair while on post guard duty but still had to rise to check identification. While on active duty in February 2007, the Veteran reinjured her lower back as a driver in an automobile accident. Shortly after the end of active duty, in April 2007, a military physician noted the Veteran's report of left knee pain and occasional swelling after exercise but with some relief with the use of medication. The Veteran denied any instability or locking. On examination, the physician noted normal left knee appearance with a normal range of motion and no laxity. Gait and stance were normal with no tenderness on ambulation. X-rays revealed mild degenerative spurring in the medical compartment and the residuals of reconstruction surgery. In June 2007, a military clinic physician noted that the Veteran had been in another automobile accident one week earlier that exacerbated her low back disorder. Imaging studies showed degenerative disc disease at several levels of the lumbar spine. The physician only briefly noted that balance, gait, and stance were normal and advised stretching exercises for the left knee. The Veteran declined a formal physical therapy program. In February 2008, the Veteran began regular primary care at a VA clinic. A physician noted the history of left knee injury and surgery and noted the Veteran's report of chronic moderate knee, back, and foot pain. The physician observed a normal gait with no limitations in range of motion and no use of a support device. The physician recommended exercise to lose weight. The same month, a VA physician performed a spine examination and noted that the Veteran was working as a security officer at a home supply store. The Veteran reported back pain radiating to the left leg that affected her ability to walk and stand on concrete floors. She acknowledged missing some days of work because of the back discomfort but did not use support devices. In January 2009, the Veteran reported further reduced mobility because of back pain radiating to both lower legs and an inability to walk more than a few yards without a back flare-up. She reported missing 60 days of work and an inability to perform daily chores because of back pain. The Veteran received an Air Force Commendation Medal for performance of duty from 2004 to 2009 that included base patrols and control of entry points. She continued to perform inactive duty training in the Air Force Reserve in 2007, 2008, and until June 2009. During a VA examination for a mental health disorder, the Veteran reported that she stopped working in May 2009 because of her back disability (for which service connection was subsequently awarded). In April 2009, the Veteran underwent a military Medical Review Board examination. Physicians noted the history of left knee surgery with on-going knee pain and swelling after exercise walking from 15 to 20 minutes. The Veteran drove two hours to the examination and reported that she was unable to run 100 yards. The physicians' report substantially addressed the lumbar spine disability with no clinical examination of the left knee. The Board found the Veteran unqualified for further service because of the lumbar spine disability. The Veteran received a medical retirement for the back in August 2009. A May 2010 magnetic resonance image of the left knee revealed degenerative joint disease, most severe at the patellofemoral joint, with small joint effusion and a Baker's cyst in addition to the residuals of the ACL reconstruction. The Veteran underwent a physical therapy evaluation in June 2010 and reported a gradual increase in left knee pain since the surgery in 2005 but no subsequent injuries. The Veteran reported difficulty walking, rising from a chair, and negotiating stairs but denied buckling, locking, or daily swelling. The Veteran ambulated with a mild antalgic gait without an assistive device and reported that a knee brace only aggravated the disability. Range of motion was from 15 degrees extension to 85 degrees flexion. The therapist noted mild valgus laxity and effusion but all other ligament tests were negative. The therapist prescribed a home exercise program. In September 2010, an outpatient clinician noted that the Veteran was looking for a job as a paralegal. In May 2011, a VA physician noted the Veteran's reports of right knee discomfort since 2007. The Veteran reported that she was unemployed but performed volunteer work. She was unable to run and performed most exercise in a pool. The physician diagnosed degenerative joint disease of the right knee and concluded that it was caused by weight shifting from the service-connected left knee. In June 2011, the RO granted service connection and a 10 percent rating for degenerative joint disease of the right knee. In response to the decision by the Court in August 2011, the Board remanded the claim in May 2012 to afford the Veteran the opportunity to submit additional evidence, obtain current VA outpatient treatment records, and obtain a current VA examination. In January 2013, the RO provided a notice and the opportunity for the Veteran to submit or identify additional relevant evidence and VA outpatient treatment records through March 2013 were associated with the claims file. In December 2012, a VA magnetic resonance image revealed the same indications as were noted in May 2010. In February 2013, the Veteran submitted a written statement accompanied by three lay statements from others who observed her symptoms. The Veteran and friends noted that she had difficulty with negotiating stairs and keeping up with the group during a walking tour of New York City. They noted that the Veteran was unable to ride in an automobile for an extended time and experienced knee stiffness upon rising after prolonged sitting. The Veteran also submitted two excerpts from internet sites that explain how an ACL tear can lead to degenerative arthritis. In March 2013, a VA physician noted a review of the claims file and the Veteran's reports of constant left knee aching with pain on kneeling, extended walking, and stiffness in the morning and on long automobile rides. The Veteran denied flare-ups. Range of motion was zero to 100 degrees with the onset of pain at 90 degrees and no pain near the maximum point of extension. There was no change after repetition. The physician concluded that the limitation of motion was caused by pain and swelling but that it was more likely caused by body habitus rather than residuals of the injury or surgery as the Veteran had a body mass index of 38.82. Joint stability tests were all normal, and the Veteran did not use assistive devices for mobility because of the knee. The Veteran walked with an antalgic gait but there were no muscle strength or neurologic deficits associated with the knee. The physician performed an examination of the surgical scars noting that none imposed any functional limitations. The Veteran has been granted service connection and a 10 percent rating for the scars. The physician concluded that the Veteran may have increased pain with activity but no additional loss of function. The physician noted that the left knee disability would impose difficulty with employment requiring extended walking, standing or kneeling but not preclude sedentary employment. In a statement received after the examination, the Veteran noted that she experienced knee crepitus on motion, used a knee brace and cane, and held handrails on stairways for support. In late June 2013, the Board received a statement in support of claim. The author of the statement is not clear, as the signature is not legible and a title is not provided. Nevertheless, the statement is phrased as if it were provided by a medical examiner. The author noted that the Veteran presented wearing a rigid brace on the left knee. The author also indicated that he or she measured range of motion with a goinometer including after three repetitions. It was further noted that flexion of the left knee was limited to 30 degrees and extension limited to 10 degrees because of pain, swelling, and tenderness, and that the Veteran experienced severe recurrent laxity and subluxation of the left knee. II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. The following analysis is undertaken with the possibility that different ratings may be warranted for different time periods. Historically, in April 2006, the RO granted service connection for reconstruction of the ACL of the left knee and assigned an initial, 10 percent rating, pursuant to Diagnostic Codes 5257-5014. However, the narrative of the decision refers to the criteria of Diagnostic Code 5003 for arthritis with limitation of motion that is noncompensable under Diagnostic Codes 5260-61. The initial assigned effective date for the awards of service connection and initial compensation was December 2005, the date of receipt of claim. In August 2010, the RO granted an earlier effective date in June 2005, the day following the completion of inactive duty training. The RO also assigned a temporary total rating for convalescence after reconstruction surgery for the period from August 15, 2005 through September 30, 2005, and contained the 10 percent from October 1, 2005. Accordingly, excluding the period during which a temporary total rating was assigned, and the period of active duty service, this appeal is for a rating in excess of 10 percent for the periods from June 4, 2005 to August 15, 2005; from October 1, 2005 to October 16, 2006; and from March 20, 2007 to the present. The Board had summarized pertinent, potentially applicable rating criteria and principles below. As for the initial 10 percent rating assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5257-5014, Diagnostic Code 5014 refers to osteomalacia, which is to be rated on limitation of motion of affected parts, as arthritis, degenerative. See 38 C.F.R. §§ 4.27, 4.71a. Diagnostic Code 5257 addresses other knee impairment including recurrent subluxation or lateral instability. A 10 percent rating is warranted if the disability is slight; a 20 percent rating if moderate; and a 30 percent rating if severe. Degenerative arthritis established by X-ray findings is evaluated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. The 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, DC 5003. The rating schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the knee to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the knee to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. For rating purposes, normal range of motion in a knee joint is from 0 degrees (extension) to 140 degrees (flexion). 38 C.F.R. § 4.71, Plate II. The VA General Counsel has held that a claimant who has arthritis (resulting in limited or painful motion) and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, cautioning that any such separate rating must be based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). The VA General Counsel has further held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Separate ratings under Diagnostic Code 5258 and Diagnostic Codes 5003/5010 are not appropriate because Diagnostic Code 5258 also contemplates manifestations of limited motion including locking as a result of dislocated cartilage. VAOGCPREC 9-98 (Aug. 14, 1998). Also, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2009); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Considering the pertinent evidence in light of the applicable rating criteria, the Board finds that an initial rating of 20 percent under Diagnostic Code 5258 (rather than an alternative rating under Diagnostic Code 5257) is warranted after the injury and prior to corrective surgery. Following convalescence from surgery and exclusive of a period of active duty, a rating in excess of 10 percent is not warranted. As for the pertinent period prior to the Veteran's reconstructive surgery-from June 4, 2005, to August 15, 2005-the Board notes that the initial, 10 percent rating was assigned under Diagnostic Code 5257, essentially, for impairment comparable to slight instability. No higher rating is assignable because, although imaging studies and the surgery showed that there had been ACL damage and although the Veteran reported a feeling of instability, clinical tests for instability were negative. However, the Board finds that the maximum, 20 percent rating under Diagnostic Code 5258 is warranted because there was then clinical and imaging evidence of a cartilage tear with effusion and reports by the Veteran of locking and pain. The Board finds that, for this period, rating the disability under Diagnostic Code 5258 is more favorable to the Veteran and better contemplates the pain and reduced mobility that ultimately warranted surgical intervention. The Board points out that assignment of a particular diagnostic code is completely dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). See also Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (holding that one diagnostic code may be more appropriate than another based on such factors as a veteran's relevant medical history, current diagnosis, and demonstrated symptomatology, and that any change in diagnostic code by a VA adjudicator must be specifically explained). However, for the period prior to August 16, 2005, no higher, or additional, rating is assignable under any pertinent provision of VA's rating schedule. As noted, the Veteran was provided an elastic sleeve and crutches immediately after the injury but was able to continue activities other than running and jumping. No rating for arthritis or based upon limitation of motion is warranted because there was then no imaging evidence of degenerative changes, and recorded range of motion testing results prior to surgery were normal. The Board also finds that, a staged rating in excess of 10 percent for the left knee is not warranted for the period from October 1, 2005 to October 15, 2006. The Board acknowledges the Court's determination that the October 2006 VA examination is not adequate because the examiner did not comment on a possible additional loss of function because of pain during motion and during flare-ups. This determination was made in August 2011 and action by the Board to obtain a new examination was taken in May 2012. It is not reasonable or productive to request a revised opinion from the October 2006 examiner after the passage of more than five years. Therefore, the Board will evaluate the disability using the remaining clinical observations and lay statements as well as the Veteran's capacity to return to full active duty at the end of this period of time. Following corrective surgery, a rating of 10 percent under Diagnostic Code 5003 is warranted because there was some noncompensable limitation of motion with imaging indications of degenerative spurring noted only one month after the period of active duty. As the active duty period was only five months, it is reasonable that the degenerative changes manifested before October 2006. The Veteran experienced chronic pain and difficulty with negotiating stairs. The Veteran was under military restriction from running, jumping, and marching but was able to perform duties as a patrol officer and checkpoint control officer while able to sit as needed. Recorded ranges of motion were from 0 to 110 - 118 degrees within several months of the surgery with the most limiting range of motion from 5 degrees on extension to 90 degrees flexion noted just prior to assuming active military duty. Normal range of motion was observed in April 2007, immediately after active duty. That the Veteran was accepted on active duty and presented an award for effective performance weighs against the clinically unobserved additional loss of function due to pain and flare-ups. There is no evidence of a loss of time on duty because of flare-ups. The Veteran was able to drive an automobile and expected to be able to work as a substitute teacher, both requiring some level of function of the knee. Even if there were some additional loss of function due to pain, the clinically measured ranges were not close to a higher rating of 20 percent for a 15 degree limit of extension or a 30 degree limit of flexion. As discussed below, these ranges were not observed until 2010, several years later and after retirement from Reserve service. As will be further discussed below, the Veteran was examined in March 2013 more than six years later without any intervention and minimal therapy. The Veteran denied any flare ups and the results of motion testing show pain only within 10 degrees of maximum flexion. Notwithstanding the absence of adequate observations by the October 2006 examiner, the Board concludes that a 10 percent rating under Diagnostic Code 5003 is warranted, but that, for this period, no higher, or additional, rating is assignable under any other provision of VA's rating schedule. As indicated, the Veteran did not meet the criteria for even the minimum, compensable (10 percent) rating under Diagnostic Code 5260 or 5261. Further, following corrective surgery, clinicians and examiners noted no instability or cartilage deficits or other abnormalities on imaging studies, and, in April 2007, the Veteran denied any locking or instability. Therefore, following the Veteran's corrective surgery, there was no basis for evaluation of the disability under Diagnostic Code5257 or 5258. The Board likewise determines that a rating in excess of 10 percent for the residuals of reconstruction of the ACL of the left knee is not warranted at any time from March 20, 2007 to the present. During this period of time, the left knee disability had been manifested by complaints of constant pain and stiffness that contributed to limited extended sitting, standing, and walking. There is imaging study evidence of degenerative arthritis with limitation of motion less than normal; however, the limitation is not to a compensable degree. Extension has been greater than 5 degrees and flexion greater than 45 degrees. Therefore, while a 10 percent rating continues to be warranted under Diagnostic Code 5003, no higher, or additional, rating under any other diagnostic code is assignable. . Because the Veteran denied any instability and no ligamentous instability or cartilage damage has been noted on clinical examination or imaging studies, there is no basis for evaluation of the disability under Diagnostic Code 5257 or 5258. Moreover, as noted, no compensable rating is assignable under Diagnostic Code 5260 or 5261 on the basis of limitation of extension and/or flexion, respectively, even when the provisions of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca, are considered. Notwithstanding the comments of the most recent VA examiner who noted pain beginning only at 90 degrees flexion, the Board accepts the Veteran's reports of constant ache or pain as competent and credible. Pain throughout the range of motion is credible and a cause for the limitation in flexion. However, the examiner specifically addressed whether pain caused an additional reduction of the range of motion and concluded that it did not do so. The Board considered the June 2013 statement from a possible medical examiner of unknown identity or qualification. Therefore, the Board concludes that there is insufficient information on its face to conclude that it is from a competent source. Even if from a qualified examiner, the Board would accord this brief statement low probative weight because there is no indication that the author had any knowledge of the history of the injury or treatment and previous examination and medical observations. See 38 C.F.R. § 4.41 (2012). The data presented is limited to a recitation of the criteria under three diagnostic codes and is dramatically more severe than any previous clinical observations including the most recent VA examination three months earlier. The author cites the use of a brace but no other support devices as would be appropriate for a range of motion of only 20 degrees with severe instability. The author did not discuss the functional impairment imposed by the severe limitation of motion and instability, and the ranges of motion and level of instability are inconsistent with the Veteran's participation in a walking tour of New York City three months earlier. Most importantly, the statement was not accompanied by any explanation by the Veteran or her representative as to the identity of source or date of the presumed examination. Furthermore, regarding the Veteran's and her friend's credible reports of difficulty walking, standing, sitting, rising, and negotiating stairs, these symptoms were also noted in medical records of care and treatment for several other service and nonservice connected disabilities of the lumbar spine, radiculopathy of each lower extremity, right knee, and pes planus. The Board is mindful that where it is not possible to distinguish the effects of a non-service- connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. 38 C.F.R. § 3.102; Mittlieder v. West, 11 Vet. App. 181 (1998). In this case, there is evidence indicating that the Veteran's lumbar spine disability imposes a significant level of mobility impairment. The Veteran was retired from the Air Force Reserve and stopped working in 2009 because of her back. Imaging studies show multilevel degenerative disc disease with significant limitation of back motion and endurance such that the disability is rating as 40 percent disabling with additional ratings for bilateral radiculopathy. Further, the Veteran's service connected right knee provides some contribution to reduced mobility. Moreover, the most recent examiner noted that body habitus was a more likely cause of knee pain than the residuals of the left knee injury and corrective surgery. Without clinical quantification, it is reasonable that not all mobility limitation is attributable to the left knee. Finally, the internet excerpts confirm what is already shown in the medical records-the Veteran has developed degenerative arthritis following ACL reconstruction, which is contemplated in the assigned rating. As final point, the Board that no other diagnostic code for evaluating musculoskeletal disability of the knee is applicable at any point in this appeal. The Veteran's not been shown to involve ankylosis of the knee (DC 5256), removal of semilunar cartilage (DC 5269), impairment of the tibia and fibula (DC 5262), or genu recurvatum (DC 5263). See 38 C.F.R. § 4.71a. The above determinations are based upon consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point pertinent to this appeal has the left knee disability been shown to be so exceptional or unusual as to render the applicable criteria for rating the disability inadequate, and to warrant assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (cited in the September 2006 SOC, and discussed in the April 2013 ). The determination of whether a claimant is entitled to an extra-schedular rating is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The first step is to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. If it is determined that this is so, the second step of the inquiry requires a determination of "whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Id. at 116. Finally, if the first two steps of the inquiry have been satisfied, the third step requires referral of the claim to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether an extra-schedular rating is warranted. Id. In this case, the rating criteria contemplates the Veteran's principal, residual symptoms of limitation of motion, cartilage damage, and pain, Moreover, As indicated, the rating schedule provides for the assignment of higher ratings are assignable based upon a showing of more significant, or additional,, functional impairment shown on testing or via clinical assessment. Significantly, while the Veteran and her representative have clearly asserted her entitlement to higher ratings based on functional loss associated with pain, neither has alleged, and the record does not otherwise indicate, that applicable the schedular criteria are inadequate to rate the left knee disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, although the Veteran has submitted evidence of a medical disability, and made a claim for the highest rating possible, she had not specifically alleged, or submitted evidence of , unemployability due to the left knee, In fact, as noted above, although the Veteran is not working, she reported that she stopped working in May 2009 because of her back disability. Accordingly, the Board finds that the question of the Veteran entitlement to a total disability rating based on individual unemployability (TDIU) due to the service-connected left knee disability has not been raised as a component of the claim for higher rating, and need not be addressed. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). For all the foregoing reasons, the Board concludes that, while a 20 percent, but no higher, initial rating for service-connected left knee disability is warranted for the period from June 4, 2005 to August 15, 2005, a rating in excess of 10 percent for the disability, for the periods from October 1, 2005 to October 15, 2006, and from March 20, 2007, and thereafter, must be denied. The Board has favorably applied the benefit-of-the-doubt doctrine in assigning a 20 percent rating for the period from June 45, 2005 to August 15, 2005, but finds that the preponderance of the evidence is against assignment of a rating greater than 10 percent at any pertinent point on or after October 1, 2005. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial rating of 20 percent rating for residuals of a left knee injury, for the period from June 4, 2005 to August 15, 2005, is granted, subject to the legal authority governing the payment of compensation. A rating in excess of 10 percent for residuals of ACL reconstruction of the left knee from October1, 2005 to October 15, 2006 and from March 20, 2007 thereafter is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs