Citation Nr: 1329893 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 06-31 726A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a rating in excess of 10 percent for arthritis of the right knee. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. McPhaull, Counsel INTRODUCTION The Veteran served on active duty from January 1984 to March 1989; from March 2003 to April 2004; and from January 2007 to January 2011. The Veteran has also had periods of active and inactive duty for training. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision by the St. Petersburg, Florida Department of Veterans Affairs (VA) Regional Office (RO). In September 2010, this matter along with entitlement to service connection for right and left carpal tunnel syndrome was remanded for further development, to include VA examinations and opinions. In a January 2012 rating decision, the RO granted the Veteran's service connection claim. Consequently, such issue is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). A review of the Virtual VA paperless claims processing system reveals additional documents pertinent to the present appeal, to include service treatment records dated from 2007 to 2011, and a January 2013 VA general examination, that also addresses the Veteran's service-connected right knee disability. Relevant to this evidence, the Board observes, that it was associated with the file subsequent to the most recent January 2012 supplemental statement of the case (SSOC). In August 2013, the Veteran's representative waived initial RO jurisdiction of all the newly submitted evidence. Finally, in September 2012, the Veteran's representative raised the issue of entitlement to service connection for hypertension, as well as service connection for residuals of a nose fracture, and residuals from an in-service motor vehicle accident that include neck and back problems. Such issues are referred to the Agency of Original Jurisdiction for appropriate action. FINDINGS OF FACT 1. The Veteran's service-connected right knee disability has more closely approximated dislocation of semi-lunar cartilage with frequent episodes of locking, pain and effusion into the joint. 2. As of January 20, 2011, the Veteran's right knee extension was factually shown to be limited to 10 degrees. CONCLUSIONS OF LAW 1. The criteria for the assignment of a 20 percent rating right knee meniscal injury have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-5263 (2013). 2. The criteria for a separate 10 percent disability rating for the service-connected right knee arthritis based upon limitation of extension have been met for the period beginning on January 20, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). For an increased-compensation claim, the VCAA requirement is 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. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of this claim prior to the initial adjudication. An October 2006 letter explained how VA establishes disability ratings and effective dates. Such communication also informed him of the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. Thus, the notice requirements under the VCAA have been fully satisfied. Accordingly, no further action is required regarding the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's pertinent records of treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no additional available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any additional outstanding evidence that has not been obtained with respect to the Veteran's claim. Additionally, the Veteran was afforded VA examinations in November 2006, and pursuant to the Board remand, in January 2011. The Board also observes that there is a recent January 2013 VA general examination that, among others things, addresses the Veteran's right knee disability. The Board finds that the examinations are adequate because, as shown below, they were based upon consideration of the pertinent medical history, the Veteran's lay assertions and current complaints, and because they describe the disability in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Additionally, since the Board finds no credible lay or medical evidence of increased severity of right knee disability since the January 2013 VA examination, additional examination is not warranted. VAOPGCPREC 11-95 (Apr. 7, 1995). For the above reasons, no further notice or assistance to the Veteran 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 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board also finds that there was substantial compliance with the September 2010 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to substantial compliance with a remand order. See Stegall v. West, 11 Vet. App. 268 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to the internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). Specifically in this case, the Board directed the AMC/RO to obtain outstanding treatment records, to include VA and private, dated from February 2007 to the present. The RO was also to arrange for the Veteran to undergo an orthopedic examination in order to assess the current severity of his service-connected right knee disability. All available records, to the extent possible, have been associated with the Veteran's file. And, as noted, the Veteran was examined in January 2011. The Board's September 2010 remand also instructed the AMC/RO to readjudicate the claim and furnish a SSOC if the claim was denied. This was accomplished by a January 2011 SSOC. For these reasons, the Board finds that there was substantial compliance with the September 2010 remand directives. Accordingly, no further remand is necessary as to this issue. See Stegall, 11 Vet. App. 268 (1998); D'Aries, 22 Vet. App. at 104-05. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran contends that he is entitled to a rating greater than 10 percent for his service-connected right knee disability. He has a history of right medial meniscectomy, and reports symptoms such as pain, discomfort, stiffness, swelling, give-way, lack of endurance, locking and deformity. He further describes functional impairment difficulty with walking and standing for prolonged periods of time. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § C.F.R. 4.1. Where 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. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. 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). A claimant, however, may experience multiple distinct degrees of disability, resulting in different levels of compensation, from the time the increased rating claim is filed to the time a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration that different (staged) ratings may be warranted for different time periods during the period of appellate review beginning within one year of his October 2006 claim for increase. The Veteran's right knee injury was originally rated under hyphenated Diagnostic Code 5010-5257. In the selection of diagnostic codes assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case indicates that, under Diagnostic Code 5010, is the service-connected disorder and that instability, under Diagnostic Code 5257, is a residual condition. "Other" impairment of the knee, namely, if due to recurrent subluxation or lateral instability, is rated under Diagnostic Code 5257 as 10-percent disabling if "slight," as 20-percent disabling if "moderate," and as 30-percent disabling if "severe." Descriptive words such as "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. The Veteran has a history of right medial meniscectomy. The criteria of Diagnostic Code 5259 provide for a 10 percent rating for symptomatic removal of semi-lunar cartilage. The criteria of Diagnostic Code 5258 provide a 20 percent rating for dislocation of semi-lunar cartilage with frequent episodes of "locking," pain and effusion into the joint. The VA Office of General Counsel has also stated that DC 5259, removal of semilunar cartilage, may result in complications producing loss of motion. As such, limitation of motion is a relevant consideration under DC 5259. VAOPGCPREC 9-98 (Aug. 14, 1998). Diagnostic Code 5260 provides that flexion limited to 15 degrees warrants a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a 0 percent (noncompensable) rating. Diagnostic Code 5261 provides that extension limited to 45 degrees warrants a 50 percent rating; extension limited to 30 degrees warrants a 40 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 5 degrees warrants a 0 percent (noncompensable) rating. For comparison, normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (July 1, 1997; revised July 24, 1997). The General Counsel subsequently clarified in VAOPGCPREC 9-98 (August 14, 1998) that for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. VA's General Counsel further explained that, if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, a separate rating for arthritis also could be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. This is because, read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). VA's General Counsel has additionally held that separate ratings may be assigned, as well, for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59, 990 (2004). Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same knee, the limitations must be rated separately to adequately compensate him for functional loss associated with injury to his leg and knee. Id. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. Schedular rating In the present case, the Board finds by comparing the Veteran's symptoms to the rating criteria, a 20 percent rating under Diagnostic Code 5258 is warranted for the entire appeal period, and a separate 10 percent rating for limitation of extension under Diagnostic Code 5261 is warranted effective January 20, 2011. The Veteran has described right knee pain and weakness with locking episodes at least two times per month, and swelling 2 to 3 times per week. His complaints are consistent with the results from a magnetic resonance imaging (MRI) scan of the right knee in 2003 which were interpreted as showing degenerative tear of the medial meniscus versus previous partial meniscectomy, discoid lateral meniscus with oblique undersurface tear of the anterior horn, and high grade chondromalacia in the medial compartment and medial trochlea with low grade chondromalacia of the lateral compartment. Furthermore, VA Compensation and Pension (C&P) examination in confirmed the presence of moderate suprapatellar knee effusion. Overall, the Board finds that the Veteran's service-connected right knee disability has more closely approximated the criteria for dislocation of semi-lunar cartilage with frequent episodes of "locking," pain and effusion into the joint for the entire appeal period. To this extent, a 20 percent rating is warranted under Diagnostic Code 5258 for the entire appeal period. The Board also finds that a separate 10 percent rating for limitation of extension is warranted under Diagnostic Code 5261 since January 20, 2011. For the entire appeal period, the Veteran's right knee disability has not been manifested by flexion limited to 45 degrees or less - to even warrant a minimum compensable rating under Diagnostic Code 5260. Prior to January 20, 2011, the Veteran's limitation of extension was not shown to be limited to 10 degrees to warrant consideration of a compensable rating, but a 10 degree of limitation of extension was shown on VA examination on January 20, 2011. The Veteran's treatment records note symptoms of crepitus and medial line tenderness, but also report "full range of motion." The Veteran underwent a VA examination in November 2006, where he complained of intermittent pain in the right knee both on the lateral and medial aspects that was precipitated with prolonged walking and sitting, with occasional swelling and giving out of the knee. Upon clinical evaluation, flexion was to 110 degrees with pain starting at 90 degrees and extension was to -5 degrees. There was no additional limitation of motion following repetitive use. On January 20, 2011 VA examination, the Veteran reported daily right knee stiffness, swelling 2 to 3 times a week, weakness, and locking at least 2 times a month for approximately 15 minutes. He denied any giving away of the right knee but did report a popping sound 3 to 4 times a week. He reported flare-ups 1 to 2 times a day that lasts up to an hour. The Veteran also reported that he had not had any additional right knee surgery since 1992. Upon physical examination, the Veteran was noted to ambulate with a normal gait, and without assistive devices such as a cane or crutches. Active and passive right knee range of motion after three repetitions revealed that the Veteran lacked 10 degrees from full extension; but was able to flex to 115 degrees with pain starting at 60 degrees. There was infrapatellar bursal tenderness; however there was no suprapatellar bursal tenderness. There was no popliteal mass. There was no redness, warmth or crepitus around the right knee after taking off the knee brace. On January 2013 VA general examination, the Veteran reported right knee weakness, stiffness, swelling, giving way, lack of endurance, locking, deformity, and pain. He denied that he experiences heat, redness, fatigability, tenderness, drainage, effusion, subluxation, and dislocation. The Veteran reported that he experiences flare-ups as often as 3 times per week that lasts for up to 3 hours. During the flare-ups, the Veteran reported difficulty with standing and walking. He indicated that his condition had not resulted in any incapacitation. See page 2 of the VA examination report in Virtual VA. Physical examination of the right knee revealed tenderness and medial joint line tenderness, pain with McMurray and squatting. There were no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, and drainage. There was no subluxation. Right knee range of motion revealed flexion was to 120 degrees with pain at 110 degrees. Extension was limited to 10 degrees. There was no additional degree of limitation with repetitive range of motion. The examiner found that the right knee joint was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. See page 7 of the VA examination report in Virtual VA. Overall, these findings show, at best, that the Veteran falls well short of a compensable rating for loss of flexion under Diagnostic Code 5260. VA examination in November 2006 found limitation of extension limited to 5 degrees, but found no further motion loss on repetitive testing. The Veteran himself did not describe limitation of flexion to 10 degrees. As such, even with consideration of 38 C.F.R. §§ 4.40 and 4.45, there is no credible factual basis for the assignment of a compensable rating for limitation of flexion or extension prior to January 20, 2011. There is also no lay or medical evidence of right knee extension limited to 15 degrees for any time during the appeal period. On VA examination on January 20, 2011, the Veteran did demonstrate limitation of extension to 10 degrees. This meets the criteria for a 10 percent rating under Diagnostic Code 5261. The Board finds no precedential authority which speaks to whether separate ratings may be assigned under Diagnostic Codes 5258 and 5261, and the Board can find no persuasive reason which specifically states that Diagnostic Code 5258 contemplates limitation of extension. Thus, a separate 10 percent rating for limitation of extension will be assigned effective January 20, 2011. The Board also finds that a higher rating still cannot be awarded under Diagnostic Code 5257. At the outset, the Board notes that the RO originally coded a 10 percent disability rating under Diagnostic Code "5010-5257." An April 2006 RO rating decision contains hand-written notations which manually crossed out "5257," thus apparently reflecting use of Diagnostic Code 5010. A December 2011 RO rating decision again reflects Diagnostic Code "5010-5257," but also contains an explanation sheet that the Veteran has been assigned a 10 percent rating under Diagnostic Code "5261." As none of the ratings assigned by the RO are "protected" and the Board awards increased compensation, the Board is not constrained to the RO's use of diagnostic coding. See generally Murray v. Shinseki, 24 Vet. App. 420, 424 (2011); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The treatment records describe the Veteran as having full right knee motion with "firm/intact ligaments." Similarly, at the November 2006 VA examination, the examiner found that upon physical examination, the right knee was stable to testing. The collateral and cruciate ligaments were intact, and Lachman, anterior drawer, as well as McMurray tests were negative. The VA examiner in January 2011 found no right knee instability, laxity or subluxation. The Veteran's medial and lateral collateral ligaments were intact to valgus and varus stresses. There was negative anterior and posterior drawer sign, negative Lachman, and negative McMurray's. There was a slightly positive grind test. The right knee was tender to the medial and lateral joint line. The examiner noted no laxity, or instability; and found only mild functional limitations. The VA examiner in January 2013 found that the right knee stability tests were within normal limits for anterior and posterior cruciate ligaments, medial, and lateral collateral ligaments and the medial and lateral meniscus. Here, the Veteran does report symptoms of weakness, locking, give-way, etc., but his clinical evaluations have found no evidence of instability or subluxation. Notably, his "locking" symptoms are directly rated under Diagnostic Code 5258. As such, the Board finds that the Veteran does not meet the minimal criteria for "slight" recurrent subluxation or lateral instability of the knee under Diagnostic Code 5257. While the Veteran reports functional impairments, the VA examinations do not show any further limitation of motion due to functional impairment, or other functional impairment which is not contemplated by his 20 percent rating under Diagnostic Code 5258 and the separate 10 percent rating under Diagnostic Code 5261. Thus, a higher rating is not warranted on the basis of limited flexion or extension, even when considering functional limitation due to the DeLuca factors. 38 C.F.R. § 4.71a, Codes 5260-5261. Finally, other schedular criteria for rating knee disability do not apply as the pathology/impairment required for rating under those criteria is not shown. There is no evidence of ankylosis. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."). Because the Veteran is able to move his right knee joint in both flexion and extension (albeit less than normally would be expected in flexion), by definition, his right knee is not immobile or fixated and therefore not ankylosed. In so holding, the Board finds that the Veteran's subjective complaints are credible and consistent with the evidentiary record. However, to the extent that the Veteran argues entitlement to a higher rating still, the Board places greater probative weight to the VA examiner findings as they possess greater training, expertise and use of precision equipment, such as a goniometer to measure motion loss. There is no further doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). Both periods The Board observes that the Veteran has a 6cm well-healed scar due to surgery on the right knee. Such has not been noted to limit motion or function. See November 2006 VA joints examination; see also January 2013 VA general examination in Virtual VA. Therefore, a separate compensable rating for the scar is not warranted. Extraschedular Considerations The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the Veteran reports symptoms such as pain, discomfort, stiffness, swelling, give-way, lack of endurance, locking, deformity and functional impairment on use. He has also reported during examinations that his right knee disability did not particularly interfere with his work duties, other than pain with lifting, gripping, running, squatting, and prolonged standing. Here, the Veteran's symptoms of locking, pain and swelling have been addressed with the assignment of a 20 percent rating under Diagnostic Code 5285, and his limitation of motion has been separately evaluated under Diagnostic Code 5261. The Board has considered whether further compensation can be awarded for ankylosis, instability, subluxation and functional impairment on use, but finds that the criteria for a higher rating still have not been met. In the opinion of the Board, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. Thus, the Veteran's right knee symptomatology does not present an exceptional or unusual disability picture. Consequently, the Board need not address whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 115-16. For these reasons, the rating schedule is adequate to evaluate the disability, and referral for extraschedular consideration is not in order. Finally, as the Veteran is currently employed, a claim of entitlement to total disability rating due to individual unemployability is not for consideration. ORDER A 20 percent rating right knee meniscal injury under Diagnostic Code 5258 is granted subject to the regulations governing monetary awards. A separate evaluation of 10 percent for limitation of right knee extension as of January 20, 2011, is granted, subject to the regulations governing monetary awards. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs