Citation Nr: 1331984 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 06-08 061 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE 1. Entitlement to an initial rating in excess of 10 percent for arthritis as a residual of left knee anterior cruciate ligament (ACL) reconstruction with chondromalacia debridement. 2. Entitlement to an initial rating in excess of 10 percent for instability as a residual of left knee ACL reconstruction with chondromalacia debridement. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran served on active duty from April 1996 to July 2004. This appeal to the Board of Veterans' Appeals (Board) arose from a June 2005 rating decision in which the Muskogee, Oklahoma, RO granted service connection and assigned an initial, 10 percent rating for left knee, status post ACL repair, effective July 12, 2004. In September 2005, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in January 2006, and in February 2006, the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals). This appeal also arose from a January 2006 rating decision in which the RO granted a temporary evaluation of 100 percent based on surgical treatment necessitating convalescence, from April 7, 2005 to May 31, 2005. In April 2006, the Veteran filed an NOD, requesting a temporary evaluation prior to April 7, 2005. Because the Veteran has disagreed with the initial rating assigned following the grant of service connection for his residuals of left knee ACL reconstruction, the Board has characterized this claim in light of Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). During the pendency of the appeal, the Veteran's claims file was transferred to the jurisdiction of the RO in Roanoke, Virginia, which has certified the appeal to the Board. In his substantive appeal, the Veteran requested a hearing before a Veterans Law Judge at the RO. A March 2010 letter informed him that his hearing was scheduled for May 2010. However, in correspondence received in May 2010, the Veteran cancelled his hearing request, requesting a Board hearing in Washington, D.C. A July 2010 letter informed him that his hearing was scheduled at the Board in Washington, D.C., for September 2010. However, in correspondence received in September 2010, the Veteran cancelled his hearing request, requesting a new hearing be rescheduled. The Veteran's hearing was rescheduled in March 2011, and the Veteran was informed by a letter dated in December 2010. Although the hearing notification was not returned by the U.S. Postal Service as undeliverable, the Veteran failed to report for the scheduled hearing, and has not requested rescheduling of the hearing. As such, his hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(d) (2013). In an April 2011 decision, the Board dismissed claims for (1) an initial rating in excess of 70 percent for PTSD with sleep disorder, (2) an initial compensable rating for sexual dysfunction, and (3) service connection for right knee ACL tear because those claims had been withdrawn. The claim for an initial rating in excess of 10 percent for residuals of left knee ACL reconstruction was remanded. Also, a claim for a temporary total disability rating, pursuant to 38 C.F.R. § 4.30, prior to April 7, 2005, was remanded for the issuance of an SOC addressing that matter because the Veteran has filed a timely NOD with the January 2006 rating decision denying that claim. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); Holland v. Gober, 10 Vet. App. 433, 436 (1997). In that remand, and citing 38 U.S.C.A. § 7105 and 38 C.F.R. §§ 20.200, 20.201, 20.202, the Board emphasized that for the Veteran to obtain appellate review of any issue not currently in appellate status, a perfected appeal must be filed. Subsequently, in October 2001 and in compliance with the April 2011 Board remand, the RO issued an SOC in October 2011 addressing the issue of a temporary total rating under 38 C.F.R. § 4.30 prior to April 7, 2005. However, neither the Veteran nor his representative filed a Substantive Appeal which would have perfected the appeal to the Board of that issue. Following the Board remand the Veteran claimed entitlement to a separate compensable rating for a sleep disorder (distinct from his service-connected PTSD), claimed as due to inservice asbestosis exposure. That claim was denied by a February 2013 rating decision. That decision also classified the left knee disorder as left knee ACL repair with chondromalacia debridement. However, no NOD has been filed which would initiate an appeal from that decision. Thus, this matter is not developed for appellate consideration and is not now before the Board. The Board notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal, except as otherwise specified herein. Because the Board finds that a compensable rating is warranted for instability of the left knee, separate from the 10 percent rating assigned for arthritis, the issues have been recharacterized as stated on the title page. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim on appeal have been accomplished. 2. The Veteran's service connected post-operative left knee residuals has been manifested by radiologically documented osteoarthritis and complaints of pain but no compensable degree of limitation of extension or flexion; and there have been no medical findings of locking, ankylosis, impairment of the tibia or fibula, or genu recurvatum. 3. The Veteran's service connected post-operative left knee residuals has been manifested by surgical screw fixation of the ACL to the tibia which equates to mild instability but there is no subluxation and instability which is more than mild. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for residuals of left knee ACL reconstruction based on arthritis are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.3, 4.7, 4.40, 4.45, 4.71, 4.71a, Diagnostic Codes 5099-5024 (2013). 2. The criteria for an initial rating of no more than 10 percent for residuals of left knee ACL reconstruction based on instability are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.3, 4.7, 4.40, 4.45, 4.71, 4.71a, Diagnostic Code 5257 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Here, the Veteran was provided appropriate VCAA notice of what was required to substantiate his July 2004 claim for service connection for left knee disability by RO letter in August 2004, prior to the initial adjudication, and grant of service connection for left knee disability, by the June 2005 RO rating decision which is appealed. This appeal arises from the Veteran's filing an NOD with the initial 10 percent rating assigned upon granting service connection. Once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Accordingly, the Board finds that VA satisfied its duties to notify the Veteran in this case. As for the duty to assist, the RO obtained the Veteran's service treatment records (STRs), VA treatment records, and private clinical records. In fact, additional VA treatment records from Richmond and Fredericksburg, Virginia, have been obtained pursuant to and in compliance with the 2011 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998). Also, the Veteran was afforded a VA examination of his left knee in January 2005, in conjunction with his claim for service connection for left knee disability. During the remand of this case, although not required by the terms of the 2011 Board remand, the Veteran was twice scheduled for examination of his knees, in October 2011 and March 2012 but he failed to appear for such examination. Because an initial rating claim is considered to be "an original compensation claim" in applying 38 C.F.R. § 3.655(b), when a veteran fails to report for an examination in conjunction with a claim for a higher initial rating the disability should be rated based on the evidence of record, as opposed to being summarily denied. See Turk v. Peake, 21 Vet. App. 565, 570 (2998). The Board also finds that no additional RO action to further develop the record in this appeal is warranted. As there is neither an indication that the Veteran was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board concludes that there has been full VCAA compliance. II. Background The Veteran's STRs show that in 2004 he underwent a repair of the ACL of the left knee. A private medical statement from Dr. S. M. in March 2004, prior to the surgery, indicated that the Veteran might have a left medial meniscus tear. Dr. W. C. reported in November 2004 that the 2004 surgery was an ACL reconstruction with a hamstring graft. Thereafter, he had had persistent swelling, for which he had aspirations, one of which suggested an infection and for which he was put on anti-biotics but had had persistent pain and stiffness. On examination he had moderate left quadriceps atrophy with left knee flexion to 120 degrees and full extension to 0 degrees. The ACL felt a bit loose, compared to the right knee but left collateral ligaments were intact and there were no joint line pain or menisceal signs. X-rays revealed tibial fixation with a "washer lock system." It was felt that he would benefit from rehabilitation. On VA general medical examination in January 2005, the Veteran reported that he experienced left knee stiffness and swelling following his in-service left knee surgery. He had not been free of pain or discomfort at any time, and described the severity of the left knee problem as fluctuating from 5 to 9 on a scale of 10. The problem also caused him to occasionally lose sleep but he had not missed any work. He had flare-ups when engaged in any hard impact activity and Hydrocodone provided relief. He was not now using an assistive device due to his left knee. The examiner specifically noted that upon entering the examining room the Veteran did not use an assistive device and he appeared not to lean from one side to the other or to favor one side to the other. He sat, stood, and changed bodily positions in a normal fashion. On physical examination, the Veteran had a postoperative left knee scar with irregular texture but regular margins and there was no redness, swelling or discharge. There was minimal adherence to underling tissue without elevation or depression. The color of the scar was nearly that of surrounding tissue. Patellar inhibition test was minimally positive. Drawer's test was negative and there was no evidence of instability. Left knee extension was to zero (0) degrees passively and unreduced by resistance or repetition without shortening of duration. Flexion was to 115 degrees, actively. Passively, left knee flexion was to 120 degrees without discomfort, particularly beyond 85 degrees. Quadriceps reflex was barely obtainable, likely due to guarding. Muscle mass and strength appeared to be normal. Left knee X-rays revealed post-surgical changes of the ACL repair, including a screw through the proximal tibia. Otherwise, the bones and joint space as well as soft tissue were normal. The pertinent diagnosis was left knee, status post ACL repair. The examiner remarked that as to "DeLuca" criteria it was not foreseen that there would be any further loss of range of motion in the near future. A February 2005 private magnetic resonance imaging (MRI) scan revealed moderate left knee effusion but the ACL repair with graft was intact; there was a loose body, posteriorly, in the intercondylar notch versus an area of synovial osteochondromatosis; and focal areas of osteochondral injury, centrally, in the patellar articular surface and at the lateral aspect of the medial femoral condyle. On file are reports in March and April 2005 from R. R.., D. O. In March 2005, the Veteran walked without an assistive device and he had well healed left knee incisions. He had moderate effusion and patellofemoral crepitus. He had full extension and full flexion. Knee stability was good and strength was 4/5. On examination later that month he had joint line tenderness and tenderness to compression of the patella in the femoral groove. He again had full extension and flexion was to 120 degrees. In April 2005, stability testing suggested some looseness to the endpoint of the ACL. Later that month it was noted that he was exercising, and on examination he had knee guarding and some decreased strength. He had some redness of the skin and the diagnosis was postoperative cellulitis but septic arthritis was to be ruled out. Two days later, the area of redness had decreased and the diagnosis was postoperative cellulitis. He was to return to his activities as his pain allowed. VAOPT records on file include a January 2006 notation that the Veteran had left knee osteoarthritis for which he had had continued medical management but it was very doubtful that additional knee surgery, short of a knee replacement, would given him satisfactory pain relief, and his last "clean out" procedure (in April 2005) had not been of great help. VA CAPRI treatment records in VA's paperless Virtual VA system show that in January 2007 left knee weight-bearing X-rays revealed postsurgical changes with a large caliber orthopedic screw within the proximal left tibia. There was narrowing along the medial compartment with adjacent sclerosis. There was no malalignment or other bony pathology. There had been interval resolution of small suprapatellar joint effusion. The impressions were postsurgical changes of the left knee with a large caliber orthopedic screw within the proximal left tibia, unchanged; and osteoarthritis involving the left knee. VAOPT records show that, in September 2007, it was noted that the Veteran still had mechanical pain and catching. Following an infection after his first left knee surgery, during service, he had an infection and an arthroscopy (in April 2005) had helped but, still, the knee had gotten worse again in the last 1 1/2 years because it would hang up, popped, and sounded as if there was gravel within that knee. He walked with a flexed knee gait, and was obviously quite debilitated. He wanted further surgical intervention. A surgeon, who had reviewed the Veteran's MRI results, informed the Veteran that if all he had were patches of damage on the back of his kneecap, these were not amenable to arthroscopic surgery. In terms of his motion, it was excellent. His stability was very good as well. His graft seemed to have worked well. Physicians were unsure if he had some scar tissue that was catching, or perhaps it was a cartilaginous flap. The Veteran did not want to take the narcotic pain management that he had had in the past, and he had not been taking it for some time. Rather, he wanted one more surgical attempt made to obtain a functional knee. The surgeon discussed with the Veteran the very real possibility that no surgically correctable pathology would be found. The surgeon did not see any evidence of infection or bony injury in the knee. VAOPT records show that, in January 2008, the Veteran's gait was slow but steady and he appeared grossly neurologically intact. He underwent a left patellar chondroplasty on January 17, 2008, with removal of a medial scar. It was noted that in addition to his inservice surgery, he had had an arthroscopic evaluation of his left knee on one prior occasion (for a total of three procedures). VAOPT records show that, in June 2008, the Veteran had some slight, but unmeasured, decreased left knee motion after having wrenched that knee. In November 2008, his postoperative left knee scars were well-healed. VA CAPRI treatment records in VA's paperless Virtual VA system show that, in November 2008, the Veteran had full range of motion of the left knee, but pain on forced left knee flexion. There was no joint effusion. There was some varus and valgus stress laxity of the left knee. VAOPT records show that in April 2009 the Veteran took Hydrocone for chronic left knee pain. Contained within Virtual VA records is a report of a May 2009 VA examination which revealed that as to the Veteran's left knee there were no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement. There was no 'locking' pain, genu recurvatum or crepitus of that knee. Left knee extension was to 0 degrees and flexion was to 140 degrees. Left knee joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The anterior and posterior cruciate ligaments stability test of the left knee is within normal limits. The medial and lateral collateral ligaments stability test of the left knee is within normal limits. The medial and lateral meniscus test of the left knee is within normal limits. On neurological examination of the lower extremities motor function is within normal limits. Sensory function is within normal limits. The left lower extremity reflexes reveal knee jerk 2+ and ankle jerk 2+. Peripheral nerve involvement was not evident during examination. There was no pertinent diagnosis. VA CAPRI treatment records in VA's paperless Virtual VA system show that, in June 2009, the Veteran was fitted for a knee brace. It was noted that a report of the 2008 surgery showed basically an intact anterior cruciate ligament graft, intact posterior cruciate ligament, lateral ligaments, menisci, some mild chondromalacia patella and some scar tissue formation which was debrided. However, he continued to have chronic knee pain and stated that, when he tried to stand after sitting for a while, he felt a popping in the knee and had significant pain. He had pain after walking a distance, and had swelling of the knee but no true locking of the knee. On physical examination, he had well-healed surgical scars. Cruciate and collateral ligaments felt stable including Drawer, Lachman and pivot testing on the left knee. There was some pain with varus and valgus stress and with McMurray testing. There is a normal neurovascular check to the leg but the Veteran reported having some anterolateral decreased sensation to light touch proximally in the leg just below the knee secondary to his old surgery. His last MRI scan in August 2007, which was before his most recent arthroscopy, was fairly unremarkable other than showing the graft still to be in place. Prior X-rays of the knee had shown only the surgical screw in place. VA CAPRI treatment records from April 2012 to June 2013 in VA's paperless Virtual VA system show that, in May 2012, the Veteran complained of left knee pain which was 7 on a scale of 10. His medication which was originally for left knee pain was now also used for neck pain. A March 2012 MRI had revealed that the left ACL graft was intact, there was no definitive acute menisceal tear, and there was focal marrow edema within the medical aspect of the medial femoral condyle with associated cartilage increased representing osteochrondral abnormality on a degenerative or traumatic basis. Additional VA CAPRI treatment records show that, on examination in July 2012, the Veteran had no effusion but full range of motion of both knees. His motor strength was 5/5 in all extremities and his gait was normal. III. 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 an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Fenderson v. West, 12 Vet. App. 119 (1999). Each following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 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 (2011); 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). The Veteran's left knee disability has been rated 10 percent disabling using a built-up Diagnostic Code (DC) as tenosynovitis, and cited as DC 5099-5024. See 38 C.F.R. §§ 4.20 and 4.27 (providing for analogous ratings). In turn, tenosynovitis, DC 5024, is rated as degenerative arthritis under 38 C.F.R. § 4.71a, DC 5003. Under Diagnostic Code 5003, 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 (here, Diagnostic Codes 5260 and 5261). When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating is assignable each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. See also 38 C.F.R. § 4.71a, Diagnostic Code 5010 (prescribing that arthritis due to trauma, substantiated by x-ray findings, should be evaluated as degenerative arthritis). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Standard range of knee motion is from 0 degrees (on extension) to 140 degrees (on flexion). See 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, a noncompensable rating is assigned for flexion limited to 60 degrees. A rating of 10 percent requires limitation of flexion to 45 degrees. A rating of 20 percent requires limitation of flexion to 30 degrees, and a rating of 30 percent requires limitation of flexion to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code5260. Under Diagnostic Code 5261, a rating of 10 percent requires limitation of extension to 10 degrees. A rating of 20 percent requires limitation of extension to 15 degrees. A rating of 30 percent requires limitation of extension to 20 degrees. A rating of 40 percent requires limitation of extension to 30 degrees, and a rating of 50 percent requires limitation of extension to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code5261. The VA General Counsel has 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). Also, since the Veteran has had ligament reconstruction, the Board will also consider the potential assignment of a rating under Diagnostic Code 5257. Under that code, recurrent subluxation or lateral instability of the knee is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board also notes that DC 5259 provides for a single and maximum 10 percent rating for symptomatic residuals of removal of a semilunar cartilage of a knee and that DC 5259 provides for a single and maximum rating of 20 percent for a dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. A. Arthritis of the Left Knee The Veteran has had two postservice surgical procedures on the left knee and for these he was assigned temporary total convalescent rating under 38 C.F.R. § 4.30 from April 7, 2005, to May 31, 2005, and from January 17, 2008, to March 31, 2008. Otherwise, the left knee disability has been rated 10 percent disabling beginning July 12, 2004, the day after service discharge. Here, while there is a retained metallic screw in the tibia, the Veteran has no malunion or nonunion of the left tibia which would warrant assigning a rating under DC 5262 for tibial or fibular impairment. Likewise, there is no evidence of genu recurvatum warranting a rating under DC 5263 or of ankylosis warranting a rating under DC 5256. Also, while it was once suspected that he had a left medial meniscus tear during service, his in-service surgery consisted only of repair of the left ACL and there is otherwise no supportive clinical evidence of his ever having had a meniscectomy (removal of semilunar cartilage) or dislocation of a cartilage which would warrant a rating under DCs 5259 and 5258, respectively. The most recent MRI in 2012 showed no meniscal abnormalities. The Veteran initially had an infection after the in-service left knee surgery, but with anti-biotics this resolved and there is no radiological evidence that he developed septic arthritis, as once suspected; although, X-rays do confirm the presence of left knee osteoarthritis. He has had postoperative scarring from his three surgical procedures and a separate noncompensable rating is assigned for such scarring. To the extent that the rating for left knee scarring is implicitly a part of this appeal, the Board notes that the January 2005 VA examination found minimal adherence of left knee postoperative scarring but this is in contrast to a private physician's statement two months later, in March 2005 and prior to the second knee surgery in April 2005, that the incisions were well healed. Thereafter, VA clinical records of November 2008 and June 2008, after the second and third knee surgeries, specifically found that the postoperative incisional scars were well healed. From this the Board concludes that the preponderance of the evidence shows that the postoperative scars have been well healed and asymptomatic. Thus, a separate rating for disability due to such scarring is not warranted. See Esteban v. Brown, 6 Vet. App. 259 (1994). Following the third left knee surgery, by VA, in January 2008 the Veteran reported at an outpatient evaluation in June 2009 that he had decreased sensation below the left knee due to his knee surgery. There were no such complaints prior to this most recent surgery, so it must be assumed that he averred that such complaint stemmed from this recent surgery. On the other, hand on examination on an outpatient basis in May 2009 he underwent an extensive examination, and this included a neurological evaluation. That neurological evaluation found that his sensory function was within normal limits, his knee reflexes were normal, at 2+, and there was no peripheral nerve involvement. Significantly, the June 2009 outpatient evaluation only noted that he complained of decreased sensation and there were neither actual clinical finding relating to that complaint nor any diagnosis of a postoperative neurological abnormality. In this regard, had the Veteran attended the VA examinations scheduled for rating purposes in October 2001 and March 2012 it is possible that more information could have been obtained regarding this matter. However, he did not and as a result the Board concludes that from the evidence of record there is no persuasive evidence of a neurological abnormality of the left lower extremity stemming from any left knee surgery which would warrant a separate compensable disability rating. It is undisputed that the Veteran now has radiologically documented left knee osteoarthritis. Thus, range of motion in extension and flexion must be addressed, as well as any functional impairment from pain. In this regard, he has never had any clinically documented limitation of either flexion or extension which would warrant a compensable rating. His extension has always been found to be full and his flexion has never been less than 115 degrees, which is a noncompensable degree of limitation of flexion. The current 10 percent rating is based upon the Veteran's complaints of pain together with the finding of a noncompensable degree of limited left knee flexion. A higher rating based on impairment due to the effect of pain on motion and function is not otherwise shown to be warranted. Accordingly, the Board concludes there is no basis for staged rating for arthritis as a residual of left knee ACL reconstruction with chondromalacia debridement, pursuant to Fenderson, and that the claim for higher rating must be denied. In this determination, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating for left knee arthritis, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. B. Instability of the Left Knee On the other hand, the evidence is clear that the left ACL is held in place in its attachment to the tibia by a surgical screw. The Veteran has also been prescribed a knee brace to assist with ambulation and stability. In the judgment of the Board, this pathologic change within the anatomical structure of the left knee joint warrants a compensable evaluation as analogous to mild instability of the ACL. Since the surgery which brought about the surgical fixation, via a screw, of the ACL to the tibia was done during service, a separate 10 percent rating for this impairment is warranted since the day after service discharge, inasmuch as the original claim for service connection, from which this initial rating matter arises, was filed later in July 2012. The Board finds that the evidence does not establish such impairment of the left knee ACL repair as to warrant a rating in excess of 10 percent based on subluxation or instability. Specifically, in November 2004 the ACL felt a bit loose but his ligaments were stable in January and March 2005, with another notation in April 2005 of some looseness at the end point of the ACL. Subsequently, in September 2007 he walked with a flexed gait but his ligaments were stable and they were again found to be stable in May and June 2009. Varus and valgus stress testing in November 2008 revealed some stress laxity, and in June 2009 he had pain on such testing. More recently, he has been given a brace to use for his left knee. However, the evidence simply does not show that the Veteran has such instability or subluxation of the left knee as to equate with moderate instability or subluxation. Accordingly, the Board concludes there is no basis for staged rating for instability as a residual of left knee ACL reconstruction with chondromalacia debridement, pursuant to Fenderson, and that no higher rating may be assigned. In reaching the conclusion to the claim, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating for left knee arthritis, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. In making its determinations as to both issues in this case, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected disability and notes that the Veteran lay statements are competent to describe certain associated symptoms. These have been considered credible and competent and have been contemplated by the disability ratings assigned. However, the Board has placed the greatest probative weight to the clinical findings by medical examiners as they possess greater training and expertise than the Veteran in accurately measuring and assessing medical findings such as instability, subluxation, motion loss expressed in degrees, etc. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). Extraschedular Consideration The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, but not from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for such purpose. The threshold factor for extraschedular consideration is that the evidence presents such an exceptional disability picture that the schedular ratings are inadequate. This is done by comparing the level of severity and symptoms of the service-connected disability with the schedular rating criteria and if the latter reasonably describe the disability level and symptoms, then the disability picture is contemplated by the Rating Schedule and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008); aff'd Thun v. Peake, 572 F.3d 1366 (Fed.Cir. 2009). An extraschedular rating is applicable only as to individual service-connected disorders and not the collective or cumulative impact of multiple service-connected disorders. See Johnson v. Shinseki, slip op., No. 10-1785 (Vet. App. Mar. 27, 2013) (en banc). Thus, the Board may not consider the impact of the Veteran's other service-connected disabilities, including his service-connected PTSD and sleep disorder; tinnitus; right ear hearing loss, acid reflux, right foot plantar wart, tension headaches or sexual dysfunction in determining whether an extraschedular rating is warranted for the service-connected left knee disability at issue. Comparing the Veteran's current symptoms and disability levels to the Rating Schedule, the degree of functional impairment due to the arthritis and the instability from the postoperative left knee residuals is contemplated by the Rating Schedule and the assigned schedular ratings are adequate. By regulation, the rating assigned for the service-connected left knee disorder must encompass the factors enumerated at 38 C.F.R. §§ 4.40, 4.45, and 4.59. 38 C.F.R. § 4.40 requires consideration of functional loss, including normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Similarly, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or malaligned joints, and crepitation. Additionally, the Rating Schedule is adequate for compensation purposes because higher schedular ratings are possible; particularly if the Veteran in the future actually develops compensable limitation of motion in one or more planes of knee motion which would allow for separate ratings for limited motion in each plane of motion; or a degree of instability of the knee which would allow for a rating greater than 10 percent. Thus, no referral for extraschedular consideration is required. 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); Thun v. Peake, 22 Vet. App. 111, 115 (2008); aff'd Thun v. Peake, 572 F.3d 1366 (Fed.Cir. 2009). Lastly, in Rice v. Shinseki, 22 Vet. App. 447 (2009) it was held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. When evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case CAPRI clinical records within the Virtual VA system show that in May 2012 the Veteran was working as a budget analyst. Additionally, the Veteran has not suggested or intimated that he is now unemployed. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. ORDER An initial rating in excess of 10 percent for arthritis as a residual of left knee ACL reconstruction with chondromalacia debridement is denied. An initial rating of no more than 10 percent for instability as a residual of left knee ACL reconstruction is granted, subject to applicable law and regulations governing the award of monetary benefits. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs