Citation Nr: 1333295 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 07-28 706 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for degenerative arthritis of the left knee. 2. Entitlement to a compensable disability rating for conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from March 1965 to April 1969, from June 1972 to June 1974, and from August 1979 to April 1984. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office & Insurance Center (RO&IC) in Philadelphia, Pennsylvania, and a December 2006 rating decision of the VA Regional Office (RO) in St. Louis, Missouri. The case was subsequently transferred to the RO in Pittsburgh, Pennsylvania. The Veteran and his wife presented testimony at a personal hearing before the undersigned Veterans Law Judge in August 2008. A transcript is of record. In February 2009 and October 2011, the Board remanded the claims for further development. The requested development has been completed, and the case has been returned to the Board for further appellate action. The record before the Board consists of paper claims files and an electronic file known as Virtual VA. The Board also remanded a claim for entitlement to service connection for a heart attack with stent placement, to include coronary artery disease (CAD) in October 2011. Service connection for CAD was subsequently granted in a November 2012 rating decision issued by the Appeals Management Center. As such, that issue is no longer before the Board for appellate review. The issue of entitlement to service connection for PTSD was previously referred to the RO for further clarification. Review of the claims folder reveals that no action has been taken on this issue. Therefore, the Board still does not have jurisdiction over it and it is again referred to the agency of original jurisdiction for appropriate action. FINDINGS OF FACT 1. The Veteran's left knee is manifested by subjective and objective evidence of pain, but flexion has not been limited to 30 degrees or less and there is no objective evidence of instability. 2. The average Puretone threshold in decibels during an authorized audiological evaluation in December 2005 was 62.5 in the right ear and the speech recognition score using the Maryland CNC word lists was 64 percent. 3. The average Puretone threshold in decibels during an authorized audiological evaluation in September 2006 was 58.75 in the right ear and the speech recognition score using the Maryland CNC word lists was 96 percent. 4. The average Puretone threshold in decibels during an authorized audiological evaluation in November 2011 was 73.75 in the right ear and the speech recognition score using the Maryland CNC word lists was 90 percent. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for degenerative arthritis of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260 (2013). 2. The criteria for a compensable rating for conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.85, Tables VI, VIA and VII (Diagnostic Code 6100); 38 C.F.R. § 4.86; 38 C.F.R. § 4.87, Diagnostic Code 6201 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100%" based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO provided the appellant pre-adjudication notice by a letter dated in November 2005 and additional notice by letters dated September 2006, March 2006 and June 2008. The claims were readjudicated in supplemental statements of the case dated April 2011 and November 2012. Mayfield, 444 F.3d at 1333. VA has obtained service treatment records; assisted the appellant in obtaining evidence, to include records from the Social Security Administration (SSA); afforded the appellant physical examinations; obtained medical opinions as to the severity of his disabilities; and afforded the appellant the opportunity to give testimony. All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file, and the appellant has not contended otherwise. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claims at this time. Increased ratings Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When service connection has been in effect for many years, the primary concern for the Board is the current level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Yet, the relevant temporal focus for adjudicating an increased rating claim is on the evidence establishing the state of the disability from the time period one year before the claim was filed until a final decision is issued. Hart v. Mansfield, 21 Vet. App. 505 (2007). Thus, staged ratings may be assigned if the severity of the disability changes during the relevant rating period. When evaluating disabilities of the musculoskeletal system, an evaluation of the extent of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). In other words, when rated for limitation of motion, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. A finding of functional loss due to pain must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. A February 1985 rating decision granted service connection for degenerative arthritis of the left knee and conductive hearing loss of the right ear. A 10 percent evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5257, was assigned for the left knee and a noncompensable evaluation pursuant to 38 C.F.R. § 4.87, Diagnostic Code 6296, was assigned for the right ear. The effective date assigned for both ratings was April 17, 1984. In the April 2006 rating decision that is the subject of this appeal, the right ear disability was recharacterized as conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty, and the noncompensable rating was continued under 38 C.F.R. § 4.87, Diagnostic Codes 6201 and 6100. The rating criteria used to evaluate degenerative arthritis of the left knee was changed to 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5003. See also December 2006 rating decision. The Veteran testified in August 2008 that he is entitled to a compensable rating for conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty, because he hears absolutely nothing out of his right ear. He indicated that he wears a hearing aid in his right ear and if he took it out and covered his left ear, he would be totally deaf. The Veteran reported that he has recurrent right ear infections and that he has had a total of three surgical procedures, the first two in 1979 and the most recent one in August 2005. He reported continuous drainage out of his right ear, which resulted in the August 2005 surgery, and his wife reported he had a large mastoid infection in the right ear with the third surgery. The Veteran also indicated that he does not watch a lot of television or listen to the radio because he cannot understand what is going on. He also reported problems in crowds or in stores for the same reason. The Veteran also testified that he is entitled to a rating in excess of 10 percent for degenerative arthritis of the left knee because his left knee gives out/buckles and locks such that he cannot walk long distances and needs to use a scooter. He also reported using a cane to walk and having trouble walking with a cane. The Veteran indicated that he had fallen as a result of his left knee and that the use of a brace had been suggested to him, but it made his knee swell and hurt worse. He reported that he had last fallen two weeks prior to his hearing. The Veteran indicated that he had daily, constant left knee pain at a level four in severity on a scale of ten and that he took Tylenol to ease the pain, but he denied receiving ongoing treatment for his left knee. The Veteran's wife has written two statements in support of the Veteran's claims. In pertinent part, she reported in April 2006 that the effect of his knee problems was increasing, that he was having a difficult time with standing and walking for any long periods of time, and that VA had given him a scooter in June 2005 to help him get around more easily. She also reported that it had taken almost a full year for his right ear to heal following his August 2005 surgery and that she had been helping him to clean the ear. In August 2008, the Veteran's wife reported, in pertinent part, that he did very little walking due to leg instability and poor balance. She indicated that he used a cane to keep steady and had a scooter to use when they went out to help give him some freedom of mobility. The Veteran's wife reported that he had no hearing in his right ear and when he lied on his left side, he was unable to hear anything, which makes it hard for him to wake up. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under 38 C.F.R. § 4.59, painful motion is an important factor of disability from arthritis and actually painful joints are entitled to at least the minimum compensable rating for the joint. The rating criteria provided for limitation of motion of the knee and leg are found at 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides ratings for limitation of flexion. Flexion of either leg limited to 60 degrees is noncompensable, flexion limited to 45 degrees merits a 10 percent rating, limitation of flexion to 30 degrees warrants a 20 percent evaluation, and a 30 percent evaluation requires that flexion be limited to 15 degrees. Diagnostic Code 5261 provides ratings of 0 percent for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and 50 percent for extension limited to 45 degrees. For rating purposes, normal range of motion of the knee is from zero to 140 degrees. See 38 C.F.R. § 4.71a, Plate II (2013). Diagnostic Code 6201 provides that chronic nonsuppurative otitis media with effusion (serous otitis media) is to be rated for hearing impairment. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to numeric designations assigned after audiometric evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Evaluations of bilateral sensorineural hearing loss range from noncompensable (zero percent) to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests together with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second (Hertz ). See 38 C.F.R. § 4.85 (2013). To evaluate the degree of disability for service-connected hearing loss, the rating schedule establishes eleven (11) auditory acuity levels, designated from Level I for essentially normal acuity through Level XI for profound deafness. See 38 C.F.R. § 4.85 and Tables VI, VIA, and VII (Diagnostic Code 6100) (2013). If impaired hearing is service-connected in only one ear, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I in order to determine the percentage evaluation from Table VII. See 38 C.F.R. § 4.85(f) (2013). Section 4.86 provides an alternative rating method which may be used for certain defined "exceptional patterns of hearing impairment." Section 4.85(a) requires that an examination for hearing loss be conducted by a state-licensed audiologist, and must include both a controlled speech discrimination test (Maryland CNC test) and a pure tone audiometry test. Examinations must be conducted without the use of hearing aids. Section 4.85(c) indicates that Table VIA, "Numeric designation of Hearing Impairment Based Only on Puretone Threshold Average," will be used when the examiner certifies that use of the speech discrimination test is not appropriate because of inconsistent speech discrimination scores. The pertinent medical evidence in this case consists of VA treatment records and several VA examination reports. VA treatment records reveal that the Veteran was seen by three clinics in June 2005 with complaint of right ear pain at a level five out of 10 with serosanguinous drainage with duration of two weeks. He had tried ice topically and Tylenol with slight relief. The Veteran also reported right ear swelling but indicated that even though the ear canal had been swollen to the point where it is shut, he had managed to get a Qtip into the ear. Objective examination revealed positive pinna and tragus tenderness to the point where when the examiner touched the tragus, the Veteran almost jumped off the table. The tragus region was described as mildly erythematous. Without using the otoscope, the canal was completely closed and there was serosanguinous drainage coming from the canal itself. The assessment was acute otitis media and the Veteran was to be followed up by ENT to have a wick applied. See June 2005 prevention note and primary care note. The ENT consult took place that same day. In pertinent part, the Veteran reported hearing loss in both ears with greater loss in the right ear. The examiner reported that clinically, there appeared to be falling of the right tragus and some mucosanguinous discharge at the meatus, which was suctioned out. Beyond this, there was a canal low down cavity with a small amount of moist squamous debris. Due to a very stenotic meatus, the examiner reported difficulty visualizing the cavity and the tympanic membrane, although most of the inflammation and tenderness appeared to be in the tragal area. The cavity was cleaned and a 10 day course of medication and warm compressors to the right ear were recommended. A July 2005 ENT note reveals that the Veteran returned after oral antibiotic therapy for a chronic otitis media in the right ear, which he had completed. On examination, there was continued blood tinged purulent drainage from the right ear. The meatus was again very stenotic and limited the ability to visualize the entire cavity. The source of drainage was not clear due to the stenotic meatus. There were no signs of acute mastoiditis at that time. The examiner recommended a temporal bone CT scan. The CT scan was conducted in July 2005. The impression, in pertinent part, was extensive, right-sided abnormalities including postoperative change from prior mastectomies, opacification of all mastoid air cells with bony sclerosis, deformity of the ossicles, and thickening of the tympanic membrane. Another July 2005 ENT note reveals that clinical examination again revealed an extremely stenoitic meatus. It was not possible to visualize the ear canal or cavity. The Veteran's postauricular incision was well-healed and facial function was normal. Review of his temporal bone CT scan showed opacification of the remaining mastoid air cells in the right ear along with some fluid in the middle ear and canal. The examiner noted that an audiogram had been scheduled and that in light of the difficulty in visualization and debridement of the right ear in the clinic, a revision tympanomastoidectomy had also been scheduled, with likely canal wall down with meatoplasty and facial nerve monitoring. An audiological evaluation consult was conducted in August 2005. The examiner noted that thresholds were within normal limits through 1000 Hz with a moderate to profound mixed hearing loss on the right. Word recognition score on the right side was 92 percent. The Veteran was seen by ENT on two other occasions in August 2005. He reported for his one-week postoperative follow up following a canal wall down mastoidectomy on the right side. The pack was removed and a moderate amount of purulent drainage around the pack and within the cavity itself was reported. This was suctioned. The examiner reported that there appeared to be packing still intact within the cavity and that the postauricular incision was healing well with no signs of erythema or purulence. A two-week course of medication and drops was recommended for infection. The Veteran was seen one week later, at which time it was noted that his infection had greatly improved. The results of an August 2005 right ear culture revealed heavy proteus mirabilis and heavy other proteus mirabilis. A September 2005 ENT consult reveals that the Veteran was one-month status post a revision, right modified radical mastoidectomy with meatoplasty. He continued to have some drainage from his right ear along with discomfort. Clinically, the tympanic membrane appeared intact and well-healed. The mastoid was filled with a moderate amount of dead, devitalized soft tissue, which was debrided. Alcohol/vinegar irrigations for cavity cleaning were started and the Veteran was to continue using ear drop medication. A later September 2005 ENT note reveals that, in pertinent part, the Veteran denied any drainage but reported continued decreased hearing in the operative right ear. Physical examination revealed right mastoid cavity with cerumen and desquamated debris build up. They were suctioned and removed. There was an area of necrotic tissue that was excised from the mastoid space. The eardrum was otherwise intact and healthy looking. The impression was that the Veteran was healing well from the right modified radical mastoidectomy performed in August. There was evidence of healthy cerumen production as well as epithelial lining of the mastoid cavity, but there was an area of necrotic tissue removed. It was therefore recommended that the Veteran continue to follow water precaution and to continue using drops and the alcohol/vinegar solution after showering. A September 2005 primary care note reveals that the Veteran arrived riding on an electric scooter. He complained of degenerative joint disease (DJD) involving many of his joints and rated his leg pain at a level six/seven on a scale of 10. Physical examination revealed that the Veteran was able to walk into the room with the aid of a cane after he got out of his electric scooter. His gait was severely impaired secondary to the pain he experienced on ambulation, hence the reason for the electric scooter. The diagnosis was DJD of the peripheral joints. A November 2005 ENT note reveals that the Veteran was three-months status post right revision modified radical mastoidectomy with meatoplasty. He had necrotic tissue in his mastoid cavity, which was trimmed completely. There was a small amount of granulation tissue underlying this. The Veteran also had mucosalized areas within the mastoid cavity. The tympanic membrane appeared intact but there was a small area of perforation in what would be the area of the mastoid antrum. There was no obvious cholesteatoma. The ear was completely debrided and a small paper patch was placed over the perforation. Boric acid powder was then instilled in the cavity. The discontinuation of ear irrigations was recommended and the Veteran was advised to use boric acid powder daily and observe dry air precautions. The Veteran underwent a VA joints examination in November 2005, at which time his claims folder was reviewed. In pertinent part, the Veteran was reported to be ambulatory with a cane, but could not walk long distances as he begins to feel weak. The Veteran reported left knee pain, which was described as a stabbing, toothache-type pain, especially in the cold weather. The stabbing pain reportedly occurred three to four times a month. The toothache-type pain was chronic. Weakness and instability occurred four to five times a day. Treatment in the form of Tylenol was effective. The Veteran reported occasional stiffness with tightness, and swelling with weather changes. He denied heat, redness and locking and indicated that prior cortisone injection and physical therapy were ineffective. Flareups occurred with changes in the weather about three to four times a month. The Veteran noted that he makes himself get up and function to move around. Flareups lasted about two hours. The Veteran was ambulatory with a cane, which he had used for several years. He did not use it around the house but would use it when he went out of the house. He had recently been issued an electric scooter by VA. The Veteran reported losing his balance easily when performing daily activities. He noted he just had to walk slower and use his handrail in the shower. When driving, he reported increased knee pain if he drove for a long period of time. Getting out of a low car was very difficult such that he had to have a car that sits higher up, like an SUV. Physical examination of the left knee at the time of the November 2005 joints examination revealed that the Veteran was ambulatory 10 feet from the waiting area to the examination room. He presented in an electric scooter but did ambulate from the scooter to the room with a cane. He was slow to rise and unsteady at the knees but able to ambulate in the office without the cane with very stiff posturing to the knees and holding on to furniture for stability around the room. Significant instability of the patella medially and laterally to the left knee was noted. Lachman's, anterior and posterior drawer, and McMurray's tests were negative. There was significant crepitus on passive and active range of motion but no increased pain against forced range of motion. Left knee flexion was from zero to 100 degrees, with increased pain at 100 degrees. Absent 40 degrees of full flexion. The knee was tender to palpation around the entire joint but no swelling or redness was noted and there was no obvious deformity. Pain was noted to be the most limiting factor with repetitive range of motion, but repetition did not change degrees. There was no weakness, decreased endurance, or easy fatigability with repetitive range of motion to the left knee. The examiner obtained x-rays and reported that a three-view series revealed mild medial joint space narrowing in the left knee. This imaging report is of record. The diagnosis at the time of the November 2005 VA joints examination was left knee degenerative arthritis with no ligament instability and chronic pain. A December 2005 ENT note reveals that the Veteran was almost four months status post a revision light modified radical mastoidectomy with meatoplasty. His cavity was mostly skin lined and there was a very small area of mucosalization in the mastoid cavity itself. The tympanic membrane was intact. Boric acid powder was applied and the Veteran was asked to continue its use twice weekly in the cavity to keep the ear dry. The Veteran underwent a VA audio examination in December 2005, at which time the right ear showed conductive low frequency hearing loss through 2000 Hertz and mixed in the high frequencies. Puretone air conduction threshold results in the right ear were: 50 at 500 and 1000 Hertz; 55 at 2000 Hertz; 70 at 3000 Hertz and 75 at 4000 Hertz. The Puretone decibel threshold average equates to 62.5. Word recognition score in the right ear was 64 percent. Tympanometry could not be conducted in the right ear due to the recent surgery. Otoscopically, there was a while powder assumed to be boric acid. The tympanoplasty was not completely healed. The Board notes that the actual audiological evaluation conducted in December 2005 is of record. See VA Form 10-2364. A February 2006 ENT note reveals that the Veteran was six months status post a right revision tympanoplasty with canal wall-down mastoidectomy. Examination revealed that the cavity had a moderate amount of cerumen and squamous debris, which was cleaned out completely. The tympanic membrane appeared to be intact. There was an area of attic collapse, although no frank cholesteatoma was noted. The plan was to apply boric acid powder to the right ear. A March 2006 primary care note reveals that the Veteran reported continued chronic pain in the bilateral legs. He was using Tylenol arthritis tablets on an as-needed basis. The Veteran ambulated with a cane and stated he was doing well with his scooter such that he and his wife were able to go out quite a bit more. Pain was at a level four, which he noted to be very tolerable. Physical examination revealed active and passive range of motion to about 90 degrees without crepitus. Gait was slow but steady and the Veteran had trouble standing without the use of his cane. The assessment was degenerative arthritis/chronic leg pain. A June 2006 ENT note reveals that the Veteran was seen for routine evaluation and cleaning. Examination revealed some minimal cerumen debris within the right mastoid cavity, which was removed. There was no moisture and there were signs of good healing within the cavity itself. A July 2006 audiology consult reveals that the Veteran was seen for hearing aid evaluation. Thresholds were rechecked and were stable. A moderate to severe/profound mixed hearing loss in the right ear was reported. The Veteran was fitted for hearing aids in August 2006. See audiology note. The Veteran underwent another VA audio examination in September 2006, at which time his claims folder was reviewed. There had been no change in his hearing health history since his December 2005 VA examination. The Veteran noted that his ear had been dry since the August 2005 surgery. Prior to that surgery, he had constant drainage from his right ear. The examination showed the right ear had a moderate to severe mixed hearing loss. Pure tone air thresholds in the right ear were 45 at 500 Hertz; 50 at 1000 and 2000 Hertz; 60 at 3000 Hertz and 75 at 4000 Hertz. The Puretone decibel threshold average equates to 58.75. Word recognition score in the right ear was 96 percent. Tympanometry could not be conducted in the right ear due to the surgical cavity. The Veteran underwent another VA joints examination in September 2006, at which time his claims folder was reviewed. He was ambulatory with a cane and recently mobile with a motorized scooter. He was unable to walk for long distances as he begins to feel weak. The Veteran reported continued stabbing and toothache pain to the left knee, especially in the cold weather. He had recent shooting pain down the shins, which started two weeks prior. It lasted all well the week prior but was not present at examination. Otherwise, the pain continued with weather changes, especially in the cold weather, approximately two to three times per week, which the examiner noted was an increase from his most recent examination. The chronic pain is the toothache pain; the stabbing pain is the intermittent pain. The Veteran had weakness with instability to the left knee on a daily basis depending on his level of activity, at least four to five times per day. He was unsure which activities caused subluxation. He did not walk steps if necessary. The Veteran reported stiffness with edema, namely with flare ups to the knee; swelling with weather changes, two to three times per week lasting at least two days or until the weather stabilizes; locking four to five times per week, lasting until he is able to work the locking out; lack of endurance and fatigability. The Veteran denied heat, redness and treatment, to include injections and physical therapy. Flare ups with the weather, at least one to two times per week and lasting longer than they used to, at least two to three days, were again noted. The Veteran was able to function during those episodes, although function was significantly decreased. He used his cane more than he did at the time of his last VA examination and reported using it around the house, although not constantly because he did not like to. The Veteran reported that he continued to lose his balance easily when performing activities of daily living. He had to walk slower and use a hand rail in the shower. Increased knee pain while driving was again noted. He had to use a vehicle that sits higher off the ground for driving long periods and because getting out of a low car remained difficult. Physical examination of the left knee at the time of the September 2006 VA examination revealed the Veteran was ambulatory 10 feet from the waiting area to the exam room. He had a cane in the right hand and significant antalgic gait. He presented in an electric scooter but was able to ambulate from the hallway to the room. The left knee was more painful than the right and pain was noted around the circumference and along the joint line without any significant edema. McMurray test was negative but mild positive anterior and posterior drawer test was reported. Left knee flexion was from zero to 80 degrees with pain beginning at 80 degrees. 60 degrees of flexion was absent in the left knee secondary to pain. Repetitive range of motion was positive for weakness, decreased endurance and easy fatigability. Repetition did not change degrees and pain was noted to be the most limiting factor. The Veteran showed extreme unsteadiness and was very slow to rise when getting up from a sitting position and he had to hold on to furniture for stability when ambulating in the exam room. The examiner reported that a three-view knee series taken contained an impression of very mild degenerative changes, not significantly changed; and mild left medial compartment narrowing. The imaging report is of record. The diagnosis at the time of the September 2006 VA examination was left knee degenerative arthritis with instability. A December 2006 ENT note reveals that the Veteran was 16 months status post a canal wall down tympanomastoidectomy in the right ear and was currently aided binaurally with hearing aids. The examiner cleaned out moist debris from the right mastoid cavity and middle ear. There was no active infection. Boric acid powder was applied. A March 2007 primary care note reveals that the Veteran ambulated with a cane and appeared to have somewhat of a wide-based gait. The assessment was chronic DJD with leg pain. The Veteran went in for right ear cavity management in April 2007, at which time some wet squamous debris in the anterior portion of the ear canal and middle ear was noted and removed. The cavity itself was dry and well healed. Some boric acid powder was instilled in the anterior portion of the canal. See ENT note. An October 2007 ENT note reveals that the Veteran had some wet squamous debris in the anterior portion of the ear canal and middle ear was noted and removed. The cavity itself was dry and well healed. Ear drops were given. A July 2008 ENT note reveals that the Veteran had some cerumen in the right mastoid cavity, which was cleaned out. He also had a mucosalized area in the lateral most aspect of the mastoid cavity and some wet debris in the medial canal, which was cleaned out. A small granulomatous polyp in the anterior sulcus was cauterized. Once cleaning was completed, boric acid powder was applied. An August 2008 audiology consult reveals that the Veteran was seen with chief complaint of worsening hearing and right ear infection. He denied ear pain and reported his hearing aids were working well. The Veteran reported having difficulty participating in activities of daily living due to hearing loss and having decreased social contact and feeling embarrassed, isolated and upset/angry because of hearing difficulties. Otoscopic examination revealed a moist right ear cavity. Results of audiologic evaluation revealed a mild to profound mixed hearing loss in the right ear, with essentially no change since the 2006 evaluation. Word recognition score in the right ear was 96 percent. The Veteran was seen by ENT on two occasions in January 2009. During the first visit, the right mastoid cavity was cleaned and a polyp in the anterior sulcus reportedly bled slightly when overlying debris was suctioned. There was also moist debris on the lateral tympanic membrane. During the second visit, the right cavity was moist, especially posterior to the facial ridge, and was moist just lateral to the tympanic membrane. No polyp was seen. An April 2009 otolaryngology note reveals that the Veteran was seen for follow up for right ear dampness with complaint of right ear moisture accumulation when wearing hearing aid. He denied frank otorrhea, otalgia and pruritis. Microscopic examination revealed anterior and interior right bowl with moist debris and without polyps or inflammation. The mid portion was dry. A May 2009 audiology consult reveals complaints of worsening hearing, right ear drainage, and malfunctioning hearing aid. The Veteran denied dizziness and ear pain. Otoscopic inspection revealed surgical ear/moistness on the right. Results of audiologic evaluation revealed a moderate to severe mixed hearing loss in the right ear. Significant change from the August 2008 test was noted. Word recognition score in the right ear was 96 percent. Tympanometry showed reduced tympanic membrane mobility in both ears. An August 2009 otolaryngology note reveals that the Veteran was seen for follow up for right ear otorrhea, which had resolved with two weeks of antibiotics. There were no changes in the Veteran's hearing reported. The right ear mastoid cavity was dry and there was minimal cerumen/debris that was cleaned. The tympanic membrane was intact. A December 2009 ENT note reveals the same findings. A June 2010 ENT note reveals that the Veteran reported no pain or drainage from his right ear and denied any change in hearing. Physical examination revealed the right ear with canal wall down mastoid cavity with yellow, thick drainage with wet debris. This was removed with suctioning. The assessment was right otitis externa. An October 2010 ENT note reveals the Veteran's report of very minimal drainage from the right ear. He denied any pain or acute changes. The right ear had some cerumen removed but the ear canal and tympanic membrane both appeared normal. The assessment was right otitis externa in the previous mastoidectomy site. In February 2011, the right ear showed copious white debris over the tympanic membrane. The cavity was not bad. Lotrisone cream was instilled. See ENT note. The cream was removed the following month with suction. This made the Veteran very dizzy. The tympanic membrane and external auditory canal were intact following removal or cerumen and debris. The Veteran underwent a third VA audio examination in November 2011, pursuant to the Board's October 2011 remand. The claims folder was reviewed and the Veteran indicated he was not using hearing amplification, as he perceived little benefit. The Veteran reported difficulty with sound localization and overall hearing and discriminating speech. He noted treatment for otitis externa in the right ear in March 2011 and indicated he saw ENT routinely for cleaning/care of the mastoid cavity. The Veteran reported minimal otorrhea from the right ear and denied otalgia. Results from the evaluation showed a moderate to profound mixed hearing loss in the right ear. Puretone air conduction thresholds for the right ear were 50 at 500 Hertz; 55 at 1000 Hertz; 70 at 2000 Hertz; 80 at 3000 Hertz and 90 at 4000 Hertz. The Puretone decibel threshold average equates to 73.75. Word discrimination score in the right ear was 90 percent. Tympanometry was not completed in the right ear but the tympanic membranes appeared intact. The key diagnosis was mixed hearing loss, right ear. The Veteran underwent a knee and lower leg conditions Disability Benefits Questionnaire (DBQ) in December 2011, at which time he was diagnosed with left knee strain. He denied treatment but reported left knee pain, which was constant and described as sharp and stabbing at a level six or seven on a scale of 10. The Veteran indicated that flare ups impacted the function of his left knee, namely once-monthly diminished functioning at a level nine or 10 on a scale of 10 that would last a day or more. Range of motion testing revealed left knee flexion to 110 degrees, with objective evidence of painful motion beginning at 110 degrees. Extension ended at zero degrees. Post-test flexion and extension were unchanged. The Veteran did not have additional limitation in range of motion of the left knee following repetitive use testing but did have functional loss and/or functional impairment of the left knee in the form of less movement than normal and pain on movement. There was no tenderness or pain to palpation for the left joint line or soft tissues. Muscle strength testing was normal for knee flexion and extension. Joint stability tests, to include Lachman (for anterior instability), posterior drawer (for posterior instability), and medial-lateral instability testing (with valgus/varus pressure applied to the knee in extension and 30 degrees of flexion) were all normal. There was no evidence or history of recurrent patellar subluxation or dislocation and no meniscal conditions. The Veteran was noted to use assistive device as a normal mode of locomotion, namely a cane, which he used constantly due to imbalance issues. The examiner reported that imaging studies revealed degenerative or traumatic arthritis of the left knee but no evidence of patellar subluxation. A December 2011 x-ray contained an impression of minimal degenerative change in the medial tibiofemoral compartment. The preponderance of the evidence does not support the assignment of a compensable rating for conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty, under Diagnostic Codes 6100 and 6201. The Board acknowledges the assertion made by the Veteran and his wife that the Veteran's hearing acuity has decreased, as well as their contention that if his left ear were covered up, he would not be able to hear anything at all. It finds these assertions to be competent and credible. As noted above, however, VA audio examinations were performed in December 2005, September 2006 and November 2011. Using the audiometric findings during these examinations, the Veteran's right ear hearing loss is not compensable under Diagnostic Codes 6100 and 6201. During the December 2005examination, the Veteran's Puretone decibel threshold average in the right ear was 62.5 and his speech discrimination score was 64 percent. In September 2006, the Veteran's Puretone decibel threshold average in the right ear was 58.75 and his speech discrimination score was 96 percent. During the November 2011 examination, the Veteran's Puretone decibel threshold average in the right ear was 73.75 and his speech discrimination score was 90 percent. Under Table VI, 38 C.F.R. § 4.85, the results for the right ear in December 2005, September 2006 and November 2011 correspond to Level VI, Level II and Level III, respectively. As the Veteran's left ear is not service-connected, a Level I designation has been assigned to determine the percentage evaluation from Table VII. See 38 C.F.R. § 4.85(f) (2013). The applicable percentage rating for hearing impairment at Level VI, Level II and Level III for the poorer ear (right ear) and Level I in the better ear (left ear) is zero under Table VII, 38 C.F.R. § 4.85 (2013). The Veteran exhibited the exceptional patterns of hearing impairment described in 38 C.F.R. § 4.86(a) at the time of the November 2011 VA examination, but not at the time of the December 2005 or September 2006 examinations. Therefore, the Board must reference Table VIA. Under that table, the November 2011 results correspond to a Level VI in the right ear. Using Level I in the left, the applicable percentage rating remains 0 percent under Table VII. See 38 C.F.R. § 4.85. The Board has considered whether 38 C.F.R. § 4.86(b) applies in this case. Consideration under this provision, however, is not warranted, as the right ear did not display pure tone thresholds 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, with each ear evaluated separately. See December 2005, September 2006 and November 2011 VA audio examination reports. At this juncture, the Board acknowledges the Veteran's assertions that he is entitled to an increased rating in part due to continuous drainage out of his right ear. The Board finds this assertion to be competent and supported by the medical evidence of record. The Board also acknowledges that the Veteran has undergone several procedures related to mastoiditis. Given the foregoing, it has considered whether an increased rating, or additional separate compensable rating, is warranted for the right ear under any other provision pertaining to diseases of the ear. The Veteran's service-connected disability, however, is conductive hearing loss in his right ear, and the original grant of service connection was premised only on the diagnostic criteria pertaining to decreased hearing acuity. It was not premised on any other diagnostic criteria related to diseases of the ear, to include Diagnostic Code 6200, which provides the rating criteria for chronic suppurative otitis media, mastoiditis, or cholesteatoma. See 38 C.F.R. § 4.87. In the absence of evidence to suggest that the noted right ear drainage and/or mastoiditis is the result of the service-connected right ear conductive hearing loss, the assignment of a rating under Diagnostic Code 6200 is not warranted. In sum, a compensable rating is not warranted for service-connected conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty. The preponderance of the evidence does not support the assignment of a rating in excess of 10 percent for degenerative arthritis of the left knee under Diagnostic Code 5260. This is so because the Veteran's left knee did not exhibit flexion limited to 30 degrees at any time during the appellate period. Rather, at worst, flexion was limited to 80 degrees at the time of the September 2006 VA examination. The Board has also considered the other diagnostic criteria related to the knees to determine whether an increased rating, or additional separate compensable rating, is warranted for the left knee under these provisions. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Most of the remaining diagnostic codes, however, are simply not applicable to the Veteran's service-connected degenerative arthritis of the left knee as there is no evidence of ankylosis (Diagnostic Code 5256); dislocated semilunar cartilage with frequent episodes of "locking," pain and effusion into the joint (Diagnostic Code 5258); symptomatic removal of the semilunar cartilage (Diagnostic Code 5259); any impairment of the tibia and fibula (Diagnostic Code 5262); or genu recurvatum (Diagnostic Code 5263). In addition, extension has never been reported as limited, which does not support the assignment of a separate, compensable rating under Diagnostic Code 5261. See VAOPGCPREC 9-04; VA examination reports; VA treatment records; VA imaging reports. The Board has considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5257 for recurrent subluxation or lateral instability. See VAOPGCPREC 23-97. The Veteran has reported that his left knee gives out/buckles and that he had fallen on several occasions. See August 2008 hearing transcript. His wife has also reported left knee instability and poor balance. See August 2008 statement in support of claim. The Board remanded the claim in October 2011 in part because the September 2006 VA examiner found evidence of left knee instability, but did not comment on its severity. The Board instructed that a new VA examination be conducted, during which, in pertinent part, the examiner was to identify whether there was any evidence of left knee laxity and, if so, to determine whether it was slight, moderate or severe. During the December 2011 knee and lower legs DBQ, however, joint stability tests, to include Lachman's, posterior drawer, and medial-lateral instability testing, were all normal. The Board acknowledges that the November 2005 VA examiner noted that the Veteran's knees were unsteady and that there was significant instability of the left patella, both medially and laterally, during physical examination. Stability testing at the time of this examination, however, to include the Lachman's, McMurray, and anterior and posterior drawer tests, was negative. The McMurray test was also negative at the time of the September 2006 VA joints examination. The objective findings of record, which the Board finds more probative than the Veteran's subjective accounts, do not support a separate rating under Diagnostic Code 5257 for the Veteran's left knee. Lastly, consideration has been given to any functional impairment and any effects of pain on functional abilities due to the Veteran's service-connected left knee disability. The Board acknowledges the subjective complaints of pain made during the entire appellate period, as well as the objective evidence of pain during range of motion testing in November 2005, September 2006 and December 2011. See VA examination reports. The Board also acknowledges the objective findings of weakness, decreased endurance and easy fatigability at the time of the September 2006 VA examination, and the objective finding of functional loss/impairment in the form of less movement than normal at the time of the December 2011 VA examination. Repetitive motion, however, did not limit the Veteran's motion any further at the time of the November 2005, September 2006 and December 2011 VA examinations. In other words, post-test left knee flexion and extension were unchanged. Taking into account the objective findings of pain during range of motion testing at the time of the November 2005, September 2006 and December 2011 VA examinations, as well as the objective findings of weakness, decreased endurance and easy fatigability at the time of the September 2006 VA examination and functional loss/impairment in the form of less movement than normal at the time of the December 2011 VA examination, the Veteran was still able to achieve zero to 100 degrees of left knee motion in November 2005, zero to 80 degrees of left knee motion in September 2006, and zero to 110 degrees of left knee motion in December 2011. These ranges represent 70, 50 and 80 degrees of flexion more than the limitation of flexion needed to support the next highest (20 percent) rating under Diagnostic Code 5260. See 38 C.F.R. § 4.71a. In addition, even if range of motion had been limited by pain beyond that shown during examination, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. In this case it does not. In light of the foregoing, the Board finds that a rating in excess of 10 percent for the Veteran's service-connected left knee disability is not warranted based on functional impairment. 38 C.F.R. §§ 4.40, 4.45 (2013); DeLuca, 8 Vet. App. at 204-06. Extraschedular consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's service-connected right ear and left knee disability pictures are not so unusual or exceptional in nature as to render the zero and 10 percent ratings assigned, respectively, inadequate at any time during the period on appeal. The Veteran's service-connected right ear disability is evaluated under the rating criteria for hearing impairment and his service-connected left knee disability is evaluated under the rating criteria for the knee and leg. The Board finds that the rating criteria used to evaluate these disabilities specifically contemplates the level of disability and symptomatology associated with right ear conductive hearing loss and degenerative arthritis of the left knee. See 38 C.F.R. §§ 4.71a, 4.85. The Veteran's right ear disability is manifested by subjective and objective evidence of decreased hearing acuity, which leads to subjective complaints of difficulty hearing the television and radio, difficulty being in crowds, difficulty participating in activities of daily living, and decreased social contact. His left knee disability is manifested by subjective and objective evidence of pain and limited motion. When comparing these disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the zero and 10 percent disability ratings assigned. Compensable ratings are provided for decreased hearing acuity not exhibited by the Veteran; ratings in excess of 10 percent are provided for certain manifestations of a knee disability not demonstrated by the medical evidence of record in this case. The criteria for the zero and 10 percent disability ratings assigned more than reasonably describe the Veteran's disability levels and symptomatology. Therefore, the schedular evaluations currently assigned to the service-connected right ear and left knee are adequate and no referral is required. Inferred claim for TDIU The Board has considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. The Board acknowledges that the Veteran has not worked at any time during the appellate period. See VA examination reports. The Veteran has not indicated that he is not employed as a result of his left knee or right ear disabilities. In the absence of a history of unemployability due to degenerative arthritis of the left knee or conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty, or other competent evidence suggestive of unemployability due to these disabilities, the Board finds Rice is inapplicable. See also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER A rating in excess of 10 percent for degenerative arthritis of the left knee is denied. A compensable rating for conductive hearing loss of the right ear, status-post mastoidectomy and tympanoplasty, is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs