Citation Nr: 1333339 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 08-21 809 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to an increased rating (evaluation) for status post left knee meniscal repair, in excess of 10 percent prior to February 8, 2011, and in excess of 30 percent thereafter. 2. Entitlement to an increased rating in excess of 10 percent for a right knee disability. 3. Entitlement to an increased rating in excess of 10 percent for left hip traumatic arthritis. 4. Entitlement to service connection for a right hip disability, to include as secondary to service-connected disabilities. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran (Appellant) and spouse ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from September 1979 to August 1982. This matter comes on appeal before the Board of Veterans' Appeals (Board) from October 2007 and December 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. The Veteran provided testimony at a March 2010 Board videoconference hearing at the RO in Boise, Idaho, before a Veterans Law Judge (VLJ) in Washington, DC. The hearing transcript has been associated with the claims file. The VLJ who conducted the March 2010 hearing is no longer employed at the Board, and the Veteran was offered the opportunity for a new Board hearing. In September 2012, the Board remanded the appeal for a new Board hearing based on the Veteran's request; however, the Veteran withdrew the request for a new hearing in April 2013. In a May 2012 rating decision, the RO granted two separate 10 percent disability ratings for the left hip under Diagnostic Codes 5251 and 5253 from February 8, 2011. The RO did not disturb the 10 percent rating already in effect for left hip traumatic arthritis. While the RO characterized this as a grant of service connection, because service connection was already in effect for a disability of the left hip joint, the Board finds that the May 2012 grant constitutes a grant of separate 10 percent ratings for a left hip disability, in addition to the rating for left hip traumatic arthritis (previously granted) that is currently on appeal. The Veteran did not submit a timely appeal to the separate 10 percent ratings (to be rated under Diagnostic Code 5253) or the effective date assigned in the May 2012 rating decision based on impairment of the thigh. Therefore, the Board finds that the only remaining issue is whether an increased rating in excess of 10 percent is warranted for left hip traumatic arthritis. As the Board will explain in more detail below, while a change in the assigned ratings is not warranted, the Diagnostic Codes under which the left hip is rated should be corrected to reflect that the Veteran has the following service-connected hip disabilities: a 10 percent evaluation for left hip traumatic arthritis under Diagnostic Code 5010-5003 for the entire rating period; a separate 10 percent evaluation under Diagnostic Code 5253 for impairment of the thigh with limitation of adduction from February 8, 2011; and a separate 10 percent evaluation under Diagnostic Code 5253 for impairment of the thigh with limitation of rotation. The Board finds that Diagnostic Code 5251 for the left hip disability should be changed to Diagnostic Code 5253 to reflect what the RO actually did (though they used Diagnostic Code 5251) and to reflect that the three separate ratings are not pyramiding. A rating under Diagnostic Code 5010-5003 and Diagnostic Code 5251 would constitute pyramiding under 38 C.F.R. § 4.14; therefore, the Diagnostic Codes need to be changed. Additionally, the Board finds that, to correct the record, the Veteran's right knee disability should be rated under Diagnostic Code 5003, and not Diagnostic Code 5257. The Board remanded the case for further development in July 2009, January 2011, and September 2012. The Veteran was afforded a Board videoconference hearing pursuant to a July 2009 remand, and, as noted above, the Board remanded the appeal new hearing in September 2012, but the Veteran withdrew his second hearing request. The January 2011 Board remand directed additional development that included a request for a VA examination to address the service-connected left and right knee disabilities and left hip. This was accomplished, and the Board concludes that it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The issue of entitlement to service connection for a right hip disability, to include as secondary to service-connected disabilities is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran had a left partial menisectomy in service, additional arthroscopy and debridement of the lateral meniscus in April 2008, and a left total arthroplasty in 2010; for the entire rating period, the evidence demonstrates residual symptomatology of meniscal abnormality in the left knee. 2. For the period prior February 8, 2011, a service-connected left knee disability was manifested by degenerative arthritis with at 135 degrees flexion and 0 degrees extension with no additional limitation to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. 3. For the period from February 8, 2011, a service-connected left knee disability has been manifested by degenerative arthritis with pain and painful motion, to include 110 degrees flexion and 20 degrees extension in the left knee without additional limitation to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. 4. For the entire rating period, a right knee disability has been manifested by degenerative arthritis with painful, noncompensable limited motion, to include at least 105 degrees flexion and 0 degrees extension, with no additional limitation to range of motion in degrees on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. 5. For the entire rating period, left hip traumatic arthritis has been manifested by degenerative arthritis with noncompensable limited motion in the left thigh, to include at least 90 degrees flexion and 0 degrees extension. 6. In April 2009, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, through his authorized representative, that a withdrawal of the appeal for a TDIU is requested. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, from February 8, 2011, the criteria for a separate 10 percent disability rating for status post left knee meniscal repair have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5259 (2013). 2. For the entire rating period, the criteria for an increased evaluation in excess of 10 percent for status post left knee meniscal repair, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5259 (2013). 3. From February 8, 2011, the criteria for an increased evaluation in excess of 30 percent for left knee arthritis (previously rated under Diagnostic Code 5259) have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, 5003, 5010, 5261 (2013) 4. For the entire rating period, the criteria an increased evaluation in excess of 10 percent for right knee disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5003 (2013). 5. For the entire rating period, the criteria for an increased evaluation in excess of 10 percent for left hip traumatic arthritis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5010 (2013). 6. The criteria for the withdrawal of an appeal for a TDIU by the appellant have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. Id. The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Id. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In an August 2007 letter, the RO provided preadjudicatory notice to the Veteran regarding what information and evidence is needed to substantiate his increased rating claims, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. The August 2007 notice letter included information regarding how disability ratings and effective dates are assigned. The Veteran was afforded VA examinations in October 2007, November 2008, and February 2011 that address increased ratings for right and left knee and left hip disabilities. 38 C.F.R. § 3.159(c)(4) (2013). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As the Board will discuss below, the November 2008 VA examination is not adequate for rating purposes. The Board finds, however, that October 2007 and February 2011 VA examinations are adequate. October 2007 and February 2011 VA rating examinations included complete physical examinations of the Veteran and, cumulatively, addressed all the relevant rating criteria for the knees, hip and thigh. For these reasons, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board finds that the RO/AMC substantially complied with the January 2011 Board remand order in obtaining the updated February 2011 VA examination and the Board finds that the February 2011 VA examiner adequately addressed findings from prior VA examinations and VA and private treatment records in the examination report. While the February 2011 VA examiner did not discuss discrepancies between October 2007 and November 2008 VA examinations, because the Board finds that range of motion was not properly tested during the November 2008 VA examination and range of motion findings are inconsistent with other VA examinations of record, the Board finds that the examination is inadequate for rating purposes and a medical opinion is not necessary to resolve discrepancies in the examination report. Accordingly, the Board finds that the RO/AMC substantially complied with the January 2011 Board remand order in obtaining the opinion and VA's duty to assist with respect to obtaining a VA examination or opinion has been met. See Stegall, 11 Vet. App. at 270 (1998) (holding that a remand by the Board imposes upon the Secretary of the VA a concomitant duty to ensure compliance with the terms of the remand). The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, SSA medical records, VA and private treatment records, and the Veteran's statements and hearing testimony. During the March 2010 Board videoconference hearing, to assist the Veteran, the VLJ conducting the hearing asked questions to direct the Veteran's testimony as to identify occupational and functional limitations associated with his service-connected disabilities and identify any recent treatment to include surgery. These actions fulfilled the duties under 38 C.F.R. § 3.103 (2013). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board finds that VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claims, and to respond to VA notices. The Veteran and representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Disability Rating Legal Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether a staged rating is warranted. The Board finds that the severity of the Veteran's right knee and left hip disability has not changed during the course of the appeal to warrant a staged rating. Because the Veteran is in receipt of a staged rating for the left knee disability, the Board will consider whether an increased evaluation is warranted for the left knee prior to and from February 8, 2011. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2013). Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45 (2013). With any form of arthritis, painful motion is an important factor of disability; therefore, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2013). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2013). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Diagnostic Code 5010 provides that arthritis due to trauma is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a. Under Diagnostic Code 5003, degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under 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 10 percent evaluation is assigned with x-ray evidence of involvement of two or more major joints; a 20 percent rating is assigned with x- ray evidence of involvement of two or more major joints with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. Hip flexion is measured from 0 degrees to 125 degrees; abduction is measured from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5251 (limitation of extension of the thigh), a 10 percent evaluation is assigned with extension limited to 5 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5252 (limitation of flexion of the thigh), a 10 percent evaluation is assigned with flexion limited to 45 degrees; a 20 percent evaluation is assigned with flexion limited to 30 degrees; a 30 percent evaluation is assigned with flexion limited to 20 degrees; and a 40 percent evaluation is assigned with flexion limited to 10 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5253, pertaining to impairment of the thigh, a 10 percent evaluation is warranted for limitation of abduction of the thigh such that the legs cannot be crossed or there is limitation of rotation such that it is not possible to toe out more than 15 degrees; a 20 percent rating requires limitation of abduction with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5255 contemplates impairment of the femur. Malunion of the femur warrants a 10 percent evaluation with slight knee or hip disability, a 20 percent evaluation with moderate knee or hip disability, and 30 percent evaluation with marked knee or hip disability. 38 C.F.R. § 4.71a. The terms "moderate" and "marked" are not defined in the VA Schedule. Rather than applying a mechanical formula, it is incumbent upon the Board to arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6 (2013). Terminology such as "moderate" and "marked" used by VA examiners and others, although an element of evidence to be considered by the Board, are not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). Ankylosis of the knee is evaluated under Diagnostic Code 5256. A 60 percent evaluation is assigned for extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more; a 50 percent evaluation is assigned for flexion between 20 and 45 degrees; a 40 percent evaluation is assigned for flexion between 10 and 20 degrees; and a 30 percent evaluation is assigned for a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5257 (other impairment of the knee) assigns a 30 percent evaluation for severe recurrent subluxation or lateral instability; a 20 percent evaluation for moderate recurrent subluxation or lateral instability; and a 10 percent evaluation for slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a 10 percent evaluation is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, limitation of flexion of the leg is noncompensable where flexion is limited to 60 degrees. A 10 percent evaluation is warranted where flexion is limited to 45 degrees; a 20 percent evaluation is warranted where flexion is limited to 30 degrees; and a 30 percent evaluation is warranted where flexion is limited to 15 percent. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261 (limitation of extension of the leg), a 10 percent rating is warranted where extension is limited to 10 degrees; a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a. VA's Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban, 6 Vet. App. at 262. VA's General Counsel interpreted that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97. In VAOPGCPREC 9-98, VA's General Counsel reiterated that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, the General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 38 C.F.R. § 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004. Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Increased Rating Analysis Because the record contains evidence from a November 2006 VA examination, dated within one year of the August 2007 claim for an increase, the Board has considered the November 2006 examination report in evaluating the Veteran's disabilities. See Hart v. Mansfield, 21 Vet. App. 505 (2007). A November 15, 2006 VA examination reflects 0 degrees extension to 105 degrees flexion in the left knee, 0 degrees extension to 95 degrees flexion in the right knee, and 50 degrees flexion, 20 degrees abduction, 20 degrees adduction, and 30 degrees external rotation in the left hip with pain at the end range of motion. The Veteran was unable to complete repetitive motion testing due to feeling faint during examination. X-rays reflect current arthritis in the bilateral knees and left hip. Because the Board finds that an increased rating is not warranted for the a left knee disability prior to February 8, 2011, and because increased ratings are not warranted for right knee and left hip disabilities at any time during the rating period, the Board finds a discernible or sustained increase in the Veteran's disabilities is not shown by the earlier November 2006 VA examination. While a veteran's entire history is reviewed when making a disability determination, where service connection has already been established and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). An August 2007 treatment summary from the Veteran's private orthopedic physician reflects a history of surgery to the left knee, chondromalacia in the left knee with degenerative changes, and the use of a brace for patellar support in the left knee. An October 2007 VA examination reflects 0 degrees extension to 135 degrees flexion in the left knee, and 0 degrees extension to 100 degrees flexion in the right knee with no change on repetitive testing. The Veteran had 90 degrees flexion, 40 degrees abduction, 40 degrees adduction, and 45 degrees external rotation in the left hip with no change on repetitive testing and no pain with range of motion in the hip. The VA examiner indicated there was no increased pain or fatigability, and no additional restrictions on ranges of motion in the hip and knees on repeat testing. A November 2008 VA examination reflects 0 degrees extension to 60 degrees flexion in the left knee, and 0 degrees extension to 40 degrees flexion in the right knee. The VA examiner stated that the Veteran "could not perform the 3 repetitive squats to test repetitive motion because of pain." The Veteran had 25 degrees flexion and 20 degrees abduction in the left hip. The examiner did not evaluate adduction in the left thigh, and indicated that external rotation could not be measured due to pain. A February 2011 VA examination reflects 20 degrees extension to 110 degrees flexion in the left knee, and 0 degrees extension to 135 degrees flexion in the right knee. The Veteran had 90 degrees flexion, 0 degrees extension, 35 degrees abduction, limitation of adduction such that he could not cross the legs, and 45 degrees external rotation in the left hip. While there was objective evidence of painful motion, the VA examiner stated that there was no additional limitation to range of motion after three repetitions of range of motion. October 2007 and February 2011 VA examinations reflect between 110 and135 degrees flexion in the left knee, and between 100 and 135 degrees flexion in the right knee without additional functional limitations due to pain on repeat testing. Conversely, a November 2008 VA examination reflects a much lower degree of flexion in the left and right knees, measured at 60 degrees and 40 degrees, respectively, with an inability to perform repeat testing. The Board finds that November 2008 range of motion measurements are inconsistent with findings from other VA examinations of record, and based on the examiner's statement that the Veteran was unable to do the "repetitive squats to test repetitive motion" it appears that the examiner conducted a standing test for knee flexion and extension, as opposed to a seated test in accordance with 38 C.F.R. § 4.71. See 38 C.F.R. § 4.71, Plate II. Range of motion findings for the hip are also, notably, inconsistent with findings from other VA examinations of record with 25 degrees of left hip flexion as compared to 90 to 95 degrees left hip flexion shown in October 2007 and February 2011 VA examinations. For these reasons, the Board finds that the November 2008 VA examination is not adequate for rating purposes, and findings from that examination will not be considered by the Board in evaluating the Veteran's service-connected disabilities. The Veteran provided hearing testimony before a Decision Review Officer (DRO) in September 2008, and during a March 2010 Board videoconference hearing. In September 2008, the Veteran reported a decrease in his physical functioning. The Veteran reported limitations in his ability to do chores, carry his young child, and walk due to knee pain. He identified limitations to waking and standing due to hip pain. During the March 2010 Board videoconference hearing, the Veteran identified limitations to lifting, bending, squatting, and twisting due to the combination of physical disabilities. He indicated that he had pain with walking half a block, and indicated that he could not perform past janitorial work which required working with equipment such as buffers, and scraping wax off of floors. The Veteran's wife also provided testimony indicating that he was unable to do physical activities such as playing with his children due to his knees. Increased Rating for the Knees The Veteran contends that higher ratings are warranted for the service-connected left and right knee based on occupational and functional limitations due to bilateral knee pain. The Veteran is currently service connected for a status post left knee meniscal repair, which was rated as 10 percent disabling under Diagnostic Code 5259 prior to February 8, 2011. From February 8, 2011, the Veteran was assigned an increased 30 percent disability rating based on limitation of extension of the leg (Diagnostic Code 5261). 38 C.F.R. § 4.71a. After a review of all the evidence, lay and medical, the Board finds that for the entire rating period, service-connected status post left knee meniscal repair has been manifested by removal of semilunar cartilage with residual symptomatology of meniscal abnormality. Prior to February 8, 2011, the Veteran was already in receipt of a 10 percent rating under Diagnostic Code 5259. The Board finds, resolving reasonable doubt in the Veteran's favor, that for the entire rating period, the criteria for a 10 percent disability rating for status post left knee meniscal repair have been met. A May 2012 rating decision shows that the RO granted an increased 30 percent rating for left knee, status post meniscal repair based on limitation of extension of the leg effective February 8, 2011; however, the rating code sheet shows that the RO purported to assign the 30 percent increased evaluation under Diagnostic Code 5259, but in fact did not. Under 38 C.F.R. § 4.71a, a maximum 10 percent schedular rating is warranted under Diagnostic Code 5259 and limitation of extension of the leg is rated under Diagnostic Code 5261. The Board finds that a change in these assigned ratings is not warranted; however, the Board finds that the RO should correct the record to reflect the assignment of a 10 percent rating under Diagnostic Code 5259 prior to February 8, 2011, and a 30 percent rating under Diagnostic Code 5261 (not Diagnostic Code 5259) from February 8, 2011. The Board finds that from February 8, 2011, a separate 10 percent rating is warranted for the status post left meniscal repair under Diagnostic Code 5259 where the Veteran is shown to have removal of semilunar cartilage that is symptomatic. Service treatment records show that in January 1989, the Veteran underwent a partial menisectomy of an anterior horn lesion and meniscal tear. Private treatment records show that during the pendency of the appeal in April 2008 the Veteran was evaluated for surgery for meniscus excision. A May 2008 operative report shows that the Veteran had a preoperative diagnosis of medial meniscus horizontal tear and anterior horn. He had arthroscopy and debridement of the anterior side of the patella and lateral meniscus. A February 2011 VA examination shows that the Veteran had a more recent total knee arthroplasty/total knee replacement in 2010. The Board finds that the evidence currently demonstrates residual symptoms associated with removal of the semilunar cartilage, that are not shown to be related to the more recent diagnosis of degenerative arthritis, and which are not symptoms contemplated under Diagnostic Codes 5003, 5010, or 5261. In that regard, the Veteran's meniscal disability was symptomatic to a degree that during the course of the appeals period an additional left knee menisectomy was required in May 2008, and a left total knee arthroplasty was performed in 2010. X-rays from the February 2011 VA examination show that the Veteran had interval placement from a left total knee arthroplasty. For these reasons and resolving reasonable doubt in favor of the Veteran, the Board finds that a separate 10 percent rating under Diagnostic Code 5259 is warranted for residual symptoms associated with removal of semilunar cartilage from February 8, 2011. A 10 percent evaluation is the maximum evaluation available under Diagnostic Code 5259. For these reasons, the Board finds that for the entire rating period, prior to and from February 8, 2011, an evaluation in excess of 10 percent is not available to the Veteran under Diagnostic Code 5259. While the Veteran is in receipt of a separate 30 percent rating from February 8, 2011 based on left knee pain and painful limited motion, these complaints are attributed to the separate diagnosis of left knee arthritis, which should be separately rated under Diagnostic Code 5261. Because the evidence demonstrates residual symptoms associated with removal of the semilunar cartilage, independent of pain and painful motion, the separate rating of 10 percent under Diagnostic Code 5259 would not constitute pyramiding based on the facts presented in this case. VAOPGCPREC 23-97 (noting that separate ratings under 5259 and 5003 must be considered); 38 C.F.R. § 4.14. The evidence of record does not reflect dislocated semilunar cartilage to warrant an evaluation under Diagnostic Code 5258 at any time. See 38 C.F.R. § 4.71a. While a September 2008 MRI reflects meniscus capsular separation, the evidence of record does not reflect dislocated semilunar cartilage with episodes of locking pain and effusion such that it approximates a 20 percent rating under Diagnostic Code 5258. See 38 C.F.R. § 4.71a. A February 2011 VA examination shows no dislocation, locking, or effusion in the left knee. Moreover, there was no subluxation or fractures shown on x-rays of the left knee in February 2011. The Veteran has not been assessed with dislocated semilunar cartilage at any time during the appeal. Additionally, the Board finds that a meniscal disability not result in additional symptoms outside of what has already been considered in evaluating the Veteran's left knee disability under Diagnostic Codes 5259 and 5261. For these reasons the Board finds that a separate evaluation is not warranted under Diagnostic Codes 5258. The Board will next consider whether separate or higher ratings are warranted under Diagnostic Codes 5260 and 5261 based degenerative arthritis with limitation of flexion and limitation of extension in the left knee. After a review of all the evidence, lay and medical, the Board finds that prior to February 8, 2011 a service-connected left knee disability is manifested by degenerative arthritis with at 135 degrees flexion and 0 degrees extension with no additional limitation to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. The Board finds that prior to February 8, 2011 a separate compensable evaluation is not warranted for limitation of flexion or limitation of extension in the left knee under Diagnostic Codes 5260 or 5261. Under Diagnostic Code 5260, a 10 percent evaluation is warranted where flexion is limited to 45 degrees and under Diagnostic Code 5261, and a 10 percent evaluation is warranted where extension is limited to 10 degrees. See 38 C.F.R. § 4.71a. An October 2007 VA examination shows that the Veteran had 135 degrees flexion and full extension in the left knee to 0 degrees. The October 2007 VA examiner indicated that there was no increased pain or fatigability, and no additional restrictions on ranges of motion in the hip and knees on repeat testing. Accordingly, the Board finds that the Veteran did not have additional functional loss shown due to flare-ups of pain, fatigability, incoordination, pain on movement, or weakness. See DeLuca, 8 Vet. App. 206-7. Even with consideration of pain and other factors on repetitive use, the Veteran was able to complete 135 degrees flexion and 0 degrees extension. For these reasons, the Board finds that, even with consideration of functional loss due to pain, weakness, and fatigability, prior to February 8, 2011, the Veteran's left knee disability does not more nearly approximate a rating based on flexion limited to 45 degrees or extension limited to 10 degrees to warrant a separate compensable rating under Diagnostic Code 5260 or 5261. See 38 C.F.R. § 4.71a. The Board finds that prior to February 8, 2011, a compensable rating under Diagnostic Code 5260 or Diagnostic Code 5261 for left knee arthritis has not been met or more nearly approximated. See 38 C.F.R. §§ 4.3, 4.7. After a review of all the evidence, lay and medical, the Board finds that from February 8, 2011, the service-connected left knee arthritis has been manifested by pain and painful motion, to include 110 degrees flexion and 20 degrees extension in the left knee without additional limitation to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. From February 8, 2011, the Veteran was in receipt of a 30 percent rating under Diagnostic Code 5261 for left knee arthritis. A higher 40 percent rating is assigned for extension limited to 30 degrees. See 38 C.F.R. § 4.71a. A February 2011 VA examination reflects 20 degrees extension in the left knee without additional limitation to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. Accordingly, the Board finds that the Veteran did not have additional functional loss shown due to flare-ups of pain, fatigability, incoordination, pain on movement, or weakness. See DeLuca. Even with consideration of pain and other factors on repetitive use, the Veteran was able to complete at least 20 degrees extension. For these reasons, the Board finds that, even with consideration of functional loss due to pain, weakness, and fatigability, from February 8, 2011 the criteria for the next higher 40 percent rating under Diagnostic Code 5261 have not been met or more nearly approximated. See 38 C.F.R. §§ 4.3, 4.7. The Board finds that from February 8, 2011 a separate compensable rating is not warranted under Diagnostic Code 5260 based on limitation of flexion in the left knee. A February 2011 VA examination report reflects 110 degrees flexion in the left knee without additional limitation to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. The Board finds that, even with consideration of functional loss due to pain, weakness, and fatigability, from February 8, 2011, left knee arthritis does not more nearly approximate a separate 10 percent rating based on flexion limited to 45 degrees under Diagnostic Code 5260. See 38 C.F.R. § 4.71a. While the Veteran had evidence of painful motion in the knee, limitations of motion and function due to pain have already been considered in the assigned 30 percent rating for left knee arthritis under Diagnostic Code 5261. Pyramiding, the evaluation of the same disability or the same manifestation of a disability under different diagnostic codes, is to be avoided when evaluating a service-connected disability. See 38 C.F.R. § 4.14. For these reasons, the Board finds that from to February 8, 2011, the criteria for a separate compensable rating under Diagnostic Code 5260 for left knee arthritis have not been met or more nearly approximated. After a review of all the evidence, lay and medical, the Board finds that for the entire rating period, a service-connected right knee disability has been manifested by degenerative arthritis with noncompensable limited motion, to include at least 105 degrees flexion and 0 degrees extension, with no additional limitation to range of motion in degrees on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. The Veteran is currently in receipt of a 10 percent disability rating for a right knee disability. Historically, in a September 2003 rating decision, the RO granted service connection for the right knee disability as secondary to a service connected status post left knee menisectomy. While the rating sheet reflects a current 10 percent rating for the right knee under Diagnostic Code 5257 (impairment of the knee with recurrent subluxation or lateral instability), the original September 2003 rating decision shows that a 10 percent evaluation was granted based on the presence of pain and limitation of motion in the right knee, and that there was no evidence of instability or subluxation in the right knee. The Diagnostic Codes which reflect service connection for rating arthritis are Diagnostic Codes 5003, 5010, and specific motion codes such as Diagnostic Code 5260 and 5261. As there in fact was no subluxation or lateral instability at the time of the grant of service connection for the right knee disability, and the RO did not indicate the 10 percent rating was based on any such finding, the RO in fact granted service connection for right knee pain and limited motion indicative of arthritis. Therefore, the use of Diagnostic Code 5257 was not proper and the Diagnostic Code should be changed to Diagnostic Code 5003 to reflect the actual disability for which service connection was granted, which now involves arthritis. Because current evidence of record reflects arthritis in the right knee with painful, noncompensable limited motion, but not instability or subluxation, the Board finds that the record should be corrected so that the right knee disability is rated under Diagnostic Code 5003. The Board will next address whether an increased rating in excess of 10 percent is warranted for right knee arthritis. The Veteran has reported pain in the knees during VA examinations and hearing testimony. The Board finds that the lay evidence provided with respect to pain on examination is credible and consistent with x-ray findings of arthritis in the knee. October 2007 and February 2011 VA examinations reflect between 100 degrees and 135 degrees flexion in the right knee with painful motion with no additional limitation in range of motion, in degrees, due to pain. The Board finds that the Veteran currently exhibits a noncompensable level of limitation of flexion and limitation of extension in the right knee under Diagnostic Codes 5260 and 5261. The Veteran's 10 percent rating under Diagnostic Code 5003 was assigned based on noncompensable painful limitation of flexion in the knee and the Veteran has current evidence of arthritis in the right knee. Thus, the 10 percent rating was actually granted under Diagnostic Code 5003. Diagnostic Code 5003 provides a 10 percent rating for arthritis where limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, and where there is sufficient evidence of painful motion. 38 C.F.R. § 4.71a. Painful joints due to a healed injury are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. The Board finds that, for the entire rating period, the criteria for a higher 20 percent rating under Diagnostic Code 5260 or a separate 10 percent rating under Diagnostic Code 5261 have not been met or more nearly approximated for any portion of the rating period. Manifestations of right knee arthritis have not more nearly approximated right knee flexion limited at 30 degrees or less, or extension limited to 10 degrees or more any time during the rating period. See 38 C.F.R. § 4.71a. VA examinations reflect at least 105 degrees flexion and full extension to 0 degrees in the right knee. Even with considerations of additional limitation of motion due to pain, the Veteran's right knee disability is not shown to approximate 30 degrees flexion or 10 degrees extension in the knee, and the Veteran's functional loss due to pain has already been considered in the assigned 10 percent evaluation under Diagnostic Code 5003. See 38 C.F.R. §§ 4.40, 4.45, 4.59, Deluca. The Board has considered whether compensable evaluation is warranted for either the left or right knees under other applicable provisions of the Diagnostic Code. The evidence of record does not reflect ankylosis of the left or right knee to warrant an evaluation under Diagnostic Codes 5256. See 38 C.F.R. § 4.71a. VA examinations show that the Veteran has measurable range of motion in both knee joints without ankylosis. The Board finds that the Veteran does not have recurrent subluxation or lateral instability of either the right or left knee to warrant a compensable evaluation under Diagnostic Code 5257. See 38 C.F.R. § 4.71a. An October 2007 VA examination shows that the Veteran wore braces on both knees; but, upon questioning, the Veteran indicated the braces were for a problem involving the knee caps. The October 2007 VA examiner did not conduct tests for subluxation or lateral instability. During a February 2011 VA examination, physical examination showed no giving way, instability, incoordination, dislocation, or subluxation in either the left or right knee. The examiner noted that, while there was no instability in the right knee, the Veteran had a three millimeter medial compartment and pseudo laxity due to loss of cartilage space. While the Veteran had pseudo laxity in the right knee, the Board finds that on objective testing it did not result in recurrent subluxation or lateral instability in the knee. For these reasons, the Board finds that for the entire rating period, the Veteran's right and left knee disability have not met or more nearly approximated the criteria for a 10 percent disability rating under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board finds that the evidence does not show dislocated semilunar cartilage or removal of semilunar cartilage in the right knee to warrant an evaluation under Diagnostic Codes 5258 or 5259. See 38 C.F.R. § 4.71a. A February 2011 VA examination shows no dislocation, locking, or effusion in the knees. The evidence of record does not reflect surgery to the right knee at any time, and the Veteran has not otherwise been diagnosed with a meniscal abnormality in the right knee. For these reasons the Board finds that a separate evaluation is not warranted under Diagnostic Code 5258 or 5259 for the right knee. Increased Rating Left Hip Arthritis The Veteran contends that an increased rating is warranted for a service-connected left hip traumatic arthritis and has described occupational and functional limitations caused by left hip pain. The Veteran is currently service connected for left hip traumatic arthritis. Historically, in an April 2002 rating decision, the RO granted service connection for left hip traumatic arthritis and assigned an initial 10 percent rating using Diagnostic Code 5010-5253. The Veteran submitted a new claim for an increased rating in August 2007. As noted above, in a May 2012 rating decision, the RO granted two separate 10 percent disability ratings for a left hip disability from February 8, 2011 (using Diagnostic Codes 5251 and 5253, but should have assigned each under Diagnostic Code 5253. The RO did not disturb the 10 percent rating already in effect for left hip traumatic arthritis (which should be reflected as Diagnostic Code 5010-5003. The Veteran did not submit a notice of disagreement to the May 2012 rating decision assignment of 10 percent separate ratings, therefore, the Board, finds that the separate ratings based on impairment of the thigh are not currently before the Board (Diagnostic Code 5253). The Board finds, however, that Diagnostic Codes for rating the left hip need to be changed to Diagnostic Code 5253 to correct the record. In that regard, the record shows that the Veteran currently has traumatic arthritis in the right hip with a noncompensable degree of limitation of flexion and extension. See 38 C.F.R. § 4.71a. Thus, the Board finds that left hip traumatic arthritis currently on appeal should be rated under Diagnostic Code 5010-5003 and not 5010-5253. While the RO indicated in the May 2012 rating decision that a 10 percent rating is warranted based on limitation of extension, a February 2011 VA examination reflects full extension in the thigh to 0 degrees. See 38 C.F.R. § 4.71, Plate II, 4.71a. A February 8, 2011 VA examination, however, shows current impairment of the thigh with a compensable level of both limitation of adduction, and limitation of rotation. Because different functions of the thigh are affected (adduction and external rotation), the Board finds that from February 8, 2011 two separate 10 percent evaluations may be assigned under Diagnostic Code 5253 for impairment of the thigh with limitation of adduction and impairment of the thigh with limitation of rotation in this particular case. For these reasons, the Board finds that, while a change in the current ratings is not warranted, the Diagnostic Codes under which the Veteran is rated should be corrected to reflect a 10 percent evaluation for left hip traumatic arthritis (currently on appeal) under Diagnostic Code 5010-5003 for the entire rating period; a separate 10 percent evaluation under Diagnostic Code 5253 for impairment of the thigh with limitation of adduction from February 8, 2011; and a separate 10 percent evaluation under Diagnostic Code 5253 for impairment of the thigh with limitation of rotation. The Board will next address whether an increased rating is warranted for left hip traumatic arthritis, currently rated under Diagnostic Code 5010-5003. For the entire rating period, the Board finds that left hip traumatic arthritis has been manifested by degenerative arthritis with noncompensable limited motion in the left thigh, to include at least 90 degrees flexion and 0 degrees extension. The Board finds that a currently assigned 10 percent evaluation is assigned based on painful, limited motion that is otherwise noncompensable. Because a 10 percent rating is the maximum rating assignable under Diagnostic Code 5251 for limitation of extension of the left thigh, the Board finds that an evaluation in excess of 10 percent is not available under Diagnostic Code 5251. Moreover, the Board finds that Veteran does not have extension in the left thigh limited to 5 degrees such that left hip traumatic arthritis more nearly approximates a 10 percent rating under Diagnostic Code 5251. An October 2007 VA examination did not include measurements for left hip extension; however, a February 2011 VA examination reflects full extension in the left hip to 0 degrees, with no additional limitation to range of motion in degrees after repetitive testing. While the Veteran had evidence of painful motion, noncompensable painful motion due to arthritis is already considered in the Veteran's 10 percent rating under Diagnostic Code 5010-5003. See 38 C.F.R. § 4.14. Under Diagnostic Code 5251, a 10 percent rating is assigned with flexion in the thigh limited to 45 degrees. October 2007 and February 2011 VA examinations reflect 90 degrees flexion in the left thigh with no additional limitation to range of motion in degrees after repetitive testing. The Board finds that Veteran does not have flexion in the left thigh limited to 45 degrees such that left hip traumatic arthritis more nearly approximates a 10 percent rating under Diagnostic Code 5252, and while the Veteran has evidence of painful motion, noncompensable painful motion is already considered in the Veteran's 10 percent rating under Diagnostic Code 5010-5003. See 38 C.F.R. § 4.14 The Board finds that for the entire rating period, a separate or higher rating is not warranted under Diagnostic Code 5253 based on impairment of the thigh with limitation of abduction beyond 10 degrees. In the regard, October 2007 and February 2011 VA examinations reflect 35 to 40 degrees abduction in the left thigh with no additional limitation to range of motion in degrees after repetitive testing, and noncompensable painful motion is already considered in the Veteran's 10 percent rating under Diagnostic Code 5010-5003. See 38 C.F.R. § 4.14 While the Board finds that the Veteran has provided credible evidence of pain in the left hip and thigh, October 2007 and February 2011 VA examinations show that the Veteran had no additional limitation of motion in degrees or functional loss due to pain, painful motion, weakness, or fatigability upon repetitive use and painful, motion is already considered by the currently assigned 10 rating. See 38 C.F.R. §§ 4.40, 4.45; DeLuca. For these reasons, the Board finds that even with consideration of pain, an increased rating in excess of 10 percent is not warranted for left hip traumatic arthritis. As for other potentially applicable diagnostic codes pertaining to the hip, the record does not contain evidence of ankylosis of the left hip or flail joint to warrant a rating under Diagnostic Code 5250 or 5254 at any time during the rating period. See 38 C.F.R. § 4.71a. The Veteran did not have x-ray evidence of malunion of the femur during December 2010 or September 2011 VA examinations to warrant a compensable evaluation under Diagnostic Code 5255. See 38 C.F.R. § 4.71a. The Veteran's statements and testimony have been considered by VA examiners in their evaluation of the Veteran's bilateral knee and left hip disabilities, and by the Board. As discussed above, during DRO and Board hearings, the Veteran described limitations to activities of daily living, limitations to walking, standing, bending, lifting, and twisting due to his bilateral knee and left hip disability, and limitations to his employment, which included past employment as a janitor and roofer. The Board finds that the Veteran is competent to describe his physical limitations, and that he is credible. The Veteran is shown to have limitations to more physical employment due to his knees and hip, and this has been discussed by a February 2011 VA examiner who indicated that the bilateral knee and left hip disabilities result in significant effects on usual occupation to include decreased mobility, lack of stamina, weakness, fatigue, decreased strength, and pain. However, the Board finds that identified symptoms of pain, painful motion, and functional limitations due such are adequately addressed by the Veteran's assigned separate evaluations under Diagnostic Codes 5003, 5010, 5259, and 5253 for disabilities of the left and right knees and left hip. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's bilateral knee and left hip disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Codes 5003, 5010, 5251, 5252, 5253, 5259, 5260, and 5261, specifically provide for disability ratings based on limitation of motion and function, and on specific abnormalities, including due to pain and other orthopedic factors. See 38 C.F.R. §§ 4.21, 4.40, 4.45, 4.59 (2013); see also DeLuca. In this case, considering the lay and medical evidence, the Veteran's knee disabilities have been manifested by pain and painful motion, as well as symptomatic removal of semilunar cartildge in the left knee. A left hip disability is additionally manifested by noncompensable painful motion. These symptoms are contemplated by the schedular rating criteria. The Board has additionally considered ratings under alternate schedular rating criteria as discussed above. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). Additionally, the Board has considered the Veteran's functional limitations described during hearing testimony and noted during VA examinations, to include limitations to walking and lifting, and performing more physical activities of daily living and occupational tasks. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the functional limitations imposed by the Veteran's disabilities are specifically contemplated by the criteria discussed above, including the effect of the Veteran's bilateral knee and left hip pain and associated limitations on his occupation and daily life. In the absence of exceptional factors associated with the knee and hip disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Withdrawal of a TDIU Claim The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran has withdrawn the appeal for a TDIU in an April 2009 correspondence; hence, there remain no allegations of errors of fact or law for appellate consideration on this issue. Accordingly, the Board does not have jurisdiction to review the appeal for a TDIU, and it is dismissed. ORDER From February 8, 2011, a separate 10 percent disability rating for status post left knee meniscal repair is granted. For the entire rating period, an increased rating in excess of 10 percent for status post left knee meniscal repair is denied. From February 8, 2011, an increased rating in excess of 30 percent for left knee arthritis (previously rated under Diagnostic Code 5259) have not been met. For the entire rating period, an increased rating in excess of 10 percent a right knee disability is denied. For the entire rating period, an increased evaluation in excess of 10 percent for left hip traumatic arthritis is denied. The appeal for a TDIU is dismissed. REMAND Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(i) (2013). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Under the current version of 38 C.F.R. § 3.310(b) which is applicable to this appeal, the regulation provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. These evaluations of baseline and current levels of severity are to be based upon application of the corresponding criteria under the VA rating schedule for evaluating that particular nonservice-connected disorder. 38 C.F.R. § 3.310(b). Service Connection for a Right Hip Disability The Board remanded the appeal in January 2011 for a VA examination and opinion to address, in pertinent part, whether service-connected disabilities of the left knee, right knee, and left hip caused or aggravated (permanently increased in severity) a currently diagnosed right hip disability. A February 2011 VA examiner opined that right hip complaints of pain and dysfunction were not caused by or a result of service-connected left thigh and hip and bilateral knee disabilities, but did not address the question of secondary service connection on the basis of aggravation. Additionally, while service treatment records do not reflect specific injury to the right hip in service, the Veteran was seen for right hip complaints in October 1989 shortly after arthroscopic surgery to the left knee. The Board finds, therefore, that a remand for VA examination is necessary to assist in determining if a right hip disability is aggravated by service-connected disabilities, or if it is otherwise related to service. Accordingly, the issue of service connection for a right hip disability, to include as secondary to service-connected disabilities, is REMANDED for the following action: 1. The RO/AMC should obtain a VA addendum opinion from the February 2011 VA examiner or appropriate substitute to assist in determining whether a right hip disability was aggravated by any service-connected disabilities. The relevant documents in the claims folder should be made available for review in connection with this request. The examiner should offer the following opinions: A) Is it at least as likely as not that a right hip disability is permanently worsened in severity (aggravated) by service-connected disabilities of the bilateral knees, and left hip? If the opinion is that there is aggravation, to the extent that is possible, the examiner is requested to provide an opinion as to approximate baseline level of severity of the nonservice-connected condition before the onset of aggravation. "Aggravation" is defined for legal purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. B) Is it at least as likely as not that a right hip disability is otherwise related to active service? In providing an opinion, the examiner should address findings in service treatment records which reflect an October 1989 complaint of right hip pain. The examiner should provide a rationale for his or her opinion with reference to the evidence of record. Citation to medical authority/treatise would be helpful. 2. After all development has been completed, the RO/AMC should readjudicate the issue of service connection for a right hip disability, to include as secondary to service-connected disabilities. If the benefits sought remain denied, the Veteran and his representative should be furnished a supplemental statement of the case, and should be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of this claim. See 38 C.F.R. § 3.655 (2013). The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs