Citation Nr: 1333636 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 06-14 367A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability evaluation in excess of 10 percent for lumbosacral strain with degenerative disc disease, prior to November 23, 2010; entitlement to an initial disability evaluation in excess of 20 percent from November 23, 2010. 2. Entitlement to an initial disability evaluation in excess of 10 percent for degenerative joint disease of the left knee. 3. Entitlement to an initial disability evaluation in excess of 10 percent for degenerative joint disease of the right knee. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran had active service from May 1990 to May 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) located in Houston, Texas, which granted service connection for left knee and right knee degenerative joint disease and a lumbosacral strain, and assigned 10 percent, noncompensable, and 10 percent disability evaluations, respectively. The Veteran appealed the assigned disability evaluations. Thereafter, the Waco, RO assumed jurisdiction. In an August 2008 rating determination, the RO increased the Veteran's disability evaluation for his right knee degenerative joint disease from noncompensable to 10 percent disabling and assigned an effective date of April 21, 2008. In February 2010, the Veteran testified at a Travel Board hearing before the a Veterans Law Judge at the RO. A transcript of the hearing is of record. In October 2010, the Board remanded this matter for further development. In an April 2012 rating determination, the Appeals Management Center (AMC), acting on behalf of the RO, increased the Veteran's disability evaluation for his lumbosacral strain, which it reclassified as lumbosacral strain with degenerative disc disease, from 10 to 20 percent, and assigned an effective date of November 23, 2010. In October 2012, the Board once again remanded this matter for further development, with the requested development being accomplished. In a June 2013 determination, the Appeals Management Center (AMC), acting on behalf of the RO changed the effective date for the Veteran's 10 percent disability evaluation for right knee degenerative joint disease to the date following his separation from service. In July 2013, the Board informed the Veteran that the individual who conducted his February 2010 hearing was no longer employed by the Board and indicated that Veteran could have an additional hearing if so desired. In July 2013, the Veteran indicated that he did not wish to appear at another hearing and wanted his case decided on the evidence of record. The undersigned has reviewed the hearing transcript. As a result of the above, the Board has listed the issues as such on the title page of this decision. FINDINGS OF FACT 1. For the time period prior to November 23, 2010, the Veteran's lumbosacral strain with degenerative disc disease was shown to have forward flexion of the thoracolumbar spine to greater than 60 degrees; the combined range of motion for the thoracolumbar spine was greater than 120 degrees; there was no demonstration of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, with no evidence of neurological abnormalities; there were also no incapacitating episodes as defined by regulation, having a total duration of at least two weeks but less than four weeks during a 12-month period. 2. For the initial rating period subsequent to November 23, 2010, the Veteran's lumbosacral strain with degenerative disc disease has not been manifested by forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar; there were also no incapacitating episodes as defined by regulation, having a total duration of at least four weeks but less than six weeks during a 12-month period. 3. The Veteran has, even taking into account functional limitation, consistently demonstrated full extension and limitation of flexion to no less than 60 degrees for the left knee throughout the course of the appeal. 4. No objective evidence of instability or subluxation in the Veteran's left knee was detected on examination of the knee. 5. The Veteran has, even taking into account functional limitation, consistently demonstrated full extension and limitation of flexion to no less than 60 degrees for the right knee throughout the course of the appeal. 6. No objective evidence of instability or subluxation in the Veteran's right knee was detected on examination of the knee. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for lumbosacral strain with degenerative disc disease prior to November 23, 2010, have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.40, 4.45. 4.71a, Diagnostic Codes 5235-5243 (2013). 2. The criteria for an evaluation in excess of 20 percent for lumbosacral strain with degenerative disc disease from November 23, 2010 have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5235-5243 (2013). 3. The criteria for a rating in excess of 10 percent for degenerative joint disease of the left knee have not been met at any time during the course of the appeal. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5257, 5260, 5261 (2013). 4. The criteria for a rating in excess of 10 percent for degenerative joint disease of the right knee have not been met at any time during the course of the appeal. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5257, 5260, 5261 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion, and a part which becomes disabled on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is to be considered in evaluating the degree of disability, but a little-used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as at least minimally compensable. See also DeLuca v. Brown, 8 Vet. App. 202 (1995) (indicates that pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain may be the basis for a rating for a disability rated based on limitation of motion, regardless of whether or not the limitation of motion specified in the Diagnostic Code criteria is shown). Diagnostic Code 5003 (5010) 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 (DC 5200 etc.). When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under 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 where X-ray evidence shows involvement of two or more major joints or 2 or more minor joint groups. Where there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent evaluation is assigned. Note (1) to Diagnostic Code 5003 states that the 20 and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Id. Lumbosacral Strain with Degenerative Disc Disease Diseases and injuries to the spine are to be evaluated under diagnostic codes 5235 to 5243 as follows: With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease Unfavorable ankylosis of the entire spine: 100 percent Unfavorable ankylosis of the entire thoracolumbar spine: 50 percent Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine: 40 percent Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine: 30 percent Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis: 20 percent Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height: 10 percent Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, General Rating Formula for Disabilities and Diseases of the Spine (2013). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is as follows: With incapacitating episodes having a total duration of at least six weeks during the past 12 months: 60 With incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months: 40 With incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months: 20 With incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months: 10 Note (1): For purposes of evaluations under 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating for Formula and Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243. In conjunction with his claim the Veteran was afforded a VA examination in August 2004. The Veteran reported that his low back had a constant dull type pain. He did not use a brace. He noted having flare-ups two to three times per week. The precipitating factors were prolonged walking and standing. Flare-ups were alleviated by taking a long hot shower and medication. X-rays of the lumbar spine showed the discs were minimally narrowed. He was also found to have minimal dextroscoliosis. Physical examination of the lower back revealed tenderness in the lumbosacral region. There was no paraspinal spasm in the lower back and no neurological deficits in the lower extremities. Flexion was to 70 degrees, extension was to 25 degrees, lateral flexion was to 25 degrees, and rotation was to 25 degrees. Neurological examination revealed normal sensation, motor power, and deep tendon reflexes. The examiner rendered a diagnosis of low back strain. At the time of an April 2005 VA examination, the Veteran reported having off and on 8/10 spasm like pain, rising to 9 with flare-ups. The Veteran noted taking Tramadol and etodolac for his knees, which also helped his back. He reported having flare-ups two to three times per week, which lasted 3-4 hours. The Veteran stated that sometimes the pain would come on for no reason but he had noticed that the pain came if he sat, stood up, or walked around too long. He noted having some decrease in range of motion during the flare-ups. The examiner stated that the back condition had no effect on the Veteran's usual occupation or usual daily activities. Examination of the spine reveal normal findings. Range of motion revealed flexion from 0 to 90 degrees, extension from 0 to 30 degrees, left and right lateral flexion from 0 to 30 degrees, and left and right lateral rotation from 0 to 30 degrees. The Veteran had mild pain at the end of range of motion. The examiner noted that there was no additional loss of motion or loss of spine function after repetitive use in the office, but during flare-ups there was both. The Veteran had no spasm, weakness, or tenderness. There was no muscle spasm or guarding or localized tenderness with spinal contour. The back condition did not result in abnormal gait, abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Neurological examination revealed normal sensory, motor, and reflex findings. Lasegue sign was negative. A diagnosis of lumbosacral strain (minimal dextroscoliosis, minimal degenerative disk disease at L3-4, L4-5) was rendered. In January 2006, the Veteran reported that his back locked up on him. He was told to stay home for five days and was restricted in his ability to do heavy lifting. In an April 2006 letter, the Veteran's wife indicated that the Veteran was bending over and suddenly experienced severe back pain which caused him to fall to the floor. She stated that she had to call 911 in order to get her husband off the floor. She stated that she always had to help him out of bed. The Veteran submitted paperwork showing he could not report to work for five days. At the time of an April 2008 VA examination, the Veteran reported that during the last 12 months he had experienced daily 8/10 intensity mechanical low back pain symptoms. He described the mechanical low back pain and a transverse band across the lower lumbar region sometimes radiating into either buttock. The Veteran reported having flare-ups three times per week with 10/10 pain that would last for 12 to 24 hours. The examiner noted that the Veteran complained of bilateral lower extremity paresthesias and dysesthesias in a vaguely L5 radicular pattern. The Veteran denied any days of physician prescribed bed rest for this condition in the last twelve months. The Veteran reported that his weight bearing tolerance, standing, and walking, were limited to 30 minutes due to his back and knee problems. He was independent in his activities of daily living. Low back symptoms were associated with activities that required strenuous or repetitive lifting or repetitive bending or twisting at the waist. Physical examination revealed that the Veteran walked freely and briskly without an antalgic gait. Examination of the thoracolumbar spine revealed a normal spinal curvature. There was no tenderness of the lumbar spinous process, bilateral lumbar paravertebral muscles, or myofascia. There was no tenderness in the bilateral sacroiliac joint or the sciatic notch, providing evidence against this claim. Neurological examination revealed sensation was intact to light touch for all dermatomes of bilateral lower extremities. Muscle strength was 5/5 for all myotomes of the bilateral lower extremities. There was no muscle wasting or atrophy. Reflexes were physiologic and symmetric. Babinski was negative. Straight leg raising was also negative. Range of motion using the DeLuca criteria revealed forward flexion to 70 degrees pre-repetitive motion and to 64 degrees after repetition. Extension was from 0 to 30 degrees pre and post-repetition. Left lateral flexion was from 0 to 20 degrees, pre and post repetition, and right lateral flexion was from 0 to 30 degrees, pre and post-repetitive motion. Right and left lateral rotation was from 0 to 30 degrees, pre and post-repetition. The Veteran complained of pain on the extremes of motion in each plane. There was no apparent weakness, fatigability, or loss of coordination during or following three repetitions of range of motion. A diagnosis of lumbar degenerative disc disease L3/4, L4/5, and L5/S1, mild, was rendered, providing more evidence against this claim. At the time of his February 2010 hearing, the Veteran reported that his back limited the amount of weight he could lift. He stated that he did not have full range of motion to bend to a 90 degree angle without pain. He noted having flare-ups that incapacitated him. He stated that during the morning the pain would flare-up to the point that he just had to lay there. He reported having problems with his back from the get-go each morning. The Veteran stated that he did not go to the doctor every time that his back hurt. He indicated that his condition had worsened in the last year. The Veteran stated that he had requested a back brace but had never received one. The Veteran's wife testified that if he sat for a long period of time he would have to move side to side, shifting constantly. She also noted that he could not lift much when going to the grocery store. Following the hearing, the Veteran was afforded an additional VA examination in November 2010 in light of his statements at hearing. At the time of the examination, the Veteran reported having no radicular radiation of back pain and no paresthesias associated with the injury. The pain was bilateral in the lower lumbar segments. He took Motrin and Tramadol for this. He had constant pain in the lower lumbar segment. The Veteran worked as conductor for the railroad, which he stated involved a lot of walking and bending. He noted an increase in the pain with standing for more than 30 minutes or walking more than 1/4 mile. He would get flares of pain two to three times per week, which would last one or two days. He missed work one day at a time approximately three to four times per month on average due to the back and knee pain. He did not use a back brace. He had no incontinence of urine or stool. Examination of the lumbar spine revealed forward flexion from 0 to 90 degrees passively, but only to 40 degrees actively, with pain throughout the maneuver. He had pain only at the extreme with passive motion. Extension was from 0 to 30 degrees with pain at the extremes. Left and right lateral rotation were from 0 to 30 degrees, with pain from 20-30 degrees. Left and right lateral flexion were from 0 to 30 degrees, with pain from 20-30 degrees, bilaterally. Repetition of all ranges of motion times three did not increase pain, fatigue, weakness, lack of endurance, or incoordination. Sensation in the lower extremities was normal . Muscle strength at the hip, knee, and ankle were judged normal and equal, bilaterally. The knee and ankle jerks were +2/4, bilaterally, and judged normal. A diagnosis of chronic lumbar myofascial syndrome with recurrent lumbar strain was rendered. Overall, it is important for the Veteran to understand that the report above provides more evidence against this claim. In a May 2011 private treatment record, the Veteran was noted to have normal neurological findings, providing more evidence against this claim, and confirming the findings above. At the time of a November 2011 visit, the Veteran was found to have normal deep tendon reflexes, 5/5 muscle strength, decreased range of motion in flexion and extension, no swelling or tenderness, and normal straight leg raising, also confirm the findings of the VA examination. In an April 2012 letter, the Veteran indicated that the VA examiner forced his body into positions to where he wanted it when checking range of motion regardless of the pain he was having. He stated that he had episodes of incapacity 5 to 6 times, up to 8 times per year. He reported that he would take off work 3 to 4 times per week when these episodes happened. He indicated that he needed this time to recover and take his medications. As noted above, the Veteran was asked to submit written authorizations so that information about lost time from work and FMLA records could be obtained. He did not provide the requested information. In a November 2012 addendum, the examiner indicated that the Veteran's back flares involved increase in pain and did not affect his range of motion. He noted that the Veteran missed a single day of work due to the increase in pain and his inability to handle his normal employment during these time periods. Time Period Prior to November 23, 2010 Prior to this time, VA examinations showed the Veteran to have forward flexion to no less than 64 degrees and a combined range of motion greater than 120 degrees. Even with consideration of functional factors there is no additional loss of motion. 38 C.F.R. §§ 4.40 , 4.45, 4.59. While the Veteran has complained of pain, the VA examiners specifically found that there was no additional limitation of motion due to pain. The Veteran was also found to have a normal spine contour and gait and no muscle spasm prior to this time. He thus did not meet the criteria for an evaluation in excess of 10 percent under the General Formula for Diseases and Injuries of the Spine. The normal neurologic findings reported support a finding that no additional rating can be awarded on the basis of neurologic impairment. While the Veteran reported that his back problems led to periods of incapacitation, the treatment records show no periods of physician prescribed bed rest, as is required for an increased evaluation. The Board does note that the Veteran has submitted a note indicating that he was to be off work for a period of five days as a result of his back in January 2006, but this is the only prescribed period of record. Hence, an increased rating cannot be provided under the formula for rating intervertebral disc disease. Although the Board notes that the Veteran has indicated that the symptomatology associated with his lumbosacral strain with degenerative disc disease warranted an increased evaluation for this time period, the competent medical evidence reflects consideration of the Veteran's complaints of pain, weakness and fatigability by medical professionals. The Veteran is competent to report his symptoms, but the observation of a competent medical professional as it bears upon clinical support for the Veteran-layman's complaints is more probative of the degree of the Veteran's impairment. Even when considering the additional limitation of motion possibly caused by fatigue, weakness and flare-ups, which was not shown to be present, neither the actual range of motion nor the functional limitation warranted an evaluation greater than that which was assigned based upon the appropriate codes governing limitation of motion. Accordingly, the Board finds that the criteria for entitlement to a rating greater than 10 percent prior to November 23, 2010 were not met. The preponderance of the evidence is against the Veteran's claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Without taking into consideration the Veteran's concerns, there would not be a basis for the 10 percent evaluation, let alone a higher evaluation during this time frame. Time Period From November 23, 2010 With regard to the Veteran's lumbosacral strain with degenerative disc disease, an evaluation in excess of 20 percent is not warranted for the initial rating period from November 23, 2010. Forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine was not demonstrated at any time. Moreover, as noted above, at the time of the November 2010 VA examination, the Veteran had forward active forward flexion to 40 degrees and passive flexion to 90 degrees, with no ankylosis being reported. While the Veteran has noted missing numerous days from work and sent a letter demonstrating that he had been approved for FMLA, there were also no reports or findings of incapacitating episodes/physician prescribed bed rest, as defined in the regulation, totaling 4 weeks over any 12 month period during the time period in question. The competent evidence reflects consideration of the Veteran's complaints of pain, weakness, and fatigability by medical professionals. Even when considering the additional limitation of motion caused by fatigue, weakness and flare-ups, neither the actual range of motion nor the functional limitation warrants an evaluation in excess of 20 percent for limitation of motion based upon the appropriate codes governing limitation of motion for this time period. There have also been no findings of neurological abnormalities which would warrant a separate compensable evaluation. Private treatment records, as cited above, rather than supporting the Veteran's claim, support the finding cited by the VA examination. Again, without taking into consideration the Veteran's complaints there would be little objective basis to award the Veteran a 20% evaluation for his back disability. Accordingly, the Board finds that the criteria for entitlement to a rating greater than 20 percent from November 23, 2010 were not met. The preponderance of the evidence is against the Veteran's claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Right and Left Knee The knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II (2013). 38 C.F.R. § 4.71a, Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating when there is severe recurrent subluxation or lateral instability. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees; 10 percent rating where flexion is limited to 45 degrees; 20 percent rating where flexion is limited to 30 degrees; and 30 percent rating where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to 5 degrees; 10 percent rating where extension is limited to 10 degrees; 20 percent rating where extension is limited to 15 degrees; a 30 percent rating where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating where extension is limited to 45 degrees. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel subsequently held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). At the time of an August 2004 VA examination, the Veteran reported having constant pain in his left knee and stated that because of the pain he used his right leg more often, which was now causing pain in his right knee. The Veteran indicated that he was not able to bend the left knee. He was also not able to squat or walk more than a few blocks. The Veteran further stated that he could not stand more than 15 minutes and that he had to take breaks as a result of the left knee. Examination of the left knee revealed several scars which were well healed and non-tender (the Board finds no basis to award a separate disability evaluation for the scar based on these findings). There was no effusion or quadriceps wasting. There was some pain and tenderness on compression over the patella. Flexion was to 120 degrees. The knee was stable and McMurray and drawer testing were negative. Examination of the right knee was unremarkable. The examiner rendered a diagnosis of left knee arthritis. The results provide evidence against the Veteran's claim. At the time of a January 2005 orthopedic consult, the Veteran reported he was a guard and spent most of his time on his feet. He complained of right knee pain as a result of extra stress he put on the knee. Examination of the right knee revealed that there was no effusion, erythema, or joint line tenderness. The Veteran had full range of motion and the knee was stable with negative Lachman and McMurray's signs. Examination of the left knee revealed no effusion or erythema. The Veteran had range of motion from 0 to 100 degrees with medial joint line and peripatellar tenderness. There was early varus. The Veteran found it difficult to relax for McMurray and Lachman testing. X-rays of the right knee were unremarkable. The Veteran was prescribed a left hinged knee brace. At the time of an August 2007 VA outpatient visit, the Veteran was noted to have no instability or effusion of the knees, providing more evidence against this claim. At the time of an April 2008 VA examination, the Veteran complained of daily knee pain which was 10/10 in intensity. He denied any flare-up pain symptoms. The Veteran noted experiencing effusion in the left knee approximately twice a week. He also reported left knee locking three or four times per week. The Veteran noted using a laterally stayed left knee brace. He reported having increased knee pain when climbing about the train. He noted having 30 minute limits for walking and standing and weight bearing as a result of his back and knees. The Veteran reported increased knee pain symptoms associated with activities that required prolonged walking or standing, kneeling, crouching, squatting, crawling, or climbing type of activities. Physical examination revealed the Veteran walked freely and briskly without antalgic gait. The left knee was minimally arthritic in appearance without effusion. The right knee was normal in appearance without visible arthropathy or effusion. There was no ligamentous laxity, bilaterally, and McMurray sign was negative, bilaterally. Range of motion for the left knee revealed extension to 0 degrees both pre and post repetitive motion and flexion from 0 to 120 degrees both pre and post repetitive motion. For the right knee, the Veteran had extension to 0 degrees both pre and post repetitive motion and flexion from 0 to 130 degrees both pre and post repetitive motion. The Veteran complained of pain with extreme motions of flexion. There was no apparent weakness, fatigability, or loss of coordination during or following three repetitions of range of motion. The examiner rendered diagnoses of mild left knee degenerative joint disease and right knee clinical and radiographic examination within normal limits, providing highly probative evidence against the Veteran's claims, notwithstanding the Veteran's statements regarding pain in the "10/10" range. At the time of his February 2010 Travel Board hearing, the Veteran testified that he had constant pain in his knees. He noted that it limited him from doing certain exercises, walking too long, or standing too long, which would cause his knees to swell. He stated that if he crossed his legs, his knee would become stiff. He noted that his knees would become locked and that it was difficult to move them. As to problems with work, the Veteran indicated that he had swelling and pain from walking. He also noted that his knee had gone out on him a few years earlier. He reported having instability and noted wearing braces when working or walking long distances. The Veteran stated that he was taking Tramadol and Motrin for his knee problems. He indicated that his condition had worsened over the last few years. Following the hearing, in light of the Veteran's concerns, and in conjunction with the October 2010 Board remand, the Veteran was afforded an additional VA examination in November 2010. At the time of the examination, the Veteran reported that he had pain in the medial and lateral portions of the left knee, with an anterior component that popped all the time. He stated that standing longer than 30 minutes or walking more than 1/4 mile increased the pain. The Veteran also noted having pain over the right knee medial, lateral, and anterior, which also occurred with prolonged standing or walking more than 1/4 mile. This increased the pain to the point where he had to sit. Physical examination of the right knee revealed flexion from 0 to 140 degrees, with pain from 120 to 140. The knee was stable to varus and valgus strain in both neutral and 30 degrees of flexion. There was negative anterior and posterior drawer, negative Lachman's, and negative McMurray's. Examination of the left knee revealed extension to 0 degrees and flexion to 115 degrees. The Veteran had pain from 90 to 115 degrees. The left knee was stable to varus and valgus strain in both neutral and at 30 degrees of flexion. There was negative anterior and posterior drawer, negative Lachman's, and negative McMurray's. There was mild tenderness over the medial aspect of the knee. On either side, there was no effusion, edema, or gross deformity. On the left side, the Veteran was found to have some patellar/subpatellar crepitus. The Veteran was noted to wear a brace on his left knee. His gait was mildly antalgic with a quick component to the left. Repetitions of range of motion times three did not increase pain, fatigue, weakness, lack of endurance, or incoordination. Diagnoses of left knee partial disruption of anterior cruciate ligament and medial meniscal tear with surgery times three with residual degenerative joint disease, and right knee myofascial syndrome and degenerative joint disease, were rendered. The Board has reviewed the examination report in detail. Overall, while noting the Veteran's complaints, the Board must find that the report and the object results provide more evidence against this claim. In an April 2012 letter, the Veteran reported that his back and knee problems had caused him to be incapacitated up to eight times per year. He noted having to take time off from work every time these episodes occurred. He stated that he had up to 12 weeks per year for FMLA. In a June 2012 letter, the Veteran's brother indicated that the Veteran constantly complained about knee pain. In a November 2012 addendum, the November 2010 VA examiner indicated that the Veteran's bilateral knee flares involved increases in pain without associated physical changes such as swelling. He stated that the Veteran's range of motion was unchanged during his flares. He reported that the Veteran occasionally missed a day of work when the flares occurred due to his increased pain with standing and his inability to handle his work as a conductor. In April 2013, the Veteran underwent an additional VA examination on his left knee. At the time of the examination, the Veteran reported having pain, popping, and swelling in his left knee. Standing, walking, or sitting with his legs crossed increased the pain. The Veteran did not indicate that flares impacted the function of the knee. Examination revealed flexion from 0 to 125 degrees. After repetitive motion, the Veteran had extension to 0 degrees and flexion to 130 degrees. The Veteran was noted to have less movement than normal, pain on movement, swelling, deformity, and disturbance of locomotion on the left. Strength was normal with flexion and extension. Anterior and posterior stability were normal and there was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran was noted to have had a meniscal tear with frequent episodes of joint pain and effusion. The Veteran stated that he used a brace constantly for his left knee arthritis. The examiner noted that the Veteran reported missing 2 to 6 days per month because of his left knee problems. As it relates to the right knee, in order to warrant an evaluation in excess of 10 percent for arthritis, compensable limitation of motion must be demonstrated. However, in the present case, the Veteran has consistently been shown to have shown full extension (that is extension to 0 degrees) at each VA examination. As such, a compensable rating is not warranted under 5261. With regard to limitation of flexion, the flexion of the Veteran's right knee has not been shown to be limited to 60 degrees or less. Moreover, at the time of his most recent VA examination, the Veteran was found to have flexion to 140 degrees. As such, at no time during the course of the Veteran's appeal has he been shown to have compensable limitation of motion in his right knee based on either limitation of extension or limitation of flexion. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, a higher rating is also not warranted in this case, even when considering both the criteria set forth in 38 C.F.R. §§ 4.40, 4.45 and the Court's holding in DeLuca. The currently assigned 10 percent rating properly compensates the Veteran for the extent of functional loss resulting from symptoms like painful motion, tenderness, and stiffness. The VA examination reports did find objective evidence of pain with motion; however, no additional loss of motion was noted on repetitive motion. Thus, while there was objective evidence of pain, it did not cause the right knee range of motion to be limited in such a way as to warrant a compensable rating based on either flexion or extension. There was no demonstration that any findings of functional loss were greater than that contemplated by the currently assigned 10 percent rating. Moreover, even if flexion was slightly limited by pain, 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. Therefore, a rating in excess of 10 percent is not warranted based on limitation of motion of the right knee. Affording the Veteran every consideration in connection with the matter on appeal, the Board will also consider other potentially applicable diagnostic codes. There has been no demonstration of right knee ankylosis based upon the ranges of motion reported throughout the appeal, including those on the numerous VA examinations afforded the Veteran. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran is clearly able to move his right knee, and it is, therefore, not ankylosed. Moreover, there was no objective demonstration of ligamentous instability or subluxation at any of the numerous VA examinations, with the Veteran being found to have no ligamentous instability on each VA examination, including the most recent VA examination where Lachman, anterior/posterior drawer, valgus/varus, and patellar subluxation/dislocation testing were all negative. While the Veteran has reported having locking and instability of the right knee, the Board finds the objective findings, performed by medical professionals, to be of more probative value. The Veteran was afforded numerous VA examinations throughout the course of the appeal in light of his concerns, with each examination revealing no subluxation and instability. As such, a separate rating is not warranted for recurrent subluxation or lateral instability under 38 C.F.R. § 4.71a , Diagnostic Code 5257. The Board itself obtained additional medical information in order to address the Veteran's concerns voiced at his hearing. The result not only did not support his claims, it provided additional medical evidence against his claim. In sum, after a careful review of the evidence of record, the Board finds that a rating in excess of 10 percent for right knee degenerative joint disease is not warranted. As it relates to the left knee, the Veteran has consistently been shown to have full extension (that is extension to 0 degrees) at each VA examination. As such, a compensable rating is not warranted under 5261. With regard to limitation of flexion, the flexion of the Veteran's left knee has not been shown to be limited to 60 degrees or less. Moreover, at the time of his most recent VA examination, the Veteran was found to have flexion to 125 degrees and to 130 degrees following repetitive motion. As such, at no time during the course of the Veteran's appeal has he been shown to have compensable limitation of motion in his left knee based on either limitation of extension or limitation of flexion. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. However, a higher rating is also not warranted in this case, even when considering both the criteria set forth in 38 C.F.R. §§ 4.40, 4.45 and the Court's holding in DeLuca. The currently assigned 10 percent rating properly compensates the Veteran for the extent of functional loss resulting from symptoms like painful motion, tenderness, and stiffness. The VA examination reports did find objective evidence of pain with motion; however, no additional loss of motion was noted on repetitive motion. Thus, while there was objective evidence of pain, it did not cause the left knee range of motion to be limited in such a way as to warrant a compensable rating based on either flexion or extension. There was no demonstration that any findings of functional loss were greater than that contemplated by the currently assigned 10 percent rating. Therefore, a rating in excess of 10 percent is not warranted based on limitation of motion of the right knee. Affording the Veteran every consideration in connection with the matter on appeal, the Board will also consider other potentially applicable diagnostic codes. There has been no demonstration of left knee ankylosis based upon the ranges of motion reported throughout the appeal, including those on the numerous VA examinations afforded the Veteran. The Veteran is clearly able to move his left knee, and it is, therefore, not ankylosed. Moreover, there was no objective demonstration of ligamentous instability or subluxation at any of the numerous VA examinations afforded the Veteran, with the Veteran being found to have no ligamentous instability on each VA examination, including the most recent VA examination where anterior and posterior stability were found to be normal and there was no evidence or history of recurrent patellar subluxation or dislocation. While the Veteran has reported having locking and instability of the left knee, and the Board notes that he has been issued a brace for the knee, the Board finds the objective examinations, performed by medical professionals, to be of more probative value. The Veteran was afforded numerous VA examinations throughout the course of the appeal, with each examination revealing no subluxation and instability. As such, a separate rating is not warranted for recurrent subluxation or lateral instability under 38 C.F.R. § 4.71a, Diagnostic Code 5257. In sum, after a careful review of the evidence of record, the Board finds that a rating in excess of 10 percent for left knee degenerative joint disease is not warranted. Extraschedular Consideration In addition to the foregoing, the Board has considered whether referral for an extraschedular evaluation is warranted for the degenerative disc disease of the lumbar spine and for degenerative joint disease of the right and left knees. 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 Veteran's back and knee disabilities have manifested in arthritis, painful movement, and limited range of motion. The schedular criteria for rating the lumbosacral spine disability (General Rating Formula for Diseases and Injuries of the Spine) and knee disabilities specifically provide for ratings based on the presence of painful arthritis; limitations of motion of the spine and knees (including due to pain and other orthopedic factors; see 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca); other clinical findings such as muscle spasm, guarding, abnormal gait, and abnormal spinal contours; and on the basis of incapacitating episodes for the spine and instability for the knee. In this case, comparing the Veteran's disability level and symptomatology of the lumbar spine and the knees to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. In the absence of exceptional factors associated with the lumbosacral spine with degenerative disc disease and left and right knee degenerative joint disease, 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). It is important for the Veteran to understand that without consideration of the Veteran's complaints there would be little basis for the current findings, let alone higher evaluations. While the Board has considered his complaints, the objective medical evidence, including multiple medical evaluations over many years, including private evaluations, have not only not supported his claim, but provided overall, highly probative evidence against his claims. Duty to Assist and Notify 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. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1) For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 has been amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). The Court has also held that that the VCAA 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's status has been substantiated. As it relates to the issue of higher initial evaluations, the courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, the Board also finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, private treatment records, VA treatment records, VA examination reports, and lay evidence. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c). No additional pertinent evidence has been identified by the claimant. The Board does note that as part of the most recent Board Remand, the Veteran was requested to provide signed releases to obtain information from the health care provider referred to by the Veteran in the December 2011 letter from his employer, with the AOJ then requesting a complete copy of the Veteran's records from the identified health care provider. Pursuant to the Board request, the AMC, acting on behalf of the RO, requested that the Veteran provide this information along with written authorizations to obtain the requested information in a November 2012 letter. To date, the Veteran has not provided the requested information. As it relates to his low back and knee claims, the Veteran has been afforded numerous VA examinations relating to the claimed disabilities. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination results to be sufficient. While the Veteran has indicated problems with some of the examinations, it is important for the Veteran to understand that the reports have been consistent with both private and VA treatment records. Thus, the Board finds that further examinations are not necessary regarding these issues. In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer (DRO) or Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the issues on appeal and informed the Veteran and his representative that for an increased rating claim the level of disability was what mattered. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim including asking about symptoms and asking for all possible treatment records and inquiring as to where the Veteran was receiving current treatment. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. In addition, the Veteran was represented by a qualified service representative. Moreover, following the examination, the Veteran was afforded an additional VA examination based upon his testimony. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), or if there was error, it was harmless due to the Veteran's actual knowledge of what was needed, and that the Board can adjudicate the claims based on the current record. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claims, including by submission of statements and arguments and through his testimony. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating these claims. ORDER An initial disability evaluation in excess of 10 percent for lumbosacral strain with degenerative disc disease, prior to November 23, 2010 is denied. An initial disability evaluation in excess of 20 percent for lumbosacral strain with degenerative disc disease, from November 23, 2010 is denied. An initial disability evaluation in excess of 10 percent for degenerative joint disease of the right knee is denied. An initial disability evaluation in excess of 10 percent for degenerative joint disease of the left knee is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs