Citation Nr: 1333850 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 08-36 703 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for residuals, right knee injury, status post total knee arthroplasty, from April 1, 2006 to December 5, 2012. 2. Entitlement to an initial disability rating in excess of 10 percent for degenerative disc disease of the lumbar spine prior to November 5, 2008; from January 1, 2009 to January 25, 2011; and from March 1, 2011 to April 15, 2013; and a disability rating in excess of 20 percent for degenerative arthritis of the spine on and after April 16, 2013. 3. Entitlement to an initial disability rating in excess of 10 percent for sciatica of the right lower extremity. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and his daughter ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1974 to June 1975. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in September 2006, October 2007, and July 2009 by the Department of Veterans Affairs (VA) Regional Offices (RO) in St. Petersburg, Florida, San Juan, the Commonwealth of Puerto Rico, and Atlanta, Georgia, respectively. Jurisdiction rests with the RO in Atlanta, Georgia, from which the Veteran's appeal was certified. In July 2012, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing held at the VA RO in Atlanta, Georgia. A transcript of that hearing is associated with the claims file. The RO has granted temporary 100 percent disability ratings for residuals, right knee injury, status post total knee arthroplasty, from December 6, 2012 to January 31, 2014, and for degenerative disc disease of the lumbar spine from November 6, 2008 to December 31, 2008 and from January 26, 2011 to February 28, 2011. As the Veteran is receiving the maximum disability ratings during these periods for the respective disabilities, the Board will not address the issues of entitlement to higher disability ratings for these periods. In addition, the RO granted a disability rating of 30 percent for residuals, right knee injury, status post total knee arthroplasty, on and after February 1, 2014. As this period commences on a date subsequent to the Board's appellate review, evaluation of the Veteran's disability is not possible at this time, and the Board will not address an increased disability rating for this period. In July 2009, the RO granted a separate 10 percent disability rating for sciatica of the right lower extremity. As this disability is considered a manifestation of the Veteran's service-connected degenerative disc disease of the lumbar spine, the Board finds the Veteran's disagreement with the initial rating assigned for his degenerative disc disease of the lumbar spine includes the separate disability rating for sciatica of the right lower extremity. Therefore, the Board will consider the issue of a disability rating in excess of 10 percent for sciatica of the right lower extremity on appeal. In June 2013, the RO granted a disability rating of 20 percent for degenerative arthritis of the spine, effective April 16, 2013. Because the increased disability rating assigned is not the maximum rating available for this disability, the claim remains in appellate status, and the Board has re-characterized the issue to include staged ratings as shown on the title page. See AB v. Brown, 6 Vet. App. 35 (1993); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. From April 1, 2006 to December 5, 2012, the Veteran's residuals, right knee injury, status post total arthroplasty, consisted of severe pain and weakness. 2. Prior to November 5, 2008, from January 1, 2009 to January 25, 2011, and from March 1, 2011 to April 15, 2013, the Veteran's degenerative disc disease of the lumbar spine was manifested primarily by subjective reports of pain, weakness, instability, and some limitation of motion. 3. On and after April 16, 2013, the Veteran's degenerative arthritis of the spine was manifested primarily by pain and forward flexion limited to 60 degrees. 4. Throughout the pendency of the appeal, the Veteran's sciatica of the right lower extremity was manifested by mild, incomplete paralysis. CONCLUSIONS OF LAW 1. From April 1, 2006 to December 5, 2012, the criteria for a disability rating of 60 percent for residuals, right knee injury, status post total arthroplasty, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5055 (2013). 2. Prior to November 5, 2008, from January 1, 2009 to January 25, 2011, and from March 1, 2011 to April 15, 2013, the criteria for a disability rating in excess of 10 percent for degenerative disc disease of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). 3. On and after April 16, 2013, the criteria for a disability rating in excess of 20 percent for degenerative arthritis of the spine have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). 4. The criteria for an initial disability rating in excess of 10 percent for sciatica of the right lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 8520 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). The information contained in letters dated in May 2006, June 2007, and October 2008 satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With respect to an increased disability rating for residuals, right knee injury, status post total knee arthroplasty, the October 2008 letter notified the Veteran that he must submit, or request that VA obtain, evidence of the worsening of his disability, the different types of evidence available to substantiate his claim for a higher rating, the need to submit evidence of how such worsening affected his employment, and the requirements to obtain a higher rating. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1275-82 (Fed. Cir. 2009). Following the issuance of the October 2008 letter, the Veteran's claim was re-adjudicated in a November 2008 Statement of the Case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (finding that a notice defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim). The Veteran's claims concerning the proper disability ratings to be assigned to his service-connected degenerative disc disease of the lumbar spine and sciatica of the right lower extremity arise from his disagreement with the initial disability ratings assigned to these conditions following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice as to these claims is needed under VCAA. For these reasons, the Board finds that the content requirements of the notice VA is to provide have been met, and, thus, no further development is required regarding the duty to notify. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The Veteran's service treatment records, VA treatment records, and identified private treatment records have been obtained and associated with the claims file. In February 2013, the Board remanded the Veteran's claims for additional development. Specifically, the Board instructed that the RO/Appeals Management Center (AMC) obtain all available records for the Veteran from the VA Medical Centers in Decatur, Georgia and Augusta, Georgia and all associated outpatient clinics from May 2008 to the present. In addition, the Board requested that the RO/AMC schedule the Veteran for VA spine and neurological examinations to determine the current severity of his service-connected lumbar spine disability and right leg sciatica and a VA joints examination to determine the current severity of his right knee disability. The record contains VA treatment records dated from May 2008 to May 2013. In addition, the Veteran underwent VA examinations in April 2013. The record demonstrates that the April 2013 VA examiners reviewed the pertinent evidence and the Veteran's lay statements. Additionally, the examination results provide sufficient information to decide the issues. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds the April 2013 VA examinations to be sufficient and adequate for rating purposes. In addition, the record shows the RO/AMC substantially complied with the remand directives. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2013) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. At the July 2012 hearing, the VLJ explained the necessity to submit evidence indicating an increase in the severity of the Veteran's service-connected disabilities and asked questions to ascertain the extent of any current symptoms or treatment for the disabilities. In addition, the Veteran was assisted at the hearing by an accredited representative from the Georgia Department of Veterans Services. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or his representative. The hearing focused on the elements necessary to substantiate the claims for higher disability ratings, and the Veteran, through his testimony, demonstrated that he had actual knowledge of those elements. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). There is no indication in the record that any additional evidence relevant to the issues is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's claims file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matters. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2013). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule but findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability following an initial award of service connection for that disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45 (2013); see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). The factors involved in evaluating and rating disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint; or pain on movement. Id.; 38 C.F.R. § 4.45. Residuals, right knee injury, status post total knee arthroplasty The record indicates the Veteran underwent right total knee arthroplasty in February 2005 and that he underwent right total knee replacement revision in December 2012. As a result, the RO granted a disability rating of 100 percent from May 10, 2005 to March 31, 2006 and from December 6, 2012 to January 31, 2014. From April 1, 2006 to December 5, 2012, the Veteran's residuals, right knee injury, status post total knee arthroplasty, are rated under Diagnostic Codes 5259-5055. A total knee replacement is a prosthetic implant that is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5055. For one year after a prosthetic replacement of the knee joint, the knee status post prosthetic replacement is rated at 100 percent. After that point, if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, the rating is 60 percent. If there are intermittent degrees of residual weakness, pain, or limitation of motion, this is rated under Diagnostic Codes 5256 (ankylosis), 5261 (limitation of extension), and 5262 (impairment of the tibia and fibula). The minimum rating after a knee replacement is 30 percent. Acute, subacute, or chronic osteomyelitis is rated under Diagnostic Code 5000. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Unfavorable ankylosis of the knee in flexion between 10 degrees and 20 degrees is to be rated as 40 percent disabling; unfavorable ankylosis of the knee in flexion between 20 degrees and 45 degrees is rated as 50 percent disabling; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more is rated as 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 30 degrees is rated as 40 percent disabling; and extension of the leg limited to 45 degrees is rated as 50 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated as 40 percent disabling. 38 C.F.R. § 4.71a. Evaluations in excess of 30 percent are not available for recurrent subluxation or lateral instability under Diagnostic Code 5257; for dislocated semilunar cartilage, frequent episodes of locking, pain, and effusion under Diagnostic Code 5258; semilunar cartilage removal, symptomatic, under Diagnostic Code 5259; limitation of flexion under Diagnostic Code 5260; or genu recurvatum under Diagnostic Code 5263. The evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding contrary to the provisions of 38 C.F.R. § 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). In June 2006, the Veteran underwent VA examination in connection with his claim. The Veteran reported that he suffered from weakness, an inability to support his full weight, stiffness at rest, swelling with movement, giving way when applying full weight, and lack of endurance when walking. He suffered from pain located at the surgery site which occurred constantly and was localized. The pain was burning, aching, and sharp in nature. From one to 10, the pain level was a six. The Veteran stated that his condition did not cause incapacitation, and he was not receiving any treatment for his condition. There was no painful motion or weakness of the implanted joint. The symptoms were stiffness when sitting down, and there was no functional impairment. His gait was normal. On physical examination, there were no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement. Flexion was to 140 degrees and extension was to zero degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Stability testing was normal, and X-ray findings were within normal limits. The VA examiner diagnosed subjective pain in the right knee and objective residual of tear. The effect of the Veteran's disability on his daily activities was inability to squat and lift due to pain. An October 2006 private treatment record shows the Veteran complained that he had never really gotten over the knee pain he had postoperatively. He had fallen recently and re-injured his knee. His gait was antalgic. In April 2007, the Veteran submitted a written statement in support of his appeal asserting his symptoms and pain were consistent with a higher evaluation. A May 2007 VA treatment record shows an assessment of chronic knee pain, stable with medication. A January 2008 VA treatment record indicates the Veteran had persistent pain four months post surgery. There was tenderness around the right knee joint but no soft tissue swelling, joint effusion, or instability. Range of motion was from zero degrees to 100 degrees. An April 2008 VA treatment record indicates the Veteran had a leg length difference since his right total knee replacement and had abnormal right knee flexion contracture which made his gait awkward. VA treatment records dated in May 2008 show the Veteran received epidural steroid injections. A September 2008 private treatment record shows the Veteran continued to have chronic pain in the right knee area. In November 2008, the Veteran reported that he was still unable to walk short distances unassisted as the result of his right knee replacement. He stated that he had chronic pain and instability and that even after six surgeries, he still had major problems that included inability to walk, stand, sit, and go up or down stairs for any periods of time. X-ray examination in March 2009 reflects an impression of total right knee prosthesis with slight anterior tilt off of the femoral component with associated small suprapatellar effusion. A March 2009 private treatment record indicates the Veteran was having some problems with his right knee replacement. An April 2009 VA treatment record shows the Veteran complained of pain when walking or getting up from sitting. His pain level was a six out of 10. He was independent with his activities of daily living. He ambulated with a single point cane switching from hand to hand at times. He was able to walk from the parking lot to the clinic independently but was unable to drive. Range of motion was negative 25 degrees to 125 degrees. On palpation, the right knee was warm to the touch, and there was moderate edema. His balance was deemed fair to poor, and he had an antalgic, shuffling gait with decreased step length. His right knee had increased flexion and decreased extension. There was right quad atrophy and weakness. In May 2009, the Veteran reported that his knee seemed to be better as long as he did not sit for a long time. He stated that his knee pain was a five to six out of 10. The Veteran underwent additional VA examination in June 2009. He reported constant pain in the right knee that was sharp and cramping. The pain level was a seven on a scale from one to 10 and could be elicited by physical activity and relieved by medication. He reported symptoms of weakness, stiffness, swelling, giving way, lack of endurance, locking, and fatigability. He did not have heat, redness, or dislocation. He also reported painful motion and weakness and stated that his functional impairment involved not being able to walk very far. Physical examination revealed tenderness but no signs of edema, effusion, weakness, redness, heat, or guarding of movement. There was no subluxation, locking, pain, genu recurvatum, or crepitus. Flexion was to 140 degrees and extension to zero degrees. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Stability test results were within normal limits. X-ray examination revealed post-operative changes. The VA examiner diagnosed status post right knee surgery with scarring and right knee strain, which was a progression of the previous diagnosis. The VA examiner opined that the residuals of the right knee condition were pain and scarring. The effect of the Veteran's condition on his usual occupation was that he could not walk very far, had difficulty bending, and had difficulty lifting. In June 2009, private X-ray examination revealed satisfactory position and alignment. There were no adverse features, and there was no evidence of loosening or fracture. The impression was satisfactory postoperative view right knee. A June 2009 VA treatment record reflects an assessment of right knee pain. A July 2009 VA treatment record indicates the Veteran had chronic knee pain with decreased range of motion and degenerative changes on radiographs. He had used a walking cane for eight weeks. There was chronic knee pain with a history of intermittent locking, catching, or swelling. In September 2009, the Veteran's representative submitted a statement in support of his claim. The representative argued that the criteria for a disability rating of 60 percent had been met based on the documentation showing painful motion, pain killing medications, and weakness. The representative also asserted that the VA examination was inadequate because it did not define the actual distance that the Veteran was able to walk. In June 2010, the Veteran's range of motion was five to 115 degrees, passively. He reported knee pain and instability. There was mild laxity with valgus stress and a two to three + anterior drawer. There was a moderate amount of popping noted in the knee. X-ray examination showed good alignment, and sensation was intact. His gait was unsteady, and his knee demonstrated increased instability with joint play. X-ray examination in September 2011 revealed total knee prosthesis in anatomical position and vascular calcifications in soft tissues. There was a question of a small joint effusion in the suprapatellar region. In July 2012, the Veteran testified that since his knee surgery his knee gave away quite regularly, especially if he tried to go up stairs. He also reported that he required braces and a walker to be able to ambulate. He also stated that he was unable to help his wife with the chicken farm anymore. The Veteran's daughter testified that he stayed in bed practically all day. Given the above record, the Board finds the evidence demonstrates that from April 1, 2006 to December 5, 2012, the Veteran's residuals, right knee injury, status post total knee arthroplasty, consisted of severe pain and weakness. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Veteran underwent right total knee arthroplasty in February 2005, and in December 2012, he underwent right total knee replacement revision. During the period between the two surgeries, the Veteran reported constant pain, weakness, and an inability to support his full weight. He also reported symptoms of stiffness, swelling, giving way, lack of endurance, locking, and fatigability. In this respect, lay persons can attest to observable symptomatology, and the statements made by the Veteran and his daughter describing his symptoms are considered to be competent evidence. Jandreau, v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The record also shows that during the period, the Veteran ambulated with a cane, a knee brace, and a walker, and he had an antalgic gait and poor balance. The evidence also indicates the Veteran had increased instability and was unable to walk very far as the result of his right knee disability. Therefore, the Board finds a disability rating of 60 percent is warranted for residuals, right knee injury, status post total knee arthroplasty, from April 1, 2006 to December 5, 2012. An evaluation in excess of 60 percent is not available under Diagnostic Code 5055 after one year following implantation of the prosthesis. In addition, a disability rating in excess of 60 percent is not available under any of the other applicable Diagnostic Codes related to the knee. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, 5262. Furthermore, the evidence does not demonstrate that any additional Diagnostic Codes provide for separate disability ratings for the Veteran's residuals, right knee injury, status post total knee arthroplasty, from April 1, 2006 to December 5, 2012. 38 C.F.R. § 4.71a, Diagnostic Code 5000, Note 1 provides, as an exception to the amputation rule, that a rating of 10 percent is to be assigned in any case of active osteomyelitis where the amputation rating for the affected part is no percent. Here, the evidence does not demonstrate a clear diagnosis of active osteomyelitis during the period on appeal. Moreover, the Veteran's right knee disability is now rated as 60 percent disabling. Therefore, a separate disability rating under Diagnostic Code 5000 is not permitted. Separate ratings for arthritis under Diagnostic Codes 5002-5010 are rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. A separate rating of 10 percent is only for application if the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes. 38 C.F.R. § 4.71a. As limitation of motion is already considered by the currently assigned disability rating of 60 percent, the evidence does not show a separate disability rating for arthritis is warranted. As noted above, under Diagnostic Code 5055, the rating criteria for a 30 percent disability rating allow that the knee replacement may be rated analogous to Diagnostic Codes 5256, 5261, or 5262. However, Diagnostic Code 5257 for recurrent subluxation or lateral instability is not one of the identified Diagnostic Codes for rating intermediate degrees of disability, which indicates that a separate rating may be awarded for recurrent subluxation or lateral instability if shown by the medical evidence. In this case, however, the Veteran is in receipt of a 60 percent disability rating for chronic residuals consisting of severe pain and weakness in the affected extremity, and the Board finds that this disability rating already contemplates any instability demonstrated on examination. Because assigning a separate disability rating under Diagnostic Code 5257 would result in pyramiding contrary to the provisions of 38 C.F.R. § 4.14, a separate disability rating is not permitted. Furthermore, as stated above, the amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. Thus, a separate disability rating for recurrent subluxation or lateral instability is not permitted as the Veteran's knee disability is now rated as 60 percent disabling. Furthermore, the Board finds the assigned 60 percent disability rating already contemplates any impairment of the femur in connection with a right knee disability, and therefore, a separate disability rating is not warranted. In order to warrant a disability rating in excess of 60 percent under the amputation rule, Diagnostic Code 5160 provides a 90 percent disability rating for amputation of the thigh, disarticulation, with loss of extrinsic pelvic girdle muscles, and Diagnostic Code 5161 provides an 80 percent disability rating for amputation of the upper third, one-third of the distance from perineum to knee. As the evidence does not demonstrate disarticulation, with loss of extrinsic pelvic girdle muscles, or amputation of the upper third, one-third of the distance from perineum to knee, a disability rating in excess of 60 percent is not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5160-5161 (2013). Extraschedular Consideration An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service. 38 C.F.R. § 3.321(b)(1) (2013). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the rating assigned herein inadequate. The Veteran's service-connected residuals, right knee injury, status post total arthroplasty, is evaluated as a disability of the musculoskeletal system, the criteria of which is found by the Board to specifically contemplate the level of impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.71a, Diagnostic Code 5055. Throughout the period on appeal, the Veteran's service-connected disability was manifested by severe pain and weakness. Specifically, the Veteran reported constant pain, weakness, and an inability to support his full weight. He also consistently reported symptoms of stiffness, swelling, giving way, lack of endurance, locking, and fatigability. A 60 percent disability rating is warranted for chronic residuals consisting of severe painful motion or weakness in the affected extremity. When comparing the Veteran's disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the severity of the Veteran's symptoms are contemplated by a 60 percent disability rating. Therefore, the schedular evaluation is adequate, and no referral is required. See 38 C.F.R. § 4.71a, Diagnostic Code 5055; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Degenerative disc disease of the lumbar spine and degenerative arthritis of the spine The general rating formula for diseases and injuries of the spine (General Rating Formula) provides for the disability ratings under Diagnostic Codes 5235 to 5243, unless the disability is rated under 5243 and considered under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes for diseases and injuries of the spine, 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. Under the General Rating Formula, a 20 percent rating is assigned for forward flexion greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 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. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) to the General Rating Formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, 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 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. As noted above, intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 20 percent rating is warranted when there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, and a 40 percent rating is warranted when there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. An incapacitating episode is defined as 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1) (2013). As noted above, Note (1) to the General Rating Formula for Diseases and Injuries of the Spine (38 C.F.R. § 4.71a) specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. A December 2002 private treatment record shows the Veteran complained of a backache, and an April 2003 private treatment record indicates the Veteran's back became sore because he tended to lean forward. An August 2005 electromagnetic study revealed no evidence of nerve damage in the right lower extremity. A February 2007 record indicates the Veteran may have right L5 radiculopathy. A February 2007 magnetic resonance imaging scan (MRI) showed degenerative changes and disc protrusions, most notably at L4-5, where there was lateral accentuation of a broad-based protrusion to the right, possibly involving the L5 and L4 roots. At L3-4, degenerative changes and a broad-based disc bulge were noted, although with some narrowing of the neural foramina, but less marked. A June 2007 private treatment record shows the Veteran continued to have back pain and right lower extremity pain. A June 2007 VA neurosurgery consultation report shows the Veteran complained of low back pain for several years, gradually worsening, and right leg sciatica. The pain had radiated into the right sacroiliac joint and down the posterior right leg into the foot, causing numbness and tingling of the great toe and second toe of the right foot, for three years. The assessment was degenerative disc disease of the lumbar spine and L5-S1 radiculopathy. An additional June 2007 VA treatment record indicates that examination was basically normal and that a MRI had shown multi-level degenerative changes but no definitive compressive pathology. According to a June 2007 VA treatment record, there was decreased sensation to light touch along the medial to lateral aspect of the right foot. In August 2007, the Veteran underwent VA examination in connection with his claim. The Veteran reported stiffness when he sat down and tried to get up and weakness for the first 10 to 20 steps after sitting, with no stability. The Veteran stated his spine condition did not cause incapacitation. His posture was within normal limits, and his gait was abnormal, with limping. He required a cane for ambulation as he needed help standing up. Examination revealed no evidence of radiating pain on movement, no muscle spasm, and no ankylosis. There was tenderness and negative straight leg raising tests on both legs. Flexion was to 90 degrees, with pain beginning at 90 degrees; extension was to 30 degrees, with pain beginning at 30 degrees; right lateral flexion was to 30 degrees, with pain beginning at 30 degrees, left lateral flexion was to 30 degrees, with pain beginning at 30 degrees; and right and left rotation were to 30 degrees. The joint function was additionally limited by pain after repetitive use, and pain had the major functional impact. There was no degree of additional limitation. It was not additionally limited by fatigue, weakness, lack of endurance, or incoordination after repetitive use. Neurological examination of the lower extremities revealed normal motor function and sensory function. There was normal head position with symmetry in appearance and symmetry of spinal motion with normal curvatures of the spine. There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. X-ray findings were within normal limits. The VA examiner diagnosed lumbar strain and reported that the subjective factors were lower back pain, stiffness, and weakness. The objective factors were tenderness on range of motion exercises. An August 2007 private treatment record indicates the Veteran's main problems remained his back and right lower extremity pain due to his herniated disk. His gait was right antalgic, mainly, and somewhat shuffling. In September 2007, the Veteran reported that when he got up, his right lower extremity was weak. As he walked, he got stronger and his pain lessened. The VA physician found the Veteran had moderate pain behavior in moving around and ambulating with a cane, with diffuse tenderness in the lower back but particularly over the right sacroiliac and right hip joint. The Veteran reported decreased sensation in a global fashion over most of the right lower extremity. The assessment was back pain and pseudosciatica secondary to a combination of lumbar degenerative disc disease/spondylosis without neural element compression and sacroiliac joint dysfunction and probable piriformis muscle syndrome. A September 2007 MRI reflected broad base disc bulges at L2-3, L3-4, and L4-5 and right-sided neural foraminal stenosis at L3-4 and L4-5. In December 2007, the Veteran reported that he had pain in the right lower extremity occasionally to the ankle. His pain was a six out of 10 in his back and right lower extremity. There was moderate loss of range of forward flexion, with pain a six out of 10 in the back, and there was moderate loss of external flexion with increased back pain. His strength was normal. A January 2008 private treatment record shows the Veteran still had back pain and required one to two Lorcet a day. He was receiving some injections into his lumbar spine. According to an August 2007 VA treatment record, the Veteran's right lower extremity had a 1+ reflex patellar, and there was evidence of lumbar radiculopathy. A January 2008 VA treatment record shows the Veteran complained of daily, continuous back pain, pressure, and sharp pain doing down his right leg that radiated along the lateral side of his right leg to the inferior of the knee. Positional changes and laying down aggravated the pain. He also reported balance problems. There was complete loss of normal lumbar lordosis and pain with palpation at bilateral sacroiliac joint areas, with the left worse than the right. Range of motion was limited, and strength was five out of five. The assessment was degenerative disc disease at L4-5 with possible right side L4, L5 impingement causing pain around the right knee in the right leg. Low back pain was more likely from left sacroiliac malfunction. An April 2008 VA treatment record shows the Veteran reported lower back pain with radiation down his right leg to the top of his toes. He described the pain as dull and radiating. He had abnormal posture when sitting and standing, and his range of motion was described as limited. Strength was normal, with diminished sensation, and straight leg raises were limited. An abnormal right knee flexion contracture made his gait awkward. The Veteran attempted extension; however, it made his symptoms worse. The Veteran tended to sit with flex posture and with right lateral lean. An additional April 2008 VA treatment record indicates lumbar flexion was to 90 degrees with pain, extension was to 30 degrees without pain, and there was no pain with side bending. Straight leg raises were negative bilaterally. The assessment was multilevel degenerative disc disease with mechanical axial lower back pain, and leg length differential on the right causing abnormal gait mechanics and muscular strain. A November 2008 private treatment record indicates the Veteran had limited range of motion, especially with extension. Strength was five out of five bilaterally in the lower extremities. Deep tendon reflexes were absent in the right lower extremity. The impression was lumbar herniated nucleus pulposus, lumbar radiculopathy. A March 2009 X-ray showed multilevel degenerative changes without superimposed acute compression fractures or subluxations. In June 2009, the Veteran underwent VA examination in connection with his claim. The Veteran reported symptoms of stiffness, constant pain, and numbness. The pain traveled to his right lower extremity and was burning, sharp, and cramping. The Veteran reported that his condition had not resulted in any incapacitation. His posture was normal, and his gait was antalgic. Examination revealed evidence of radiating pain on movement described as extension, muscle spasm was absent, and there was tenderness. There was no ankylosis of the lumbar spine. Flexion was to 90 degrees, extension was to 25 out of 30 degrees, with pain beginning at 25 degrees, right and left lateral flexion were to 30 degrees, and right and left rotation were to 30 degrees. Joint function was limited after repetitive use by pain, and pain had the major functional impact. There was no additional functional limitation after repetitive use from fatigue, weakness, lack of endurance, or incoordination. There was no additional limitation in degrees. There were no signs of lumbar intervertebral disc syndrome with chronic and permanent nerve root involvement. Motor function and sensory function of the lower extremities were normal, and right lower extremity reflexes revealed +2 knee jerk and +2 ankle jerk. The VA examiner diagnosed status post lumbar surgery with scarring and lumbar degenerative disc disease. The effect of the Veteran's condition on his usual occupation was that he could not walk very far and had difficulty bending and lifting. An August 2009 private treatment record shows the Veteran's pain had reportedly radiated to both buttocks. Lumbar films showed no instability. There was right L3 and L4 foraminal stenosis that was not high grade. The assessment was lumbar degenerative disc disease. X-ray examination revealed 4 millimeter anterior displacement of L4 on L5, showing no change between flexion and extension. There was no instability. An August 2009 MRI showed no significant interval change. There was no residual spinal canal stenosis at L3-L4 or L4-L5. There was mild left and moderate right foraminal stenosis at each of those levels, and disc bulging at L2-L3 with borderline central canal stenosis, probably not clinically significant. The disc bulge was asymmetrical to the left, and there was mild to moderate left foraminal stenosis. There was chronic grade 1 degenerative subluxation at L4-L5 measuring approximately three to four millimeters and moderate type I reactive changes in the vertebral body endplaces. There was no evidence of discitis or osteomyelitis. A March 2010 VA treatment record indicates the Veteran had a history of right lower extremity pain and had burning pain in the anterior thigh and lateral leg which was fairly continuous. The impression was probably right L4 radiculopathy and possible old/inactive S1 radiculopathies bilaterally. An April 2010 MRI reflected grade I degenerative spondylolisthesis L4 over L5; right hemilaminectomy defects at L3/4 and L4/5 with mild enhancing epidural fibrosis; and multilevel spinal canal and neuroforaminal stenosis. A June 2010 VA treatment record indicates the Veteran's clinical picture was primarily consistent with sacroiliac joint dysfunction and secondary pseudosciatica that required pain management and musculoskeletal low back pain. In June 2010, a MRI revealed significant degenerative disc disease with neural foramina stenosis predominantly on the right side. There were also previous laminectomies at L4-L5 and L5-S1 on the right side and questionably at L3-L4. A March 2011 MRI showed interval laminectomies at L3, L4, and L5 and partial right facetectomy at L3-4 and L4-5. There was no significant residual spinal canal stenosis at surgical levels. There were signal changes within the L3-4 vertebral body endplates consistent with type 1 degenerative changes but could also be seen with osteomyelitis. Disc bulging at L2-3 with mild central canal stenosis was unchanged. X-ray examination in September 2011 showed narrowed vacuum disks at L2-L5, scoliosis, and severe obstipation. The Veteran testified in July 2012 that his back pain had increased in severity and loss of motion as the result of the leg length discrepancy. He also testified that the radiating pain from his lower back to his toes got worse every day. The Veteran asserted that he used a walker, a neck brace, a reacher, and a knee brace. In addition, he had an awkward gait. He reported that he had surgery in January 2012 for his back. He stated that he could barely move his back at all and that he was unable to tie his shoes. His daughter testified that she tied his shoes for him. In December 2012, the Veteran had weakness in the right lower extremity, specifically in the quads and hamstrings, and decreased independence with functional transfers and gait activities. The Veteran ambulated with a rolling walker without loss of balance. He demonstrated decreased right heel strike and foot clearance, decreased right terminal knee extension in stance phase of gait, and decreased step length. It was noted that the Veteran did not require assistance for lower extremity management. An additional VA record notes the Veteran was independent with transfers and activities of daily living. He had modified independence with lower extremity dressing, bathing, and toileting. He reported that his back pain limited his activity and positioning. A January 2013 VA treatment record indicates strength was five out of five in all extremities. In April 2013, the Veteran underwent VA examination in connection with his claim. The VA examiner diagnosed degenerative joint disease of the lumbosacral spine and compression fracture L3. The VA examiner reported that it was difficult for the Veteran to stand up and walk. When he walked he was unstable and he had a hard time getting in and out of bed and using a bathtub. The Veteran could not stay in one position for very long, and he had non-stop back pain. The pain was present in the low back and went down the right leg to the ankle. The leg was numb and cramped up. He had no bowel or bladder problems and had injections in his back on two occasions. The Veteran denied flare-ups that impacted the function of his spine. Forward flexion was to 60 degrees with no objective evidence of painful motion. Extension ended at five degrees, with no objective evidence of painful motion. Right and left lateral flexion ended at 25 degrees, with no objective evidence of painful motion, and right and left lateral rotation ended at 30 degrees or greater with no objective evidence of painful motion. After repetitive-use testing, forward flexion was to 60 degrees, extension was to five degrees, right lateral flexion was to 25 degrees, left lateral flexion was to 25 degrees, right lateral rotation was to 30 degrees, and left lateral rotation was to 30 degrees. There was no additional limitation of range of motion following repetitive-use testing. The Veteran did not have any functional loss or functional impairment of the back. There was no localized tenderness and no guarding or muscle spasms. Muscle strength was normal and there was no muscle atrophy. On sensory examination, the right upper anterior thigh was normal, the right thigh/knee was normal, and there was decreased sensation in the right lower leg/ankle and right foot/toes. The VA examiner reported that the decreased sensation in the right leg was probably due to the knee scars, and the right foot decreased sensation was probably due to nerve root problems. Straight leg raising tests were normal. The Veteran did not have any other neurologic abnormalities or findings related to his back condition. The Veteran had mild, intermittent pain in the right lower extremity and mild numbness in the right lower extremity but no other signs of radiculopathy. There was involvement of the L4/L5/S1/S2/S3 nerve roots on the right side and incomplete sciatica on the right side. The severity of the radiculopathy and its side effects was mild. There were no other neurological abnormalities related to the back condition. The Veteran did not have intervertebral disc syndrome of the thoracolumbar spine. The Veteran used a walker regularly. Arthritis was documented. X-ray examination revealed moderate compression fracture deformity involving the L3 vertebral body, which was most likely chronic. There was severe multi-level degenerative discogenic disease of the lower lumbar spine and atherosclerotic calcification of the abdominal aorta and iliac arteries. The VA examiner found the Veteran's back condition impacted his ability to work. Specifically, the VA examiner reported that the Veteran last worked in 2005 as a medical technologist but stopped because of Parkinson's disease. His activities of daily living were okay, in that he could dress and undress and handle his food and toilet. However, the Veteran had trouble with buttons and donning coats and shirts. A May 2013 VA treatment record shows the Veteran had problems walking related to his back and knee injuries. The Veteran reported that he liked to fish and restore cars. An additional May 2013 VA treatment record indicates the Veteran ambulated with a wheelchair. Prior to November 5, 2008; from January 1, 2009 to January 25, 2011; and from March 1, 2011 to April 15, 2013 Prior to November 5, 2008, from January 1, 2009 to January 25, 2011, and from March 1, 2011 to April 15, 2013, the Veteran's degenerative disc disease of the lumbar spine is rated as 10 percent disabling. For a 20 percent disability rating under Diagnostic Code 5243, the evidence must show functional impairment comparable to forward flexion greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 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. In addition, a 20 percent rating is provided for under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes when there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. Given the above record, the Board concludes that the evidence demonstrates that prior to November 5, 2008, from January 1, 2009 to January 25, 2011, and from March 1, 2011 to April 15, 2013, the Veteran's degenerative disc disease of the lumbar spine does not warrant a disability rating in excess of 10 percent. Here, the medical evidence of record does not demonstrate functional impairment, including due to pain, comparable to forward flexion greater than 30 degrees but not greater than 60 degrees during these periods. In August 2007, forward flexion was to 90 degrees, with pain beginning at 90 degrees, and there was no degree of additional limitation due to pain. The combined range of motion of the thoracolumbar spine was 240 degrees. There were no symptoms of muscle spasms, no ankylosis, and the Veteran's posture was within normal limits. Although the December 2007 VA treatment record shows there was a moderate loss of range of forward flexion, the physician did not provide specific measurements in degrees, and the Board finds this generic statement inadequate for determining any loss of range of motion for rating purposes. Likewise, the January 2008 and April 2008 records reflect findings of limited range of motion but do not provide specific measurements. In addition, although the January 2008 record indicates there was a complete loss of normal lumbar lordosis, the record does not indicate reversed lordosis and does not identify the etiology of the loss of lordosis. In June 2009, flexion was to 90 degrees and the combined range of motion of the thoracolumbar spine was 235 degrees. Muscle spasm was absent, and there was no ankylosis. Consideration has also been given to an increased disability rating for the Veteran's service-connected degenerative disc disease of the lumbar spine under other potentially applicable diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1995). Here, however, the evidence does not demonstrate findings of intervertebral disc syndrome, and the Veteran consistently reported that his spine condition did not cause incapacitation. 38 C.F.R. § 4.71a, General Rating Formula. In addition, the evidence does not demonstrate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, during these periods. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The Veteran is already separately compensated for sciatica of the right lower extremity in connection with his degenerative disc disease of the lumbar spine. Additionally, the Board has considered whether there is any additional functional loss not contemplated in the current 10 percent disability ratings for these periods. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013); see also DeLuca, 8 Vet. App. at 206. In August 2007, the Veteran's range of motion was not additionally limited by fatigue, weakness, lack of endurance, or incoordination after repetitive use. Likewise, in June 2009, there was no additional functional limitation after repetitive use from fatigue, weakness, lack of endurance, or incoordination. There was no additional limitation in degrees. Strength testing throughout the periods on appeal were within normal limits. In other words, any additional functional loss due to pain does not more nearly approximate a finding of forward flexion greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 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 during these periods. Accordingly, increased evaluations on this basis are not warranted. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206. This issue has also been reviewed with consideration of whether staged ratings would be warranted within the periods on appeal. However, the evidence of record does not show that a rating in excess of 10 percent would be warranted for the Veteran's service-connected degenerative disc disease of the lumbar spine at any time during these periods. 38 U.S.C.A. § 5110 (West 2002); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board also recognizes the lay statements of record attesting to the Veteran's symptoms of constant pain and the effects of that pain on his daily life. The Board notes that lay persons can attest to observable symptomatology, and the statements made by the Veteran and his daughter describing his symptoms are considered to be competent evidence. Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 469; see also Buchanan, 451 F.3d 1331 (Fed. Cir. 2006). However, these statements must be viewed in conjunction with the objective medical evidence as required by the rating criteria. In this regard, the objective medical evidence demonstrates consideration of the Veteran's statements and the information necessary to rate the Veteran's disability under the rating criteria. Consequently, when considering the overall evidence of record, including the lay statements and medical evidence, the Board finds that the Veteran's service-connected degenerative disc disease of the lumbar spine does not warrant an evaluation in excess of 10 percent for these periods. 38 C.F.R. § 4.71a, Diagnostic Code 5243. As a result, the Board finds the evidence does not support the criteria for a disability rating in excess of 10 percent for degenerative disc disease of the lumbar spine for these periods. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against an evaluation in excess of that already assigned for the periods on appeal, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). On and after April 16, 2013 On and after April 16, 2013, the Veteran's degenerative arthritis of the spine is rated as 20 percent disabling. For a 40 percent disability rating under Diagnostic Code 5242, the evidence must show functional impairment comparable to forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. In addition, an increased rating of 40 percent is provided for under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes when there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. Here, the medical evidence of record does not demonstrate functional impairment comparable to forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. On examination in April 2013, forward flexion was to 60 degrees, and as there was no fixation of a spinal segment in neutral position, the medical evidence does not show favorable ankylosis of the entire thoracolumbar spine. Furthermore, the April 2013 VA examination determined that the Veteran did not have intervertebral disc syndrome of the thoracolumbar spine, and the Veteran did not report any incapacitating episodes during the past 12 months. 38 C.F.R. § 4.71a, General Rating Formula. With respect to other neurological symptoms, the Veteran denied any bowel or bladder problems, and as stated above, his sciatica of the right lower extremity is already compensated with a separate disability rating. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The Board has also considered whether the Veteran's degenerative arthritis of the spine resulted in a level of functional loss greater than that already contemplated by the assigned rating for this period. DeLuca v. Brown, 8 Vet. App. at 206; 38 C.F.R. §§ 4.40, 4.45. In April 2013, the Veteran denied flare-ups that impacted the function of his spine. In addition, the VA examiner reported that there was no additional limitation of range of motion after repetitive-use testing, and the Veteran did not have any functional loss or functional impairment of the back. Although the record shows the Veteran reported difficulty with buttons and donning coats and shirts, the VA examiner found his activities of daily living were okay, and therefore, the Board finds this functional impairment is already contemplated in the disability rating assigned. This issue has also been reviewed with consideration of whether staged ratings would be warranted within this period. However, the evidence of record does not show that a rating in excess of 20 percent would be warranted for the Veteran's service-connected degenerative arthritis of the spine at any time. 38 U.S.C.A. § 5110 (West 2002); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board again recognizes the lay statements of the Veteran and his daughter. However, the objective medical evidence demonstrates consideration of the Veteran's statements and the information necessary to rate the Veteran's disability under the rating criteria. As a result, the Board finds the evidence does not support the criteria for a disability rating in excess of 20 percent for degenerative arthritis of the spine on and after April 16, 2013. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against an evaluation in excess of that already assigned, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The Board has also considered whether the Veteran is entitled to consideration of an extraschedular rating for his low back disability for the periods on appeal. With respect to the first prong of Thun, there is no demonstration in the lay or clinical evidence in this case that the Veteran's symptoms present an exceptional disability picture which renders the available respective schedular evaluations inadequate. Here, the rating criteria reasonably describe the Veteran's disabilities and symptomatology as due to his disabilities. The Veteran's complaints of pain, weakness, instability, and functional impairment manifested by limitation of motion are contemplated in the diagnostic code criteria for assignment of a schedular rating. Therefore, the Board finds the Veteran is not entitled to a referral for extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Sciatica of the right lower extremity Under Diagnostic Code 8520, a 10 percent rating requires mild incomplete paralysis of the sciatic nerve. A 20 percent rating requires moderate incomplete paralysis of the sciatic nerve. A 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires complete paralysis, whereby the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2013). The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. Given the above record, the Board finds the Veteran's service-connected sciatica of the right lower extremity does not warrant a disability rating in excess of 10 percent. Here, the medical evidence does not demonstrate moderate incomplete paralysis of the sciatic nerve. In June 2007, the Veteran reported radiating pain that caused numbness and tingling of the great toe and second toe of the right foot, and there was decreased sensation to light touch on the right foot. In August 2007, there was no objective evidence of radiating pain on movement. Neurological examination revealed normal motor function and sensory function. The Veteran's right lower extremity had a one+ reflex patellar. The assessments in September 2007 and June 2010 were pseudosciatica without neural element compression. In November 2008, muscle strength was five out of five in the lower extremities, although deep tendon reflexes were absent in the right lower extremity. In June 2009, motor function and sensory function of the lower extremities were normal, and right lower extremity reflexes were two+ knee jerk and two+ ankle jerk. The April 2013 VA examination reflects mild, intermittent pain and mild numbness in the right lower extremity but no other signs of radiculopathy. Deep tendon reflexes were absent in the right knee and one+ in the right ankle. Sensation to light touch was decreased in the right lower leg and ankle as well as the right foot and toes. The VA examiner found the severity of the radiculopathy and its side effects was mild. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected sciatica of the right lower extremity, the evidence does not demonstrate symptoms that would warrant a rating in excess of that already assigned at any time during the pendency of the appeal. See Fenderson, 12 Vet. App. at 126. Again, the Board recognizes the lay statements of the Veteran and his daughter. However, the objective medical evidence demonstrates consideration of the Veteran's statements and the information necessary to rate the Veteran's disability under the rating criteria. As a result, the Board finds the evidence does not support the criteria for a disability rating in excess of 10 percent for sciatica of the right lower extremity. In reaching this decision, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against an evaluation in excess of that already assigned, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The Board has also considered whether the Veteran is entitled to consideration of an extraschedular rating for his sciatica of the right lower extremity. With respect to the first prong of Thun, there is no demonstration in the lay or clinical evidence in this case that the Veteran's symptoms present an exceptional disability picture which renders the available respective schedular evaluations inadequate. Here, the rating criteria reasonably describe the Veteran's disabilities and symptomatology. The Veteran's complaints of numbness, tingling, and loss of sensation are contemplated in the diagnostic code criteria for assignment of a schedular rating. Therefore, the Board finds the Veteran is not entitled to a referral for extraschedular ratings for sciatica of the right lower extremity pursuant to 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a disability rating of 60 percent, but no more, for residuals, right knee injury, status post total knee arthroplasty, from April 1, 2006 to December 5, 2012 is granted. Entitlement to a disability rating in excess of 10 percent for degenerative disc disease of the lumbar spine prior to November 5, 2008; from January 1, 2009 to January 25, 2011; and from March 1, 2011 to April 15, 2013 is denied. Entitlement to a disability rating in excess of 20 percent for degenerative arthritis of the spine on and after April 16, 2013 is denied. Entitlement to an initial disability rating in excess of 10 percent for sciatica of the right lower extremity is denied. REMAND The Court has held that a TDIU claim is part and parcel of an increased rating claim when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As a result, the Board has jurisdiction to consider the Veteran's possible entitlement to a TDIU when the issue is raised by assertion or reasonably indicated by the evidence and is predicated, at least in part, on the severity of the service-connected disabilities in question, regardless of whether the RO has expressly addressed this additional issue. See VAOPGCPREC 6-96 (Aug. 16, 1996); see also Caffrey v. Brown, 6 Vet. App. 377 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993); EF v. Derwinski, 1 Vet. App. 324 (1991). In this case, the Veteran has not filed a formal claim for entitlement to a TDIU; however, at the July 2012 Travel Board hearing, the Veteran testified that he was no longer able to assist his wife with the chicken farm. He stated that he was no longer able to walk unassisted and therefore was a liability to the operation. In addition, the Veteran's daughter asserted that he stayed in bed practically all day. Therefore, the Board finds that the issue of entitlement to a TDIU has been reasonably raised by the record and should be adjudicated as part of the claims on appeal. Id.; see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Bowling v. Principi, 15 Vet. App. 1 (2001). As such, the claim for entitlement to a TDIU is remanded for appropriate action. Accordingly, the case is REMANDED for the following actions: 1. The RO should send the Veteran VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, with instructions to return the form to the RO. 2. The RO should send the Veteran VCAA notice d regarding his claim for TDIU. 3. The RO should complete any additional evidentiary development necessary to adjudicate a claim for entitlement to a TDIU, to specifically include collecting and verifying information concerning the Veteran's complete educational and occupational history. 4. Then, the Veteran must be provided an evaluation by a VA vocational rehabilitation specialist to determine the effect of his service-connected disabilities on his ability to secure or follow a substantially gainful occupation. The claims file should be made available for review, and the report should reflect that such review occurred. The vocational rehabilitation specialist must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on the evidence, the evaluation of the Veteran, and with consideration of the lay statements provided by the Veteran and his daughter, the specialist should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected disabilities alone, or acting in concert, preclude him from securing and following a substantially gainful occupation consistent with his education and occupational experience. This opinion must be provided without consideration of either the Veteran's nonservice-connected disabilities or age. A complete rationale for any opinion advanced must be provided. 5. Notify the Veteran that he must report for the examination and cooperate in the development of the claim. Failure to report for a VA examination without good cause may result in denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2013). 6. When the development requested has been completed, adjudicate the claim for entitlement to a TDIU. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further appellate review. 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). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs