Citation Nr: 1333972 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 10-28 171 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for left knee strain from December 30, 2006, to include whether a separate compensable rating is warranted for instability prior to September 21, 2009. 2. Entitlement to an initial evaluation in excess of 10 percent for left knee instability from September 21, 2009. 3. Entitlement to an initial evaluation in excess of 10 percent for hemorrhoids from December 30, 2006, REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD N. T. Werner, Counsel INTRODUCTION The Veteran had active service from December 2002 to December 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in St. Louis, Missouri. As to the claims for higher evaluations for the left knee disorders, given the General Counsel opinions regarding separate ratings for knee arthritis and instability as well as the United States Court of Appeals for Veterans Claims (Court) holding in Fenderson v. West, 12 Vet. App. 119, 125-26 (1999), both of which will be discussed in more detail below, the Board has characterized these issues as they appear on the first page of the decision. FINDINGS OF FACT 1. From December 30, 2006, the most probative evidence of record shows that the Veteran's left knee strain is not manifested by flexion of the knee limited to 45 degrees or extension of the knee limited to 10 degrees even taking into account his complaints of pain; nor is it manifested by ankylosis; a dislocated semilunar cartilage; impairment of the tibia and fibula; or Genu recurvatum. 2. Prior to September 21, 2009, the most probative evidence of record shows that the Veteran's left knee strain was not manifested by at least slight recurrent subluxation or lateral instability. 3. From September 21, 2009, the most probative evidence of record shows that the Veteran's left knee instability is not manifested by at least moderate recurrent subluxation or lateral instability. 4. From December 30, 2006, the most probative evidence of record shows that the Veteran's hemorrhoids are manifested by subjective complaints of leakage, pain, and itching as well as objective evidence of bleeding but not objective evidence of large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. CONCLUSIONS OF LAW 1. From December 30, 2006, the Veteran did not meet the criteria for a rating in excess of 10 percent for left knee strain nor for a separate compensable rating for instability prior to September 21, 2009. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2013). 2. From September 21, 2009, the Veteran did not meet the criteria for a rating in excess of 10 percent for left knee instability. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.71a, Diagnostic Code 5257 (2013). 3. From December 30, 2006, the Veteran did not meet the criteria for a rating in excess of 10 percent for hemorrhoids. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.114, Diagnostic Code 7336 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under 38 U.S.C.A. § 5102 VA first has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. Second, under 38 U.S.C.A. § 5103(a), VA has a duty to notify the claimant of the information and evidence needed to substantiate and complete a claim, i.e., existence of a current disability, the degree of disability, and the effective date of any disability benefits. The appellant must also be notified of what specific evidence he is to provide and what evidence VA will attempt to obtain. Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. This includes obtaining all relevant evidence adequately identified in the record and, in some cases, affording VA examinations. 38 U.S.C.A. § 5103A. In Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006), the United States Court of Appeals for Veterans Claims (Court) observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (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. See 38 U.S.C. § 5103(a). Initially, the Board finds that there is no issue as to whether the Veteran was provided an appropriate application form or issue as to whether the claimant has veteran status. Next, the Board notes that the Veteran is challenging the initial evaluations assigned following the grants of service connection. In Dingess, supra, the Court also held that in cases where service connection has been granted and initial disability evaluations have been assigned, the service connection claims have been more than substantiated, they have been proven, thereby rendering § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id, at 490-91; Also see Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, regardless of whether the notice that the Veteran was provided with before service connection was granted was legally sufficient, the Board finds that VA's duty to notify in this case has been satisfied. Moreover, the Board finds that even if VA had an obligation to provide notice under 38 U.S.C.A. § 5103(a) and failed to do so, this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claims after reading the rating decision, the statement of the case, and the supplemental statement of the case. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). As to the duty to assist, the Board finds that VA has secured all identified, available, and identified pertinent in-service and post-service evidence including the Veteran's service treatment records and post-service records from the Kansas City VA Medical Center. The claimant was provided VA examinations in October 2007, September 2008, and October 2009 which the Board finds are adequate for rating purposes. The Board has reached this conclusion because the examiners, after a review of the Veteran's medical records and/or after taking a detailed medical history from the claimant, as well as after comprehensive examinations, provided medical opinions as to the severity of his disorders that allows the Board to rate then under all applicable rating criteria. See 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007). In the June 2013 informal hearing presentation, the Veteran's representative asked for a more recent examination for the Veteran's left knee, but there is no indication, or even assertion, of worsening, and no indication that the VA examinations were inadequate. The passage of time, alone, is not sufficient to require a new examination. In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claims below, the Board has reviewed all of the evidence in the Veteran's claims file including those found in virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims files shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Claims The Veteran asserts that his left knee disorders and hemorrhoids met the criteria for higher evaluations. The November 2008 rating decision granted service connection for a left knee strain and rated it as 10 percent disabling from December 30, 2006, under 38 C.F.R. § 4.71a, Diagnostic Code 5257-5260, and granted service connection for hemorrhoids and rated it as non compensable from December 30, 2006, under 38 C.F.R. § 4.114, Diagnostic Code 7336. Thereafter, a November 2009 rating decision confirmed and continued the 10 percent rating for the left knee strain under 38 C.F.R. § 4.71a, Diagnostic Code 5260 and granted a separate 10 percent rating for left knee instability from September 21, 2009, under 38 C.F.R. § 4.71a, Diagnostic Code 5257. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this regard, regulations require that where there is a question as to which of two evaluations is to 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. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. The Board is charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Left Knee Strain from December 30, 2006 Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. If extension of the knee is limited to 30 degrees a 40 percent rating is in order. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2013). When evaluating loss in range of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id, at 206. Under 38 C.F.R. § 4.40, disability of the musculoskeletal system is primarily the inability, due to damage or infection in 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 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 the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. Additionally, 38 C.F.R. § 4.45 provides, as regards to the joints, that the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the spine is considered a major joint. In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), that Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In this regard, VA General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability, provided of course, that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-97 (July 1, 1997). At the October 2007 VA examination, the Veteran's complained of left knee pain with running, climbing stairs, and weather changes. He also reported that his standing was limited from 15 to 30 minutes and his walking was limited from 1 to 3 miles. He also complained of locking 1 to 3 times a month, flare-ups every 2 to 3 weeks that last 1 to 2 days, and problems with effusion, weakness, swelling, and tenderness. On examination, the range of motion of the left knee was 0 to 150 degrees with pain at the end of the range of motion with no additional lost motion after repetitive use. At the subsequent September 2008 VA examination, the Veteran complained of left knee pain, weakness, stiffness, swelling, heat, redness, giving way, locking, fatigue, and lack of endurance. He also complained of flare-ups every other day that last from 1 to 8 hours. On examination, the range of motion of the left knee was 0 to 120 degrees with pain at the end ranges of motion with repetition causing increased pain but no additional lost motion. The left knee was also tender. Thereafter at the October 2009 VA examination, the Veteran complained of left knee pain, weakness, stiffness, swelling, heat, redness, giving way, instability, locking, and fatigue. He also complained of daily flare-ups that last from 15 minutes to 5 hours. On examination, the range of motion of the left knee was 0 to 100 degrees taking his pain and after repetitive use but no fatigue, weakness, lack of endurance, or incoordination. In addition, the Board notes that VA treatment records periodically document the Veteran's complaints and/or treatment for left knee pain. However, nothing in these treatment records show his lost range of motion to be worse than what was reported at the above VA examinations except to note that his history included receiving a cortisone injection. See Colvin v. Derwinski 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). As to a higher evaluation under Diagnostic Code 5260, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, supra, the Veteran's functional losses do not equate to the criteria required for a 20 percent rating because flexion of the knee is not limited to 30 degrees because at its worst it was 100 degrees. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a. This is true at all times from December 30, 2006, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to a higher evaluation under Diagnostic Code 5261, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, supra, the Veteran's functional losses do not equate to the criteria required for a 20 percent rating because extension of the knee is not limited to 15 degrees because at its worst it was 0 degrees. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a. This is true at all times from December 30, 2006, and therefore consideration of staged ratings is not warranted. Fenderson, supra. The Board also finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, supra, the Veteran's functional losses do not equate to the criteria required for separate compensable ratings under Diagnostic Code 5260 and Diagnostic Code 5261 because flexion of the left knee is not limited to at least 45 degrees because at its worst it was 100 degrees and because extension of the knee is not limited to at least 10 degrees because at its worst it was 0 degrees. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; VAOPGCPREC 9-2004. This is true at all times from December 30, 2006, and therefore consideration of staged ratings is not warranted. Fenderson, supra. The Board will next consider whether the Veteran is entitled to a higher rating under one of the other criteria used for rating knee disabilities at any time since December 30, 2006. In this regard, under 38 C.F.R. § 4.71a, Diagnostic Code 5256, ankylosis at a favorable angle in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent rating; ankylosis with flexion between 10 degrees and 20 degrees warrants a 40 rating; ankylosis with flexion between 20 degrees and 45 degrees warrants a 50 rating; and extremely unfavorable ankylosis (flexion at an angle of 45 degrees or more) warrants a 60 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling. And, severe recurrent subluxation or lateral instability warrants a 30 percent rating. The terms "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). The use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, removal of the semilunar cartilage when symptomatic warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5262, impairment of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating; with moderate knee or ankle disability warrants a 20 percent rating; with marked knee or ankle disability warrants a 30 percent rating; and with nonunion (loose motion requiring brace) warrants a 40 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. As to a higher evaluation under Diagnostic Code 5256 for ankylosis, the Board notes that while the range of motion of the left knee was restricted on VA examination, the record on appeal never shows it being ankylosed. See, for example, VA examinations dated in October 2007, September 2008, and October 2009. In fact, the October 2009 VA examiner specifically noted that there was no ankylosis of the left knee. This opinion is not contradicted by any other medical opinion of record. See Colvin, supra. In the absence of ankylosis, the Board may not rate his service-connected left knee disability as ankylosis. Johnston v. Brown, 10 Vet. App. 80 (1997). Consequently, a higher evaluation is not warranted for the Veteran's service-connected left knee disability under Diagnostic Code 5256. This is true at all times from December 30, 2006, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to a higher evaluation under Diagnostic Code 5259 for removal of the semilunar cartilage when symptomatic and under Diagnostic Code 5263 for Genu recurvatum, the Board notes that the disability rating already assigned the Veteran's service connected left knee strain meets the maximum rating possible under these code sections. Therefore, a higher evaluation must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive, the Board should deny the claim on the ground of lack of legal merit). This is true at all times from December 30, 2006, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to a higher evaluation under Diagnostic Code 5258 for dislocated semilunar cartilage and/or under Diagnostic Code 5262 for impairment of the tibia and fibula, the Board notes that the record on appeal is negative for either adverse symptomatology. Therefore, the Board finds that higher evaluations under Diagnostic Code 5258 and Diagnostic Code 5262 must also be denied. See Butts v. Brown, 5 Vet. App. 532, 540 (1993) (the Board's choice of a diagnostic code should be upheld if it is supported by explanation and evidence). This is true at all times from December 30, 2006, and therefore consideration of staged ratings is not warranted. Fenderson, supra. As to a separate compensable rating under Diagnostic Code 5257 for recurrent subluxation or lateral instability prior to September 21, 2009, the Board notes that while the record documents the Veteran's periodic complaints of left knee instability, it is negative for objective evidence of at least slight recurrent subluxation or lateral instability. See, for example, VA examinations dated in October 2007 and September 2008. In fact, at the October 2007 VA examination the Veteran specifically denied having a problem with dislocation or subluxation. Similarly, at the September 2008 VA examiner the Veteran again denied having a problem with subluxation. Moreover, when examined in 2008 it was opined that the left knee was stable in the medial and lateral collateral and anterior and posterior ligament. This opinion is not contradicted by any other medical opinion of record. See Colvin, supra. Therefore, because the most probative evidence of record does not show that the Veteran's left knee instability was manifested by adverse symptomatology that equated to at least slight recurrent subluxation or lateral instability, a separate compensable evaluation is not warranted for left knee instability under Diagnostic Code 5257. This is true at all times prior to September 21, 2009, and therefore consideration of staged ratings is not warranted. Fenderson, supra. Left Knee Instability from September 21, 2009 As to a rating in excess of 10 percent for left knee instability under Diagnostic Code 5257 from September 21, 2009, the Board notes that the October 2009 VA examiner opined that the left knee was unstable and there was a positive McMurray's test in the lateral meniscus. It was thereafter opined that the Veteran's left knee instability was "mild." Moreover, while treatment records periodically document the Veteran's complaints and/or treatment for left knee instability, nothing in these records contradicts the VA examiner's opinion as to the severity of his instability. See Colvin, supra. Therefore, because the most probative evidence of record does not show that the Veteran's left knee instability is manifested by adverse symptomatology that equates to at least "moderate" recurrent subluxation or lateral instability because at its worst it was characterized by the October 2009 VA examiner as "mild," the Board finds that the criteria for a rating in excess of 10 percent for left knee instability have not been met. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. This is true at all times from September 21, 2009, and therefore consideration of staged ratings is not warranted. Fenderson, supra. Hemorrhoids from December 30, 2006 38 C.F.R. § 4.114, Diagnostic Code 7336 provides that hemorrhoids (external or internal) will be rated as zero percent disabling when they are mild or moderate. Hemorrhoids will be rated as 10 percent disabling when they are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 30 percent disability rating is warranted when they cause persistent bleeding with secondary anemia, or fissures. With the above criteria in mind, at the October 2007 VA examination the Veteran complained of anal pain, itching, and burning as well as diarrhea, difficulty passing stool, tenesmus, and bleeding twice a week. It was also reported that, while the Veteran reported that he had recurrent hemorrhoids 4 or more times a year, there is no history of thrombosis. On examination, there were no hemorrhoids present. At the subsequent September 2008 VA examination, the Veteran complained of anal pain and itching as well as diarrhea, tenesmus, swelling, and bleeding two to three times a month. The Veteran also reported that his history included thrombosis. On examination, he had normal appearing external hemorrhoids with no bleeding or rectal prolapsed as well as good sphincter tone. Moreover, there was no anemia or fissures. It was thereafter opined that since a colonoscopy saw bleeding hemorrhoids, the diagnosis was hemorrhoids was intermittent bleeding that are currently asymptomatic. Thereafter at the October 2009 VA examination, the Veteran reported that he had a problem with external hemorrhoids that come and go. He also reported that he had a problem with fecal leakage. In addition, the Board notes that VA treatment records periodically document the Veteran's complaints and/or treatment for anal itchiness, pain, and bleeding as well as constipation due to hemorrhoids. However, nothing in these treatment records show his adverse symptomatology to be worse than what was reported at the above VA examinations except to note a slightly erthematos anus in June 2009. See Colvin, supra. In fact, a November 2011 VA treatment record specifically noted that there were no obvious thrombosed external hemorrhoids. In summary, the most probative evidence of record shows that the Veteran's hemorrhoids are manifested by subjective complaints of leakage, pain, and itching as well as objective evidence of bleeding. However, the record is negative for objective evidence of large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences despite the Veteran being provided with three VA examinations during the pendency of the appeal. Given the above symptomatology, the Board finds that the Veteran's functional losses do not equate to the criteria required for a compensable rating under Diagnostic Code 7336. 38 C.F.R. § 4.114. This is true at all times from December 30, 2006, and therefore consideration of staged ratings is not warranted. Fenderson, supra. Extraschedular Ratings As to the Veteran's claim that his disabilities are worse than rated, under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board further observes that, even if the available schedular evaluations for the disabilities are inadequate (which they are manifestly not), the Veteran does not exhibit other related factors such as those provided by the regulations as "governing norms." Specifically, there simply is no objective evidence that the above disabilities resulted in marked interference with employment or frequent periods of hospitalization. See Bagwell v. Brown, 9 Vet. App. 337 (1996). Therefore, the Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. In short, there is nothing in the record to indicate that the service-connected disabilities cause impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted at all times from December 30, 2006. Fenderson, supra. In reaching the above conclusions, the Board has not overlooked the various lay statements found in the record. In this regard, the Veteran is credible to report on what he sees and feels such as pain, lost motion, itchiness, and bleeding as well as the claimant and others are credible to report on what they can see. See Davidson, supra. However, the Board finds more probative the medical opinions as to the severity of the disabilities provided by the experts at the VA examinations than these lay assertions. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators. . ."). Conclusion In adjudicating the current appeal for higher ratings, the Board has not overlooked the Court's holding in Rice v. Shinseki, 22 Vet. App. 447 (2009) (per curiam) (holding that claims for higher evaluations also include a claim for a total rating based on individual unemployability (TDIU) when the appellant claims he is unable to work due to a service connected disability). However, the Board finds that Rice is not applicable to the current appeal because the Veteran has never claimed that his left knee disorders or hemorrhoids prevent him from obtaining and/or maintaining employment, nor has the issue been otherwise raised by the record. Therefore, the Board finds that the current decision need not consider whether the Veteran meets the criteria for a TDIU. The Board has also considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claims the doctrine is not for application. 38 U.S.C.A. § 5107(b); See also, e.g., Gilbert v. Derwinski, 1 Vet. App. 49 (1990). \ ORDER Entitlement to an initial evaluation in excess of 10 percent for left knee strain from December 30, 2006, to include a separate compensable rating for instability prior to September 21, 2009, is denied. Entitlement to an initial evaluation in excess of 10 percent for left knee instability from September 21, 2009, is denied. Entitlement to an initial evaluation in excess of 10 percent for hemorrhoids from December 30, 2006, is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs