Citation Nr: 1334218 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-14 180 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for service-connected lumbosacral strain. 2. Entitlement to a disability rating in excess of 10 percent for service-connected chondromalacia of the left knee, status post surgery ("left knee disability"). ATTORNEY FOR THE BOARD N. Sonia, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1987 to May 2000. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. The RO, in pertinent part, continued the 10 percent rating for the Veteran's lumbosacral strain and continued the 10 percent rating for the Veteran's left knee disability, both effective May 22, 2000 (day following discharge from active service). The Board notes that the Veteran only perfected an appeal, in the April 2010 VA Form 9, for the issues of a lumbosacral strain and a left knee disability; the Veteran did not list sarcoidosis, which was adjudicated in the February 2010 Statement of the Case (SOC). Thus, the Board finds that the issue of an increased rating for sarcoidosis is not before the Board at this time. The Board has not only viewed the Veteran's physical claims file, but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. Giving the Veteran the benefit of the doubt, the preponderance of the evidence shows that throughout the rating period on appeal, the Veteran's back disability has been manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; the evidence does not show objective neurologic abnormalities or incapacitating episodes. 2. The preponderance of the evidence shows the Veteran's left knee disability has been manifested by flexion that is limited to a noncompensable degree, with normal extension, without lateral instability or recurrent subluxation, without ankylosis, without malunion or nonunion of the tibia and fibula, and without dislocation of semilunar cartilage. CONCLUSIONS OF LAW 1. The criteria for an increased rating of 20 percent, but no higher, have been met for the Veteran's service-connected lumbosacral strain. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.50, 4.59, 4.71a, Diagnostic Code 5237 (2013). 2. The criteria for a rating in excess of 10 percent for a service-connected left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.50, 4.59, 4.71a, Diagnostic Code 5010 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Moreover, if the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When entitlement to compensation has been established and a higher initial evaluation is at issue, the level of disability at the time entitlement arose is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consideration must also be given to a longitudinal picture of the Veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). The present appeal involves two disabilities of the musculoskeletal system: a lumbosacral strain and a left knee disability. In determining the appropriate rating for such musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The factors involved in evaluating and rating disabilities of the joints include increased or limited motion, weakness, fatigability, incoordination, painful movement, swelling, deformity or disuse atrophy. 38 C.F.R. § 4.45. Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must be considered. Deluca v. Brown, 8 Vet. App. 202, 207-08 (1995). Lumbosacral Strain As described, the Veteran's service-connected lumbosacral strain is rated as 10 percent disabling effective May 22, 2000 (day following discharge from active service). The Veteran's disability has been evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Scheduler ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes found at 38 C.F.R. § 4.71a. The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain (whether or not it radiates) stiffness, or aching in the area affected by residuals of the injury or disease. 38 C.F.R. § 4.71a. The General Formula provides that an evaluation of 10 percent rating is warranted for: Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding or localized tenderness not resulting in an abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height. Id. A 20 percent rating is warranted for: Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a 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. Id. A 40 percent rating is warranted for: Forward flexion of the thoracolumbar spine greater 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Ankylosis is defined, for VA compensation purposes, as a condition in which all or part of the spine is fixed in flexion or extension. 38 C.F.R. § 4.71a at Note (5). Any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. Id. at Note (1). 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 for the thoracolumbar spine is 240 degrees. Id. at Note (2). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent rating is assigned where there are incapacitating episodes having a total of at least one week but less than two weeks during the past twelve months. Id. A 20 percent rating is assigned where there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past twelve months. Id. A 40 percent rating is assigned where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past twelve months. Id. A 60 percent rating is assigned where there are incapacitating episodes having a total duration of at least six weeks during the past twelve months. 38 C.F.R. § 4.71a. For these purposes, 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. Id. at Note (1). Here, the Veteran asserts that his service-connected lumbosacral strain warrants a higher evaluation than the currently assigned 10 percent rating. The Veteran's primary contention is that a higher rating is warranted based on the chronic low back pain he experiences. In July 2000, the Veteran was afforded a VA spine and joints examination. The examiner noted the Veteran had a history of low back pain located in the midline without radiation to the upper or lower extremities. The Veteran indicated his pain intensified by walking and was eased by resting. The Veteran also indicated that he had been previously examined by several doctors but was not provided a specific diagnosis. Examination of the lumbar spine showed no tenderness or paraspinal spasm. The Veteran demonstrated forward flexion to 85 degrees, backward extension to 30 degrees, right and left lateral extension to 40 degrees, and right and left rotation to 35 degrees. Therefore, his combined range of motion was 265 degrees, which exceeds the normal range of motion for the thoracolumbar spine. The Veteran's gait was normal at that time, and he was diagnosed with chronic strain of the lumbosacral spine. In a July 2000 neurological examination, the Veteran reported that pain began in his back six months after his knee surgery, which included an epidural block. The Veteran indicated he could only lift twenty to thirty pounds, sit or walk for thirty minutes, and stand for fifteen minutes. The Veteran's gait was normal, and the Romberg test was negative. In his August 2002 notice of disagreement, the Veteran indicated he had constant back pain and could only stand for a short period of time before experiencing aches and spasms. The Veteran described difficulty sitting for prolonged periods of time and experiencing pain on motion. The Veteran again stated that he believed his back pain was caused by the epidural he received during his knee surgery; he described waking up from surgery in pain and becoming ill, causing him to remain in the hospital an extra day. Significant to this case, May 2003 medical records from Crofton Physical Therapy include the Veteran's range of motion testing. The Veteran demonstrated forward bending to 55 degrees, with pain; backward bending 15 degrees; sidebending to the right 20 degrees, with pain; and sidebending to the left 15 degrees, with pain. In addition, the Veteran indicated running, lifting, sitting, standing, and walking increased pain. He also stated stretching, sitting, standing and walking improved pain. Records from Johns Hopkins Community Physicians from January 2005 contain treatment for back pain; however, the records consistently document neck pain and not low back pain. In February 2005, the Veteran was afforded another VA spine examination. At that time, the Veteran reported chronic low back pain, aggravated by prolonged standing, bending, stooping, sitting, and lifting heavyweights. The Veteran indicated he started having back pain in service; he again indicated his pain began after his knee surgery. The examiner noted the Veteran had not undergone back surgery, but he had received physical therapy. The Veteran also denied bladder dysfunction or constitutional symptoms. Upon examination, the Veteran was able to walk on heel and toe and squat. The Veteran's gait was normal, and he walked without an assistive device. There was no tenderness of the lumbosacral spine; motor weakness, atrophy, and radicular neurological deficits were not present. The Veteran demonstrated forward flexion to 85 degrees, extension to 15 degrees, right and left lateral flexion to 25 degrees, and rotation 20 degrees. Therefore, his combined range of motion was 190 degrees. Moreover, the examiner noted there was no evidence of additional limitation either due to pain, loss of motion, incoordination, weakness, flare-up, or lack of endurance after repetitive motion. The examiner diagnosed chronic lumbar strain and indicated that there was no evidence of adverse impact to the Veteran's usual occupation or activities of daily living, providing evidence against this claim. The examiner also reviewed an MRI, which noted that the vertebral bodies were in satisfactory alignment and there was no evidence of fracture, destructive process, or disc degeneration. The MRI report also showed minimal spondylosis anteriorly at the L4-L5 level. In a July 2005 statement, the Veteran again described worsening pain in his back. The Veteran stated that he had difficulty going shopping with his family or going to places, such as amusement parks, because he had difficulty standing and sitting for long periods of time. The Veteran reported stretching daily, with pain worsening throughout the day. The Veteran was afforded another VA examination in August 2007 to evaluate his spine and joints. The examiner noted there was no specific history of trauma or a specific diagnosis but that the Veteran reported an 18-year history of low back pain. The examiner noted that pain was intensified by activity and eased by Motrin and rest. There was no finding of ankylosis or a history of medically prescribed bedrest within the previous twelve months. The Veteran demonstrated forward flexion to 85 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left rotation to 45 degrees. Therefore, his combined range of motion was 265 degrees, which exceeds the normal range of motion for the thoracolumbar spine, providing more evidence against this claim. Furthermore, the examiner noted there was no evidence of additional limitation either due to pain, loss of motion, incoordination, weakness, flare-up, or lack of endurance after repetitive motion. The examiner diagnosed chronic lumbosacral strain and indicated that there was no evidence of adverse impact to the Veteran's usual occupation or activities of daily living. Another VA spine examination occurred in September 2009. Although the Veteran's chief complaint at that time involved his cervical spine and associated neck pain, the examination also indicated there was no urinary or bowel incontinence and that although there were symptoms of radiculopathy, there were no correlating objective neurological findings. The examiner also noted there was no history of falls or unsteadiness. Moreover, the examiner indicated the Veteran was able to perform activities of daily living as well as his usual occupation as a systems administrator. In April 2010, the Veteran submitted a statement in support of his claim in which he again identified the chronic pain he experiences in his lower back. The Veteran indicated he cannot sit or stand for longer than thirty minutes. After a review of the evidence described above, the Board finds that a 20 percent evaluation is warranted for the Veteran's service-connected lumbosacral strain. First, under the General Formula, the Veteran was never found to have muscle spasm or guarding that resulted in abnormal gait or contour; his gait and contour have been found to be normal. Moreover, the record fails to show either ankylosis or a fractured spine. However, the Veteran's range of motion testing meets, at some points, the criteria of a 20 percent evaluation. The Board notes that the Veteran did not demonstrate forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or a combined range of motion of the thoracolumbar spine not greater than 120 degrees in any of the VA examinations that occurred in July 2000, February 2005, or August 2007. However, during treatment at Crofton Physical Therapy in May 2003, the Veteran exhibited forward flexion of 55 degrees, with pain. Thus, awarding the benefit of the doubt to the Veteran, based on the Veteran's consistent statements of pain and limitation of activity, as well as the clinical findings in the May 2003 private medical records, the Board finds a 20 percent rating more accurately represents the Veteran's disability during the appeal period. The General Formula also indicates that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, must be evaluated separately, under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 at Note (1). In this case, there are no objective findings of bowel or bladder impairment noted in the examination reports. For example, during the February 2005 examination report, the Veteran denied bladder dysfunction or constitutional symptoms. Moreover, VA has already rated the Veteran's peripheral neuropathy associated with sarcoidosis separately under Diagnostic Code 6846-8620. With regard to application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the evidence does not show that the Veteran has never required bed rest, as prescribed by a physician, nor has the Veteran made any such assertion. For example, the August 2007 examination specifically indicated that the Veteran had not had any incapacitating episodes in the previous twelve months. Accordingly, a higher rating based on the alternative ratings formula for intervertebral disc syndrome is not warranted. The Board has also considered functional loss due to pain. See 38 C.F.R. §§ 4.40 and 4.45, Deluca, 8 Vet. App. at 202. Although the Veteran has described daily pain associated with his low back, in both the February 2005 and August 2007 examination reports, the examiners found that there was no evidence of additional limitation either due to pain, loss of motion, incoordination, weakness, flare-up, or lack of endurance after repetitive motion. Moreover, the examiners indicated that the Veteran's lumbosacral strain did not adversely impact the Veteran's usual occupation or activities of daily living. As such, the Board finds the DeLuca factors have been explicitly considered by the Board and the medical evidence of record, and a higher rating is not warranted based on additional functional loss due to repetitive use. Finally, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds no other diagnostic codes would be appropriate to evaluate the Veteran's lumbosacral strain. See Schafrath, 1 Vet. App. at 595. For the reasons and bases discussed above, the Board finds that the Veteran is entitled to a 20 percent rating for his lumbosacral strain. The preponderance of the evidence is against the assignment of a rating in excess of 20 percent; therefore, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3, 4.7. In this regard, it is important for the Veteran to understand that not all the evidence in this case supports the grant of this claim to 20% and that without giving the Veteran the benefit-of-the-doubt the Board could not grant what it did, let alone grant a higher evaluation. Left Knee Disability As described, the Veteran's service-connected left knee disability is rated as 10 percent disabling effective May 22, 2000 (day following discharge from active service). The Veteran's disability has been evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5010. In the September 2001 decision granting the claim, the RO indicated that the Veteran's diagnosed chondromalacia of the left knee, status post surgery, does not have its own evaluation criteria. For this reason, the RO evaluated the left knee disability under a closely related disease or injury as contemplated in Diagnostic Code 5010. Diagnostic Code 5010 governs ratings for arthritis due to trauma and directs the rater to apply Diagnostic Code 5003, which governs degenerative arthritis. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a 10 rating is warranted for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent rating is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent rating is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of leg flexion that is limited to 45 degrees warrants a 10 percent rating, limitation to 30 degrees warrants a 20 percent rating while limitation to 15 degrees is rated as a maximum 30 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of leg extension warrants a 10 percent rating when limited to 10 degrees, a 20 percent rating when limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees and a maximum 50 percent rating when limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. For rating purposes, normal range of motion in a knee joint is zero degrees of extension and 140 degrees of flexion. 38 C.F.R. § 4.71a, Plate II. Here, the Veteran contends that a higher rating is warranted for his left knee disability. He has repeatedly described chronic pain and limitation of various activities, such as walking, standing, and climbing stairs. In July 2000, the Veteran was afforded a VA spine and joints examination. The Veteran reported that he injured his left knee in 1988 playing basketball, and, in 1991, he underwent surgery with removal of bone fragment. Since that time, the Veteran reported intermittent pain and swelling in the left knee. The Veteran reported taking Motrin and Tylenol for pain and avoiding strenuous activities. The examiner noted that there was no swelling, fluid, heat, or erythema of the left knee, but there was mild diffuse tenderness. The examiner also noted moderate crepitus on flexion and extension; there was no subluxation, contracture, laxity or instability. McMurray sign was negative and gait normal. The Veteran demonstrated extension to 0 degrees and flexion to 135 degrees. The examiner diagnosed chondromalacia left knee, status post surgery. In his August 2002 Notice of Disagreement, the Veteran stated he had functional loss related to his knee, and there was constant crunching and grinding. The Veteran explained his knee pain became pronounced when climbing stairs; his knee "gives way" causing him to almost fall. The Veteran also described difficulty walking. Records from Johns Hopkins Community Physicians from January 2005 document a left knee surgery. However, the records primarily focus on the Veteran's neck pain and do not include treatment for the left knee. In a February 2005 VA Joint examination, the Veteran reported that his left knee pain began after the basketball injury. The Veteran stated that his pain was aggravated by frequent running, jogging, and climbing stairs. The Veteran reported taking Motrin for pain and denied any injection treatments. Upon examination, the Veteran was able to walk on heels and toes and squat. He had a normal gait and walked without an assistive device. The Veteran demonstrated 0-degree extension and 135-degree flexion with discomfort between 125 and 135 degrees flexion. There was no medial or lateral instability, and no anterior or posterior drawer sign. In addition, McMurray's test and Lachman's test were negative. There was no joint line tenderness or effusion. However, crepitation was noted during range of motion testing. The examiner also reviewed X-rays of the left knee. The MRI showed that the bone and joint structures of both knee joints appeared intact with no evidence of arthritic disease. There was incomplete fusion of the anterior tibial tubercle on the right. The soft tissue was unremarkable, providing evidence against this claim. In a July 2005 statement, the Veteran again described his knee pain. The Veteran indicated he injured his knee in approximately 1989 during physical training. The Veteran indicated he had difficulty sitting, standing, running, and jogging. The Veteran described pain when using stairs and reported hearing a crunching sound. Furthermore, the Veteran reported almost falling down when using the stairs but that he kept his balance by holding onto handrails. During the August 2007 VA examination, the Veteran reported hurting his knee playing basketball in 1988. The Veteran reported intermittent pain and swelling, aggravated by prolonged sitting and climbing stairs. The Veteran reported pain was eased by rest and Motrin and that he was able to perform his job. The examiner noted that there was no swelling, fluid, heat, or erythema of the left knee, but there was mild diffuse tenderness. The examiner also noted mild to moderate crepitus on extension; there was no subluxation, contracture, laxity or instability. McMurray sign and Lachman's test were negative. There were negative anterior and posterior drawer signs, and the Veteran's gait was normal. The Veteran demonstrated extension to 0 degrees and flexion to 135 degrees. The examiner diagnosed chondromalacia left knee, status post surgery. Moreover, the examiner noted there was no evidence of additional limitation either due to pain, loss of motion, incoordination, weakness, flare-up, or lack of endurance after repetitive motion. The examiner diagnosed chronic lumbar strain and indicated that there was no evidence of adverse impact to the Veteran's usual occupation or activities of daily living, providing more evidence against this claim. In April 2010, the Veteran stated that he has difficulty walking and after approximately two blocks, he experiences pain in his left knee. The Veteran indicated he has attempted to play basketball or run for short periods of time, but that he experiences significant pain afterwards. The Veteran also reiterated that he has difficulty climbing stairs and that his knee occasionally gives out when climbing them. After a review of all the evidence, lay and medical, the Board finds that the evidence weighs against an increased rating under DC 5003 for the Veteran's left knee disability, including the pain and limitation of motion the Veteran has reported. As previously discussed, Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (e.g., Diagnostic Codes 5260 and 5261), provided the limitation of motion is compensable; however, when limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, Diagnostic Code 5003 provides that a rating of 10 percent is for application for each such major joint affected by limitation of motion. Here, neither the flexion nor extension measurements of the left knee meet the minimum criteria for compensable evaluations under Diagnostic Codes 5260 or 5261. Flexion has been no worse than 135 degrees, with one notation of discomfort between 125 and 135 degrees during the February 2005 VA examination. Further, because there is only one major joint involved (the knee), and there are no incapacitating exacerbations, a 10 percent rating for each knee is the maximum available schedular disability rating under Diagnostic Code 5003. 38 C.F.R. § 4.71a. As the left knee disability is already rated at 10 percent, and a 10 percent rating is the maximum rating provided for arthritis of a major joint under Diagnostic Code 5003, a rating in excess of 10 percent is not possible under Diagnostic Code 5003. The Board has also considered whether any other diagnostic code would allow for increased ratings for the Veteran's left knee disability. Diagnostic Code 5257 rates on the basis of lateral instability and recurrent subluxation. The only evidence of record that suggests any left knee instability are the Veteran's statement regarding difficulty climbing stairs, resulting in occasional giving way of the left knee. Yet, when the Veteran was interviewed during each of the three VA examinations in July 2000, February 2005, and August 2007, he did not describe left knee instability. Instead, he only indicated pain when climbing stairs, providing evidence against his own claim. Moreover, none of the examiners found evidence of instability upon examination. As such, the preponderance of the evidence is against a rating in excess of 10 percent for the left knee on the basis of instability under Diagnostic Code 5257. Turning to Diagnostic Code 5256 and Diagnostic Code 5262, the evidence of record contains no indication of ankylosis of the left knee or impairment of the tibia and fibula throughout the appeal period. Therefore, Diagnostic Code 5256 and 5262 are not appropriate in this case. Diagnostic Code 5258 rates on the basis of dislocation of the semilunar cartilage, with frequent episodes of "locking" pain and effusion into the joint. The evidence of record does not indicate dislocation of the semilunar cartilage. Therefore, the evidence of record does not provide a basis for a rating in excess of 10 percent for the left knee under Diagnostic Code 5258. The Board also notes that Diagnostic Code 5259, which rates on the basis of removal of the semilunar cartilage, and Diagnostic Code 5263, which rates on the basis of a finding of genu recurvatum, are not applicable in this case because the Veteran's left knee disability is already rated as 10 percent disabling under Diagnostic Code 5010. Therefore, the Veteran cannot be granted a higher evaluation under either Diagnostic Code 5259 or Diagnostic Code 5263 because each has a maximum schedular rating of 10 percent. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010. In short, the Board finds that the service-connected left knee disability, while clearly causing the Veteran a problem, is manifested by noncompensable limitation of motion, as well as tenderness, pain, and crepitus. However, there has been no indication of ankylosis, impairment of the tibia and fibula, or dislocation of the semilunar cartilage, and the preponderance of the evidence does not show recurrent subluxation or lateral instability. As a result, the Board finds that the Veteran's left knee disability continues to warrant a 10 percent rating under Diagnostic Code 5010. See 38 C.F.R. § 4.71a. The Board has also considered the Deluca factors with regard to the left knee disability. However, in light of the evidence of record, the Board finds that an evaluation in excess to the currently assigned 10 percent due to functional loss is not warranted for the Veteran's service-connected left knee disability. Although the Board acknowledges the Veteran's assertion that he has a painful left knee disability which limits his ability to stand, walk, and engage in many activities, the Veteran's symptoms are contemplated in the currently assigned 10 percent rating. Specifically, the Veteran's range of motion is not limited to a compensable degree; his range of motion testing does not actually meet the requirements of a 10 percent evaluation. Instead, the current 10 percent rating is assigned on the functional loss and pain in the left knee under the Diagnostic Code for arthritis. Therefore, the Board has already taken into consideration the Veteran's report of functional loss, and the evidence of record does not demonstrate that an evaluation in excess of 10 percent is warranted for the service-connected left knee disability based on application of 38 C.F.R. §§ 4.40, 4.45, and Deluca, 8 Vet. App. at 202. Finally, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds no other diagnostic codes would be appropriate to evaluate the Veteran's left knee disability. See Schafrath, 1 Vet. App. at 595. For the reasons and bases discussed above, the Board finds that the preponderance of the evidence is against the Veteran's claim for entitlement to a disability rating greater than 10 percent for a left knee disability. Consequently, the benefit-of-the-doubt doctrine does not apply, and the left knee rating claim must be denied on a schedular basis. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3, 4.7. Additional Considerations Also considered by the Board is whether referral is warranted for a rating outside of the schedule. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director of the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1)(2012). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular scheduler standards. 38 C.F.R. § 3.321(b). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The United States Court of Appeals for Veterans Claims has held that VA's disability-by-disability interpretation of 38 C.F.R. 3.321(b)(1) is not unreasonable, plainly erroneous, or inconsistent with the regulation or the statutory and regulatory scheme when viewed as a whole, thus the Board was not required to consider whether a veteran's was entitled to referral for extra-schedular consideration of the service-connected disabilities on a collective basis. See Johnson v. Shinseki, 26 Vet. App. 237, 239-40 (2013). First, with regards to the Veteran's service-connected lumbosacral strain, the Board finds that the scheduler rating criteria adequately contemplate and describe the symptoms and impairment caused by the disability as found at 38 C.F.R. § 4.71a and applied with consideration of 38 C.F.R. § 4.40, § 4.45, and § 4.59. The Veteran has reported pain and difficulty completing activities of daily living due to his lumbosacral strain; however, these symptoms are already contemplated under the relevant rating criteria. Moreover, as noted above, the evidence of record includes several examinations that would not support a 20 percent rating grant. However, the Veteran was given the benefit of the doubt and granted a 20 percent evaluation. Therefore, the first prong of Thun is not satisfied and the Board declines to remand this issue for referral for extraschedular consideration. Similarly, the Board finds that the scheduler rating criteria adequately contemplate and describe the symptoms and impairment caused by the Veteran's left knee disability as found at 38 C.F.R. § 4.71a and applied with consideration of 38 C.F.R. § 4.40, § 4.45, and § 4.59. The rating criteria specifically contemplate the symptoms identified by the Veteran, to include pain, limitation of motion, and instability. It is important for the Veteran to understand that the Board is not disputing the fact that the Veteran has a left knee disability, or that is causes him problems, as without some problems associated with his left knee there would be no basis for the 10 percent evaluation assigned, let alone any higher evaluation. As such, there is no basis to refer this case for extra-schedular consideration. Moreover, the Board has considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the evidence of record suggests the Veteran continues to be employed on a full-time basis working with computers. Moreover, several VA examiners have opined that the Veteran's lumbosacral strain and left knee disability have not limited his occupational activities, and the Veteran himself has not asserted he is unemployable. Thus, the Board finds that Rice is inapplicable in this case. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 2107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). As discussed below, VA has fulfilled its duties under the VCAA. When VA receives a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159 (b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For service-connection claims, the notice must address the downstream elements of disability rating and effective date. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Moreover, as it pertains to the claims for higher initial ratings, where, as here, service connection has been granted and the initial rating has been assigned, the claim of entitlement to service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required, since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The duty to assist also includes providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In connection with the current appeal, the evidence of record includes the Veteran's service treatment records, statements in support of the claim by the Veteran and his representative, VA treatment records, private medical records, and several VA examinations related to the Veteran's spine and joints. These examinations were adequate because the examiners reviewed the Veteran's relevant medical history, recorded pertinent examination findings, and provided a sufficient analysis to support the conclusions rendered. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The Veteran has not identified, and the record does not otherwise indicate, any existing, pertinent evidence that has not been obtained. The record also presents no basis for further development to create any additional evidence to be considered in connection with the matters currently under consideration. Hence, no further notice or assistance to the Veteran is required for fair adjudication of the Veteran's claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to a disability rating of 20 percent for service-connected lumbosacral strain is granted. Entitlement to a disability rating in excess of 10 percent for service-connected left knee disability is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs