Citation Nr: 1334253 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-24 754 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial disability rating greater than 10 percent for a right knee disability from January 31, 2008 to November 15, 2009. 2. Entitlement to an initial disability rating greater than 10 percent for a right knee disability from January 1, 2010 to June 23, 2010. 3. Entitlement to an initial disability rating greater than 10 percent for a right knee disability since August 1, 2010. ATTORNEY FOR THE BOARD N. Sonia, Associate Counsel INTRODUCTION The Veteran served on active duty from June 2002 to March 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which granted service connection for a right knee disability with an evaluation of 10 percent effective January 31, 2008. In between the three evaluations of the knee cited above, twice, the Veteran was granted a temporary total disability evaluation because he was in recovery due to treatment for his service connected knee problem. The temporary total has not been disputed and is not at issue before the Board at this time. The September 2008 rating decision also denied entitlement to service connection for both posttraumatic stress disorder (PTSD) and a left knee strain. 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. The Board notes that the Veteran did not submit a VA Form 9 to perfect his appeal. Instead, the Veteran submitted a statement in support of his claim, which was received by the RO in May 2010. The RO accepted the statement in lieu of a VA Form 9, and the appeal was certified to the Board in April 2013. The May 2010 statement from the Veteran provided specific arguments relating to errors of fact or law made by the agency of original jurisdiction in reaching the determinations being appealed. Specifically, the Veteran reiterated his disagreement with the September 2008 rating decision, indicating that his right knee disability had worsened, necessitating additional surgery. With regards to his claim for PTSD, the Veteran indicated that he has had difficulty "getting the proper medication to function." The Veteran did not refer to his left knee at all in his statement. Thus, the Veteran provided correspondence containing the necessary information to perfect his appeal in a timely manner with regard to the issues of entitlement to service connection for PTSD and entitlement to an initial disability rating greater than 10 percent for a right knee disability. See 38 C.F.R. § 20.202. Subsequently, in a March 2013 rating decision, the RO granted service connection for PTSD with an evaluation of 30 percent effective November 23, 2012. At this time, the Veteran has not submitted a notice of disagreement with regard to that rating decision. Therefore, the issue of entitlement to service connection for PTSD is currently not before the Board. See 38 C.F.R. §§ 20.200, 20.201. Finally, the Board notes that in a September 2010 statement in support of his claim, the Veteran asserted that while his right knee is "worse" than his left knee injury, his right knee disability causes increased weight bearing on his left knee. This claim has not been adjudicated by the RO and therefore the Board does not have jurisdiction over it and it is referred to the RO for appropriate action. FINDING OF FACT From January 31, 2008 to November 15, 2009; January 1, 2010 to June 23, 2010; and since August 1, 2010, the Veteran's service-connected right knee disability has been manifested by degenerative arthritis, by X-ray, with 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. From January 31, 2008 to November 15, 2009, the criteria for a rating in excess of 10 percent for a service-connected right 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 (2012). 2. From January 1, 2010 to June 23, 2010, the criteria for a rating in excess of 10 percent for a service-connected right 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 (2012). 3. Since August 1, 2010, the criteria for a rating in excess of 10 percent for a service-connected right 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 (2012). REASONS AND BASES FOR FINDING 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). As described, the Veteran's service-connected right knee disability is rated at 10 percent disabling effective January 31, 2008 (the date of claim). A 100 percent rating was in place for his right knee disability effective November 16, 2009. An evaluation of 10 percent is assigned from January 1, 2010. A 100 rating was then in place for the right knee effective June 24, 2010. Lastly, an evaluation of 10 percent is assigned from August 1, 2010. Therefore, the relevant temporal focus for the right knee disability as to an evaluation in excess of 10 for a right knee disability under Diagnostic Code 5010 consists of three appeal periods: January 31, 2008 to November 15, 2009; January 1, 2010 to June 23, 2010; and August 1, 2010 to present. 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. The Board will now discuss the evidence of record available in each of the three rating periods at issue in this case. The Board will address the application of the rating schedule after the chronological presentation of the evidence. As described, the first appeal period includes January 31, 2008 through November 15, 2009. In March 2009, the Veteran sought treatment for right knee pain at the Biloxi VA Medical Center (VAMC). The medical professional noted that was no swelling, tenderness, redness or edema of the right knee. The Veteran reported bruising, but the medical professional concluded he could not "appreciate blueness." The medical professional noted that the Veteran could "flex maximally" but preferred "resting 120 degrees." There was no findings of instability, and the medical professional concluded the right knee was "likely arthritic." The medical professional diagnosed chronic knee pain. A June 2009 MRI from Compass Imaging revealed the following: "At least grade II abnormal horizontal signal dissecting through the posterior horn of the medial meniscus with an associated intrameniscal cyst. A small Baker's cyst is present. . . . Partial thickness intrasubstance tear of the anterior cruciate ligament with no evidence of full thickness tear." In a June 2008 VA general medical examination, the Veteran reported right knee pain with intermittent swelling, buckling and locking every two months, and increased pain during wet weather or after physical activity. At the examination, there was no swelling, heat or erythema of the right knee. In addition, there was a negative anterior and posterior drawer sign and a negative McMurray's sign. The Veteran exhibited limited forward flexion to 100 degrees and full extension to zero degrees in the right knee. There was no additional limitation to motion, but painful motion was noted throughout the range of motion testing. The Veteran was afforded another VA examination in August 2009; that examination was specifically for the evaluation of the joints. The Veteran reported intermittent pain, swelling, stiffness, and crepitus in the right knee. The Veteran indicated that he had approximately two to three flare ups per month causing increased swelling and pain. Such flare ups were "brought on by extensive exertion," such as heavy lifting performed at work. The Veteran denied ever taking off work because of right knee pain and denied any incapacitating episodes. The Veteran exhibited limited forward flexion to 120 degrees and full extension to zero degrees in the right knee. The examiner noted "[r]ange of motion limited by subjective complaints of discomfort" as well as tenderness on palpitation. The Veteran's right knee was stable and the McMurray's sign was negative. The examiner indicated that the Veteran's functional limitation was mild. In August 2009, the Veteran submitted a statement in support of his claim in which he indicated that he would need to have surgery on his right knee. Subsequently, in early November 2009, the Veteran visited the Biloxi VAMC to receive medical clearance for right knee arthroscopic surgery. At that time, the Veteran exhibited "symmetric normal reflexes and mobility of joints in both upper and lower extremities." Such a finding of normal provides some evidence against this claim. The next appeal period at issue includes January 1, 2010 to June 23, 2010. In March 2010, the Veteran received treatment at the Biloxi VAMC for a persistent cough. At that time, the Veteran reported right knee pain. The evidence of record also includes treatment records from the Mississippi Orthopaedic Institute. On January 8, 2010, the Veteran sought treatment for a "knot" in his right knee as well as pain; the record notes the Veteran had "been working quite a bit lately." The Veteran received an injection of Marcaine and Lidocaine. The Veteran was given similar injections in February 2010 and early March 2010. Treatment records from the end of March 2010 indicate that the Veteran had right knee pain, but "[g]ood stability." The medical professional noted recurrent right knee pain was "not resolving" and ordered an MRI to determine if the Veteran re-injured his right knee because he had been "so active with his knee." The Veteran's MRI from May 26, 2010 revealed a re-injury, specifically "tear of the lateral meniscus." There was a positive medial McMurray sign. The Veteran was advised of the need for further surgery, which he received on June 24, 2010, less than one month later. Finally, the third appeal period at issue in this case includes August 1, 2010 to the present. The evidence of record includes, in the file on the "Virtual VA" system, treatment notes from September 2011 and September 2012 at the Bixoli VAMC. In September 2011, the Veteran identified bilateral knee pain, aggravated by sitting. In September 2012, the Veteran identified bilateral knee pain, aggravated by walking. Upon examination, the Veteran exhibited limited forward flexion to 110 degrees and full extension to zero degrees; the record does not indicate if this measurement was for the left, right, or both knees. The record did note there was no effusion or laxity. It is important for the Veteran to understand that these results provide more evidence against his claim. The Veteran was afforded a VA joint examination in November 2012. The Veteran reported constant pain, and daily intermittent crepitus and popping. In addition, the Veteran reported "intermittent rare swelling," approximately two times per year, and "intermittent rare weakness," stating, "my right knee went weak twice on me in the last two years." The Veteran also indicated he has flare ups approximately six to seven times per year that last for two days. Moreover, the Veteran described functional limitations, including difficulty climbing ladders, using his push mower to cut grass, bending, kneeling, and prolonged standing and walking. The Veteran indicated that had not been using the Donjoy right knee brace he was given in August 2010 because "it makes [his] knee worse." Regarding limitation of motion, the Veteran exhibited limited forward flexion of 125 degrees with no objective evidence of painful motion. The Veteran exhibited full extension to zero degrees, also with no objective evidence of painful motion. There was no change in degrees after repetitive testing, but the examiner did not there was "less movement than normal" in the right knee after repetitive testing and there was "some crepitus." Strength testing was normal, and there was no anterior or posterior instability. In addition, there was no evidence or history of recurrent subluxation/dislocation, all findings providing evidence against this claim. Further, the examiner noted the Veteran did not use an assistive device and concluded that the Veteran experienced mild functional limitation. Lastly, there were no doctor-prescribed bedrest or incapacitation due to the claimed condition in the last twelve months. Turning to the application of the rating schedule, the Board first addresses Diagnostic Code 5010, which is the code under which the Veteran's service-connected right knee disability is currently rated. As described above, there is no indication in the evidence of record for any of the appeal periods at issue that the Veteran experienced incapacitating episodes due to his right knee disability. For example, VA examiners in the November 2012 and August 2009 examinations note that the Veteran did not report any incapacitating episodes. The Veteran has asserted any incapacitating episodes in any other evidence of record. Therefore, the Veteran does not warrant a disability rating in excess of 10 percent under Diagnostic Code 5010. See 38 C.F.R. § 4.71a, Diagnostic Code 5010. Pursuant to Diagnostic Code 5010, the Board will now address the limitation of motion under the appropriate codes for the specific joint or joints involved, which is the right knee. Although there are three distinct rating periods at issue in this case, the evidence of record, as described above, indicates that in each of these periods, the Veteran has full extension of zero degrees of the right knee and any limitation of motion is not productive of flexion to fifteen degrees or less. Thus, the Veteran's measured range of extension and flexion in the right knee equates to a noncompesnable rating in each of the three appeal periods. See 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. Diagnostic Code 5257 rates on the basis of lateral instability and recurrent subluxation. The only evidence of record that suggests any right knee instability is a May 26, 2010 treatment record from Mississippi Orthopaedic Institute in which the medical professional noted decreased stability with a positive medial McMurry sign. Therefore, the evidence reveals medial rather than lateral instability. As such, there is no evidence of record in each of the three appeal periods to provide a rating in excess of 10 percent for the right 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 right knee or impairment of the tibia and fibula in each of the appeal periods currently before the Board. 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. In the first appeal period (January 31, 2008 through November 15, 2009), the evidence of record does not include dislocation of the semilunar cartilage. However, the Veteran stated in the June 2008 general medical examination that his knee locked, but it only locked every two months. Moreover, in an examination two months later, the Veteran reported only "stiffness" of the right knee and no locking. In the next appeal period (January 1, 2010 through June 23, 2010), there is no evidence of record of dislocation of the semilunar cartilage; instead, an MRI performed in May 2010 revealed a tear in the lateral meniscus. Finally, in the third appeal period (August 1, 2010 to present), the evidence of record once again does not indicate dislocation of the semilunar cartilage. Indeed, in the November 2012, the Veteran denied frequent episodes of joint "locking," and the examination report did not find a history of patellar dislocation. Therefore, the evidence of record does not provide a basis for a rating in excess of 10 percent for the right 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 right 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, for each of the three rating periods on appeal, the Board finds that the service-connected right knee disability, while clearly causing the Veteran a problem, more closely approximates manifestation of degenerative arthritis, by X-ray evidence, accompanied by noncompensable limitation of motion, as well as tenderness, pain, and crepitus. However, in each of the three appeal periods, the right knee has been stable with no indication of ankylosis, impairment of the tibia and fibula, or dislocation of the semilunar cartilage, with only one reference to infrequent "locking." In determining the appropriate evaluation for musculoskeletal disabilities, such as a right knee disability, 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 pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, 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. 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). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). 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 right knee disability. Although the Board acknowledges the Veteran's assertion that he has a painful right knee disability which limits his ability to stand, walk, and engage in many activities, especially at work, the Veteran's symptoms are contemplated in the currently assigned 10 percent rating. Specifically, the Veteran's symptoms of swelling, stiffness, and occasional locking and weakness of the right knee, as well as objective findings of painful motion are contemplated in the currently assigned 10 percent rating. Moreover, 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 presence of arthritis, which is acknowledged to be a painful condition. In sum, the entire disability picture of the service-connected right knee disability does not demonstrate that an evaluation in excess of 10 percent is warranted in each of the three appeal periods at issue based on application of 38 C.F.R. §§ 4.40, 4.45, and Deluca, 8 Vet. App. at 202. 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 right knee disability. See Schafrath, 1 Vet. App. at 595. 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. The Board finds that a claim for TDIU has not been raised in each of the appeal periods at issue. In particular, the record includes a September 2010 letter from the Veteran's employer indicating that the Veteran could return to work in July 2010. The Veteran submitted a statement in September 2010 explaining that he had been ordered by his VA physician, "Dr. J" to stay out of work until July 2010. In that same statement, the Veteran affirmed his ability to work, but he noted that he would need to wear a knee brace daily. Therefore, the record fails to show that the Veteran is unemployable, and the Board concludes that no further consideration of TDIU is warranted. Id. 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 an initial disability rating greater than 10 percent for a right knee disability in each of the three appeal periods at issue in this case. Consequently, the benefit-of-the-doubt doctrine does not apply, and the right 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. Extraschedular Consideration 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. In this case, the Board finds that the scheduler rating criteria adequately contemplate and describe the symptoms and impairment caused by the service-connected right 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. These symptoms include limitation of motion, loss of motion due to pain, and weakness. However none of these symptoms or resulting limitations fall outside of the broad statements found at § 4.40, § 4.45, and § 4.59. The evidence of record also does not demonstrate factors such as marked interference with employment (outside of the periods of convalescence for which the RO granted a temporary 100 percent disability rating) and frequent hospitalization. Therefore, the first prong of Thun is not satisfied and the Board declines to remand this issue for referral for extraschedular consideration. 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) (2012). 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). In the present appeal, the VCAA duty to notify was satisfied by a February 2008 letter that informed the Veteran of what evidence was required to substantiate the claim, and of his and VA's respective duties for obtaining evidence. The letter also included the type of evidence necessary to establish a disability rating and effective date. 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, including the most recent examination from November 2012, which focused on the joints. The examinations were adequate because the examiners reviewed the Veteran's relevant medical history, recorded pertinent examination findings, and provided a sufficient analysis to support their conclusions. 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 an initial disability rating greater than 10 percent for a right knee disability from January 31, 2008 to November 15, 2009 is denied. Entitlement to an initial disability rating greater than 10 percent for a right knee disability from January 1, 2010 to June 23, 2010 is denied. Entitlement to an initial disability rating greater than 10 percent for a right knee disability since August 1, 2010 is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs