Citation Nr: 1334257 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-15 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for instability of the right knee. 2. Entitlement to a disability rating in excess of 10 percent for limitation of motion of the right knee. 3. Entitlement to a disability rating in excess of 20 percent for instability of the left knee. 4. Entitlement to a disability rating in excess of 10 percent for limitation of motion of the left knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1971 to February 1973. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board notes that the RO characterized the four issues on appeal as entitlement to an evaluation in excess of 20 percent for internal derangement, right knee, status post repair, medial meniscal tear, with chondromalacia; entitlement to an evaluation in excess of 10 percent for traumatic osteoarthritis, right knee; entitlement to an evaluation in excess of 20 percent for left knee condition associated with internal derangement, right knee; and entitlement to an evaluation in excess of 10 percent for degenerative arthritis, left knee. However, in light of the Diagnostic Codes employed to evaluate the four disabilities on appeal, the Board has recharacterized the issues on appeal as listed on the title page. The Board notes that the Veteran has stated on numerous occasions that he is unemployable. The RO interpreted his statements as a claim for a total disability evaluation based on individual unemployability (TDIU) and conducted appropriate development. Entitlement to a TDIU was thereafter denied in a November 2012 rating decision. The Board recognizes that a request for TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). That said, claims for increased evaluations and TDIU claims may be separately adjudicated. See id. at 454. In this case, following the November 2012 rating decision the claims file does not indicate the Veteran has expressed a desire to appeal the TDIU claim as required pursuant to 38 C.F.R. § 20.1103. Therefore, the issue of entitlement to a TDIU is not on appeal. FINDINGS OF FACT 1. Throughout the period of appeal, the Veteran's right knee disability is manifested by pain and stiffness, but not by chronic objective evidence of flexion limited to 30 degrees or less; extension limited to 15 degrees or more; recurrent subluxation or objective evidence of severe lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 2. Throughout the period of appeal, the Veteran's left knee disability is manifested by pain and stiffness, but not by chronic objective evidence of flexion limited to 30 degrees or less; extension limited to 15 degrees or more; recurrent subluxation or objective evidence of severe lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. CONCLUSIONS OF LAW 1. Throughout the period of appeal, the criteria for a disability rating in excess of 20 percent for instability of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2013). 2. Throughout the period of appeal, the criteria for a disability rating in excess of 10 percent for limitation of motion of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261 (2013). 3. Throughout the period of appeal, the criteria for a disability rating in excess of 20 percent for instability of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2013). 4. Throughout the period of appeal, the criteria for a disability rating in excess of 10 percent for limitation of motion of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Duties to Notify and Assist 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. In December 2008, VA advised the Veteran of the evidence necessary to support a claim for increased ratings. He was asked to submit or identify relevant evidence. The evidence of record was discussed and the Veteran was told how VA would assist him in obtaining additional pertinent evidence. This letter also advised the Veteran of the manner in which VA determines disability ratings and effective dates. The Board finds that the content of the notice fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2013). In this case, the Veteran was most recently provided a VA examination in August 2012. The examiner considered the Veteran's claims, as well as the material in the claims file, and conducted a physical examination. The examiner recorded the Veteran's reported symptoms as well as his own objective observations. As the August 2012 VA examination report contains both the Veteran's subjective complaints as well as the examiner's objective findings, the Board finds it to be sufficient for adjudication purposes. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Rating Claim A. General Law and Regulations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Separate rating codes identify the various disabilities. See 38 C.F.R. Part 4 (2013). When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2013). In general, when an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In general, evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. The general rating schedules for limitation of motion of the knee are 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under Diagnostic Code 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5257 provides for the assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability of a knee; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. Id. Subluxation of the patella is "incomplete or partial dislocation of the knee cap." Rykhus v. Brown, 6 Vet. App. 354, 358 (1993) (citing Dorland's Illustrated Medical Dictionary at 1241, 1599 (27th edition 1988)). The Board observes that the words "slight," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. 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 (2012). The VA General Counsel has held that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97 (1997); VAOPGCPREC 9-98 (1998). In VAOPGCPREC 9-98, the VA General Counsel further explained that when a Veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. 64 Fed. Reg. 52,376 (1999). A separate rating for arthritis (in addition to Diagnostic Code 5257) could instead be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). 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. 38 C.F.R. § 4.71a (2011). When, however, limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is generally for application. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). B. Analysis Service connection was originally granted for a right knee disability in June 2001. This decision established separate disability ratings based on instability and limitation of motion of the right knee. Service connection was granted for a left knee disability in February 2007. This decision also established separate disability ratings based on instability and limitation of motion of the left knee. The present claim for increased ratings for both knees was initiated in November 2008. On VA fee basis joint examination in February 2009, the Veteran reported experiencing pain, stiffness, swelling, instability, giving way, fatigability, and lack of endurance of both knees. He said that his right knee pain rated a 6 and his left knee pain rated a 7 on a 0 (low) to 10 (high) pain scale. He stated that any walking or activity caused flare-ups. He used a cane. The examiner remarked that there was no ankylosis of either knee. Right knee flexion was to 110 degrees with pain present at 100 degrees. Right knee extension was to 0 degrees with no pain. Left knee flexion was to 100 degrees with pain present at 95 degrees. Left knee extension was to 0 degrees with no pain. Varus/valgus of medial collateral ligaments, varus/valgus of lateral collateral ligaments, anterior cruciate ligaments, posterior cruciate ligaments, medial meniscus, and lateral meniscus tests all yielded normal results bilaterally. The examiner observed pain and tenderness but no instability of either knee. On general VA examination in March 2009, the Veteran complained of bilateral knee pain and instability. He reported that he had quit his employment nine years previously due to pain. He said that he had previously received injections in his knees, and the injections did not help his pain. Both knees had active and passive range of motion from 0 to 95 degrees. Both knees were stable to varus and valgus stress. There was crepitus but no loss of motion, weakness, fatigability, or incoordination after repetitive motion. The examiner opined that the Veteran was unemployable at a job that would require constant standing. A VA treatment record from October 2009 reflects that the Veteran had right knee flexion to 100 degrees and left knee flexion to 90 degrees. Extension of both knees was noted to be decreased with no exact measurement given. On his VA form 9 submitted in March 2010, the Veteran said that he had learned how to deal with his knee pain. He stated that he could not walk 50 yards without experiencing pain. The Veteran felt he was unemployable. On VA joint examination in June 2010, the Veteran reported treating his knee pain with hydrocodone with little relief. He used a brace on his left knee. He said he was unable to work secondary to his knee disabilities. He had not worked since the year 2000. The range of motion of both knees was from 0 degrees to 100 degrees of flexion with extension back to neutral with pain. There were mild to moderate bilateral knee effusions. The examiner noted medial joint line laxity at 0 degrees and 30 degrees of flexion bilaterally. The examiner opined that the Veteran had moderately severe degenerative joint disease of the bilateral knees. A VA treatment record from March 2011 reflects that the Veteran had right knee flexion to 90 degrees and right knee extension from 0 to 170 degrees. Left knee flexion was to 100 degrees, and left knee extension was from 0 to 180 degrees. There was greater medio-lateral laxity on the right than on the left. A VA joint examination report from August 2012 reflects that the Veteran had difficulty walking great distances. The Veteran experienced flare-ups with increased physical therapy. Right knee flexion was to 115 degrees with pain at 110 degrees. Right knee extension was to 0 degrees. Left knee flexion was to 120 degrees with pain at 110 degrees. Left knee extension was to 0 degrees. Repetitive use did not decrease any of the ranges of motion, but the Veteran exhibited pain, swelling, and weakened movement. The examiner noted instability and disturbance of locomotion on the left side. Anterior instability, posterior instability, and medial-lateral instability tests yielded normal results. The examiner found no evidence of recurrent patellar subluxation or dislocation. No meniscal condition was noted. The examiner indicated that the Veteran had self-limited his employment due to alleged knee problems which prevented him from working in construction. The examiner opined that there was no reason why the Veteran could not have worked in other less physically demanding occupations; he simply chose not to do so. While the bilateral knee problems limited the Veteran's ability to perform heavy physical work, the examiner indicated that the bilateral knee disabilities would not prevent the Veteran from working in a sedentary to light duty category. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 20 percent for instability, or a rating in excess of 10 percent for limitation of motion, for either knee. In other words, the objective evidence of record does not support a higher rating of the Veteran's bilateral knee disabilities. In this regard, the Board notes that VA must consider all the evidence of record to determine when an ascertainable increase occurred in the rated disability. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Swanson v. West, 12 Vet. App. 442 (1999). Concerning limitation of motion, there is no basis for assignment of a disability rating higher than the currently assigned 10 percent for either knee under DC 5260 or DC 5261. During the time period relevant to this appeal, the evidence reflects that flexion of either knee limited, at worst, to 90 degrees (with consideration of painful motion). The aforementioned flexion measurement is consistent with no more than a 0 percent (noncompensable) rating under DC 5260. The Board also finds that during the time period relevant to this appeal, the weight of the evidence is strongly against finding a compensable degree of limitation of extension of the left knee. Concerning the right knee, a single VA treatment record reflects that right knee extension was limited by 10 degrees (see VA treatment record from March 2011). However, other medical records preceding and following that record reflect that the Veteran had full extension of the right knee (see VA examination reports from June 2010 and August 2012). Additionally, all of the other medical evidence of record reflects that the Veteran had full extension of the right knee. This evidence suggests that the limitation of extension of the right knee noted in the March 2011 VA treatment record appears to have been an acute incident and not representative of a sustained period of increased symptomatology suitable for a staged compensable rating. Hence, the extension measurements of record are also consistent with no more than a 0 percent (noncompensable) rating under DC 5261. The Board recognizes that VA examination has revealed subjective complaints of pain and weakness, but without incapacitating episodes. The Board observes that, given the Veteran's painful-albeit, noncompensable-bilateral knee range of motion, and other symptoms, the 10 percent rating currently assigned for limitation of motion of each knee appears to be consistent with DeLuca, 38 C.F.R. § 4.40, 4.45, and 4.59 (recognizing the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint). That is, even with consideration of these factors, the Veteran's functional limitation of the bilateral knees does not approach the criteria for a compensable evaluation for either limited flexion or extension. Thus, the medical evidence reflects that no higher rating is assignable, even when functional loss due to pain, weakness and other factors is considered. Turning to instability, there is no basis for assignment of a disability rating higher than the currently assigned 20 percent for either knee under DC 5257. The Board has considered the Veteran's subjective complaints of weakness and giving way, and the Board recognizes that he is competent to describe his symptoms. However, as to an increased rating, the Board finds the results of physical examination by multiple competent health care specialists suggesting no more than moderate instability to be more persuasive. In that regard, the Board notes that a majority of records and examinations during the timeframe on appeal showed no instability, even upon specific instability testing. See February 2009, March 2009, and August 2012 VA examination reports. Although laxity was noted in the June 10 VA examination, and medio-lateral laxity was observed by a VA treatment provider in March 2011, neither examiner suggested that the laxity presented was anything more than moderate. As the consistent medical instability testing yielded normal results, and the two examiners who observed laxity did not suggest that the laxity was severe, the Board finds that the objective medical evidence outweighs the Veteran's subjective complaints. As such, the Board concludes that a disability rating in excess of 20 percent under Diagnostic Code 5257 for instability is not warranted for either knee. In addition, no higher or alternative rating under a different Diagnostic Code can be applied. The Board notes that there are other Diagnostic Codes relating to knee disorders, such as Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (removal of semilunar cartilage, symptomatic), Diagnostic code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (for genu recurvatum). The Veteran's bilateral knee disabilities are not manifested by nonunion or malunion of the tibia and fibula, or genu recurvatum. Ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran is able to move both of his knees, albeit with some limitation of motion, so they are clearly not ankylosed. There are no reports or evidence of dislocated or removed semilunar cartilage. As such, he cannot receive a higher rating under Diagnostic Code 5258 or 5259. The Board notes that the Veteran's functional loss was considered, as the medical evidence shows that the Veteran has consistently complained of pain in both knees. 38 C.F.R. §§ 4.40, 4.45. However, the limitation of motion documented in the medical records as resulting from pain is already contemplated in the disability ratings currently assigned. Moreover, although the Veteran had pain on repetitive motion that pain did not result in limitation of flexion or extension to the level that a separate or higher rating would be warranted. Nor is there objective evidence of calculable decreased motion on repetition due to fatigue, weakness, incoordination, or lack of endurance. There is otherwise no evidence of significant impairment of motor skills, muscle function, or strength attributable to the Veteran's knee disabilities. Consequently, the Board finds that a higher disability rating based on functional loss is not warranted for either knee. C. Extraschedular Considerations In reaching the above conclusions, the Board also has considered whether the Veteran is entitled to a greater level of compensation for his bilateral knee disabilities on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). 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 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 Veteran's bilateral knee 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 levels and symptomatology. As such, the Board need not consider the second and third prongs of Thun, and referral for extraschedular consideration is not appropriate in this case. (CONTINUED ON NEXT PAGE) ORDER A disability rating in excess of 20 percent for instability of the right knee is denied. A disability rating in excess of 10 percent for limitation of motion of the right knee is denied. A disability rating in excess of 20 percent for instability of the left knee is denied. A disability rating in excess of 10 percent for limitation of motion of the left knee is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs