Citation Nr: 1335266 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 07-40 036 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah THE ISSUE Entitlement to an initial disability rating for right knee patellofemoral syndrome in excess of 10 percent. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran served on active duty from January 1987 to October 1998, from February 2003 to April 2003, and from December 2005 to February 2006. This appeal comes before the Board of Veterans' Appeals (Board) from a September 2006 rating decision of the RO in Salt Lake City, Utah. In February 2010, the Veteran presented testimony at a Board hearing, which was chaired via videoconference by the undersigned Veterans Law Judge, and accepted such hearing in lieu of an in-person hearing. See 38 C.F.R. § 20.700(e) (2013). A transcript of the hearing is associated with the claims file. In May 2009, April 2010, March 2012, and July 2013, the Board remanded this issue for additional evidentiary development (the Board apologies for the delay in the full adjudication of this case). It has since been returned to the Board for further appellate action. The Board also decided other issues that were on appeal at that time. The Board denied a rating in excess of 10 percent for left knee patellofemoral pain syndrome and granted increased ratings for right and left carpal tunnel syndrome. The Board's decision with respect to those matters is final. See 38 C.F.R. § 20.1100 (2013). In an April 2013 letter the Veteran requested the Disabled American Veterans be removed as his representative, a request he confirmed in writing in May 2013 in response to a letter from the Board. Therefore, the Veteran is now considered to be representing himself. In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. For the entire period of this appeal, the Veteran's right knee patellofemoral syndrome has been manifested by pain behind the kneecap which is intermittent and worse with physical activity; flexion is demonstrated at least to 90 degrees, and extension is limited at most to 5 degrees; findings of swelling, loss of range of motion, and perceived joint instability are medically attributed to a nonservice-connected knee injury. CONCLUSION OF LAW The criteria for an initial rating higher than 10 percent for right knee patellofemoral syndrome have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024, 5260, 5261 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). This current appeal arises from a claim of entitlement to service connection received at the RO in June 2006. In the September 2006 rating decision, the RO granted service connection for right knee patellofemoral syndrome and assigned an initial rating of 10 percent under Diagnostic Code 5024, effective February 5, 2006. Diagnostic Code 5024 is used to rate the condition tenosynovitis, but it simply directs to rate the condition in accordance with limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5024. Ratings for limitation of knee motion are addressed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 addresses limitation of flexion of the knee. Under that code, a 30 percent rating is for application were flexion is limited to 15 degrees; a 20 percent rating is for application where flexion is limited to 30 degrees; a 10 percent rating is for application where flexion is limited to 45 degrees; a 0 percent rating is for application where flexion limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 addresses limitation of extension of the knee. Under that code, a 50 percent rating is for application where extension is limited to 45 degrees; a 40 percent rating is for application where extension is limited to 30 degrees; a 30 percent rating is for application where extension is limited to 20 degrees; a 20 percent rating is for application where extension is limited to 15 degrees; a 10 percent rating is for application where extension is limited to 10 degrees; a 0 percent rating is for application where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The current 10 percent rating would appear to have been assigned on the basis of painful flexion that is not compensable under the applicable diagnostic code (see September 2006 rating decision). To warrant a higher rating for limited flexion, or a separate compensable rating for limited extension, the evidence would have to show flexion that is limited to 30 degrees or extension that is limited to 15 degrees. The Board notes that the Veteran was seen at the emergency room at his local VA hospital in January 2012 after having slipped on the stairs and having braced himself with his right knee. He heard a pop and was unable to bear weight thereafter. There was mild swelling. He was initially diagnosed with a sprain. However, he was subsequently found to have a torn medial meniscus and he underwent arthroscopic partial medial meniscectomy in June 2012. Service connection has neither been granted nor claimed for a torn medial meniscus or for other results of this injury. The Board remanded this appeal in July 2013 to obtain an opinion regarding what symptoms were attributable to the service-connected disability as distinguished from the nonservice-connected disability. The August 2013 VA examiner found that the only symptoms that were due to the right knee patellofemoral syndrome were intermittent pain behind the kneecap, which was worse with physical activity. The examiner found that the swelling, loss of range of motion, and perceived joint instability were all most likely due to the meniscal tear and subsequent surgery. In particular, the examiner found that the Veteran's assertion at the examination that, during flare ups, he experiences a decrease in range of flexion and extension was most likely due to his surgical repair and his lack of complete participation in post operative physical therapy. The Board acknowledges that it is precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). However, in this case, competent medical evidence has attributed specific symptoms to service-connected and nonservice-connected causes, and the Board will consider this opinion evidence in determining the appropriate service-connected rating. Range of motion testing in August 2013 revealed that the Veteran could flex the right knee to 110 degrees with no objective evidence of pain, and could extend the knee to 5 degrees with onset of pain at 5 degrees. After repetition, the ranges of motion were the same. The examiner found no functional loss of the knee or lower leg. Strength was normal on flexion and extension, providing evidence against this claim. In July 2012 (noted as 3 weeks after a right knee partial medial meniscectomy), knee range of motion was approximately 2 degrees short of full extension and flexion was measured to about 90 degrees without significant pain. In August 2012, seven weeks after surgery, range of motion was from 0 to 125 degrees with mild quadriceps weakness compared to the left side. VA orthopedic notes in March 2012 and May 2012 reveal that the Veteran could flex the right knee to 110 degrees and could extend the right knee to 0 degrees. The report of VA examination in May 2010 reveals that the Veteran could flex the right knee to 130 degrees with onset of pain at 130 degrees, and could extend the right knee to 0 degrees with onset of pain at 0 degrees. Strength was normal. The report of VA examination in January 2009 reveals that the Veteran could flex the right knee to 110 degrees with onset of pain at 80 degrees, and could extend the right knee to 0 degrees with onset of pain at 0 degrees. Repetitive motion did not change these results. Strength and sensation were normal. The report of VA examination in August 2007 reveals that the Veteran could flex the right knee to 90 degrees with onset pain at the end of motion, and could extend the right knee to 0 degrees with pain throughout. The report of VA examination in May 2006 reveals right knee flexion to 125 degrees and extension to 0 degrees, with pain at the end of range. There was no additional loss of range due to pain, weakness, impaired endurance, fatigue, incoordination, or flare ups. Thus, during the entire period under consideration here, right knee flexion has always exceeded even the 45 degrees necessary for the current 10 percent rating. Right knee extension has typically been normal, but has always been less than the 10 degrees required for a compensable rating. In addition to the measured ranges of motion, the Board has also considered other functional impairment resulting from the right knee disability. The Veteran has reported a general decline in his mobility as a result of pain, and has particularly complained about climbing stairs. On the June 2007 notice of disagreement, the Veteran reported that it was extremely hard to walk up and down stairs, which caused severe pain in the knee. He also reported that running is almost impossible. The Veteran's wife wrote that the Veteran is unable to do many of his usual chores around the house and yard, as well as outdoor activities, due to his various physical disabilities, including his knees. On the report of VA examination in August 2007, the Veteran reported that his knee pain had increased and was present with any type of standing, walking, or climbing. A July 2009 VA orthopedic consultation reveals achy pain in the morning and then pain with activities and stairs. On stairs, the knee would sometimes give away a little secondary to pain. A September 2009 VA orthopedic clinic note reveals pain associated with going up stairs. The report of VA examination in May 2010 reveals the Veteran's report that he could walk up to a half mile before he had to stop due to knee pain. He reported feeling as if his knees will lock, and occasional giving way; however, he does not fall. The Board acknowledges the Veteran's assertions that his pain can cause what he describes as buckling or collapsing. The Board interprets this as the equivalent of weakness. In other words, the Veteran experiences a decreased ability to support his weight due to pain associated with motion of the joint. In March 2009 correspondence, the Veteran reported that he had experienced "collapsing" on several occasions. A private examination in June 2009 notes the Veteran's complaints of pain with activity as well as buckling. A September 2009 VA orthopedic clinic note reveals that the knee feels like it will give out once per week. There was decreased strength in the lower extremity at 4/5. X-rays in May 2006 revealed no arthritis. X-rays in August 2006, May 2009, and March 2010 were noted as normal. X-rays in January 2012 (post-injury) showed evidence of joint space narrowing on the lateral aspect of the right knee with no evidence of fracture or dislocation. Thus the functional impairment resulting from the disability consists primarily of pain associated with motion resulting in limited motion, and weakness (giving way, buckling, collapsing) resulting from pain. The Veteran and his spouse are competent to report his experience of such symptoms, and his diminished capacity due to such symptoms. Their descriptions are deemed credible. Regarding pain, while the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to at least the minimum compensable evaluation based on limited and painful motion, see also Burton v. Shinseki, 25 Vet. App. 1 (2011), such is already assigned. Evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment that meets the stated criteria. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. Similarly, the Veteran has throughout the period on appeal described a popping or clicking sound in the knee when he is ascending stairs. While the Veteran's descriptions are competent and credible evidence, the Board finds that the popping and clicking sound itself does not constitute functional impairment. The Board has acknowledged that the Veteran's pain is associated with a perception of weakness under certain circumstances, such as ascending stairs. This weakness is considered functional impairment. However, the Board must balance the evidence of weakness and pain, which clearly limit motion, against the measured range of motion, as well as the clinical findings which have mostly demonstrated normal strength, but which at worst have shown only a slight decrease in strength (4/5 in September 2009). The Board acknowledges the Veteran's central concern that he has a painful right knee disability which limits his ability to stand, walk, and engage in many activities of daily life; however, it is important for the Veteran to understand that without some functional impairment associated with the right knee there would be no basis for the current 10 percent rating. It is also important to note that the range of motion testing conducted in this case not only does not meet the criteria for a rating higher than 10 percent, it does not actually meet the requirements of the 10 percent evaluation currently assigned. The current 10 percent rating was assigned based on the presence of patellofemoral syndrome, which is acknowledged to be a painful, and thus limiting, condition. Without consideration of the problems of pain and weakness the Veteran has described, the current evaluation could not be justified, let alone a higher evaluation. The Board notes that on the June 2007 notice of disagreement, the Veteran specifically requested a 30 percent rating for his right knee. As noted above, a 30 percent rating requires either that flexion is limited to 15 degrees or that extension is limited 20 degrees. On measured range of motion testing, such limitations have never been approached. Indeed, when the August 2013 examiner asked the Veteran to estimate his limitation of flexion during flare-ups, which were not occurring at the time of the examination, the Veteran's estimate was 90 degrees of flexion, well in excess of the 15 degrees required for a 30 percent rating. The Board acknowledges that the Veteran estimated his limitation of extension during flare-ups as 20 degrees; however, the examiner specifically identified this estimate as "most likely due to his surgical repair and his lack of complete participation in post op physical therapy." As already discussed, service connection is not in effect for the meniscal tear of January 2012 or the subsequent surgery. Regarding the obvious question of whether the results of the January 2012 injury should be attributed to the right knee disability, or the combined service-connected knee disabilities, or should be attributed to any other service-connected disability, the Board finds that this is beyond the scope of the issue on appeal. The grant of service connection in this case encompasses a specific disability of right knee patellofemoral syndrome, which was found to be directly related to service. There is clear evidence of a subsequent injury resulting in a separate and distinct disability of a meniscal tear. Service connection is not in effect for the meniscal tear, and in the absence of adjudication of such an issue by the RO, the Board has no jurisdiction over the issue of service connection for a meniscal tear. The Board has considered whether a claim of entitlement to service connection for a meniscal tear has been reasonably raised by the evidence such that a claim should be referred to the RO for adjudication. The Board acknowledges its obligation to read the filings of this pro se claimant liberally. See Moody v. Principi, 360 F.3d 1306 (Fed. Cir. 2004); Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004); and Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (each emphasizing that pro se filings must be read liberally). However, the Veteran has never asserted that his service-connected disabilities contributed to the January 2012 injury or that he was seeking service connection for the results of the injury. Indeed, the Veteran told the January 2013 VA examiner that the injury resulted from slipping on ice. None of the accounts of the event in the medical records or in the Veteran's description directly implicate a service-connected disability in causing the slip. Therefore, the Board finds that such a claim is not reasonably raised and there is no basis to refer a service connection claim to the RO. To summarize the Board's discussion of the rating under Diagnostic Code 5024, as the functional impairment due to pain and weakness are considered in the current 10 percent rating, and as additional functional impairment is not shown to the level that would warrant a higher rating based on limitation of motion, the Board finds that a higher rating for right knee patellofemoral syndrome is not warranted. The Board has considered other potential diagnostic codes. There is no ankylosis; therefore Diagnostic Code 5256 is not appropriate. Regarding Diagnostic Code 5257, a compensable rating requires evidence of lateral instability and recurrent subluxation. The Board acknowledges that the Veteran has reported a perception of instability. A private examination in June 2009 notes the Veteran's complaints of occasional instability. The Board observes that the term instability can have several meanings, including instability in the normal plane of motion of the joint (weakness). Lateral instability is a specific type of instability that is demonstrated by clinical testing, such as Lachman, anterior drawer, and varus, and valgus stress. While the Veteran testified that he has experienced episodes of "lateral" instability, he went on to describe buckling, which by his description, appears to indicate instability in the normal plane of motion. Indeed, clinical testing for lateral instability has been conducted on numerous occasions throughout the period on appeal and has repeatedly shown the right knee to be laterally stable. The report of VA examination in May 2006 reveals that the knee was found to be stable. The report of VA examination in August 2007 reveals valgus and varus stress testing was conducted and the knee was described as stable. Anterior drawer and McMurray testing were not attempted due to tenderness; however, the examiner noted that both knees appeared stable. The report of VA examination in January 2009 reveals that varus, valgus, anterior and posterior drawer testing, as well as McMurray testing was conducted and the results of each were described as normal. The knee was found to be stable. A July 2009 VA orthopedic consultation reveals the knee was stable to anterior, posterior, varus, and valgus. There was no instability. A September 2009 VA orthopedic clinic note reveals the knee was stable to varus and valgus, as well as McMurry, Lachman, and posterior drawer testing. An orthopedic clinic note dated in March 2010 reveals a negative McMurray test. The anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, and lateral collateral ligament were found to be stable. Particularly probative evidence of the absence of lateral instability comes from the report of VA examination in May 2010, which reveals the examiner's description of the knees as "quite stable" with no evidence of laxity of the cruciate or collateral ligaments. An August 2010 VA orthopedic note reveals that the knees were found to be stable to anterior, posterior, varus, and valgus stress. VA orthopedic notes in March 2012 and May 2012 (post-injury) reveal that, despite the injury, the knee was stable with anterior, posterior, varus, and valgus stress. There was a positive McMurray's sign at the medial aspect of the knee. A February 2012 orthopedic note reveals intermittent collapsing with ambulation in terms of instability, as well as pain with ascending or descending stairs. Stability testing was stable with anterior, posterior as well as varus-valgus stress. Thus, the evidence consistently shows that there has been no lateral instability at any time pertinent to the appeal. While buckling, collapsing, and giving way have been described as instability, the criteria are specific in referring to "lateral" instability, and not instability in the normal plane of motion. The Board has considered the reports of buckling, collapsing, and giving way as weakness. Moreover, as discussed above, the August 2013 VA examiner attributed the Veteran's perceived instability to the nonservice-connected injury. The consistent and specific test results are more persuasive than the Veteran's non-specific perception of instability, despite his use of the term "lateral." In sum, there is no basis to assign a separate compensable rating under Diagnostic Code 5257. Diagnostic Code 5258 rates on the basis of dislocation of the semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. Diagnostic Code 5259 provides a maximum 10 percent rating for symptomatic removal of the semilunar cartilage. While the Veteran had a partial meniscectomy in 2012, this is not a service-connected disability. Notably, the August 2013 VA examiner attributed all of the Veteran's knee symptoms other than pain associated with motion to the nonservice-connected knee injury. Despite the specific finding of the August 2013 examiner, the Board acknowledges that the Veteran reported episodes of locking prior to the January 2012 injury. The Veteran testified (February 2010) that he had experienced episodes of locking "once or twice." The Veteran is competent to describe his symptoms as well as their frequency. To this limited extent, the Board finds that the prior reports of locking carry greater probative weight than the examiner's opinion. However, even acknowledging that the service-connected right knee patellofemoral syndrome has caused episodes of locking "once or twice," this does not approximate the criteria of "frequent" episodes of locking with pain and effusion into the joint. As distinguished from the symptom of locking, the pre-injury evidence regarding effusion has been negative. Examinations conducted prior to the injury, such as in August 2010, June 2009, and January 2009, were negative for joint effusion. Although the August 2013 VA examiner noted frequent episodes of joint effusion, and post-injury examinations have noted joint effusion, this was attributed by the August 2013 examiner to the nonservice-connected injury/disability. As the examiner's opinion is consistent with the pre-injury evidence regarding the presence of effusion, the Board attaches highest probative weight to the examiner's opinion regarding attribution of effusion to the nonservice-connected disability. Thus, even though occasional locking was demonstrated prior to the 2012 injury, the criteria for a compensable rating under Diagnostic Code 5258 or 5259 are not met. Diagnostic Code 5262 rates on the basis of malunion or nonunion of the fibula and tibia, conditions which are neither shown nor alleged in this case. Diagnostic Code 5263 rates on the basis of genu recurvatum, a condition which is neither shown nor alleged. Accordingly, these codes are not appropriate. As a higher rating for right knee patellofemoral syndrome is not warranted, and as no other diagnostic code is appropriate, the Board finds that the weight of the evidence is against a rating in excess of 10 percent, and is against any separate compensable rating for the right knee disability. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2013), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected right knee disability. The criteria specifically provide for ratings based on the presence of limited motion, including due to pain, weakness, and other orthopedic factors. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. Such factors are explicitly part of the schedular rating criteria. While occasional locking is deemed to be associated with the service-connected disability, this symptom has been considered and found not to support a higher or separate rating. While the Veteran has other knee symptoms, these have been attributed to nonservice-connected factors by competent medical evidence. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Veterans Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Because this appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Veterans Court have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). When conducting a hearing, a hearing officer, to include a Veterans Law Judge, must suggest that a claimant submit evidence on any issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103 (2013). The Hearing officer also must suggest the submission of evidence when testimony during the hearing indicates that it exists (or could be reduced to writing) but is not of record. Here, during the hearing, the Veteran's knee symptomatology was discussed in detail, and testimony concerning his level of impairment was elicited. Such actions supplement the VCAA and comply with 38 C.F.R. § 3.103. The Board finds that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, and the Veteran's written assertions and personal hearing testimony. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of the service-connected right knee patellofemoral syndrome. These examinations are adequate because each was performed by a medical professional based on a review of claims file or solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The reports include findings that address the rating criteria, and the August 2013 report includes an opinion as to attribution of knee symptoms that is accompanied by the examiner's rationale and that is consistent with the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). ORDER An initial disability rating in excess of 10 percent for right knee patellofemoral syndrome is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs