Citation Nr: 1335449 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 11-18 406A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an initial compensable rating for left knee chondromalacia patella (left knee disability) for the period prior to January 26, 2012, and in excess of 10 percent as of January 26, 2012. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Luke McCabe, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1998 to October 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. During the pendency of this appeal, a rating of 10 percent for the Veteran's left knee disability effective from January 26, 2012 was granted in a February 2012 rating decision. Because this increased rating does not represent a grant of the maximum benefits allowable, the Veteran's claim remains in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a grant of a higher rating during the course of an appeal, but less than the maximum benefits allowable, does not abrogate the appeal). FINDING OF FACT The Veteran's left knee chondromalacia patella is manifested by painful movement but has normal range of motion and stability, throughout the claim. CONCLUSIONS OF LAW 1. The criteria for a rating of 10 percent, but no higher, for the period prior to January 26, 2012 for left knee chondromalacia patella have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.101, 4.3, and 4.71a, Diagnostic Code (DC) 5260 (2013). 2. The criteria for a rating in excess of 10 percent for chondromalacia patella of the left knee have not been met at any point during the pendency of this claim. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.101, 4.3, and 4.71a, DC 5260. REASONS AND BASES FOR FINDING AND CONCLUSIONS In deciding this claim, the Board has reviewed all of the evidence in the claims file, both the physical claims file and electronic ("Virtual VA") claims file, and has an obligation to provide an adequate statement of reasons or bases supporting this decision. See 38 U.S.C.A. § 7104(d)(1) (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each and every piece of evidence, certainly not in exhaustive detail. See id. The analysis below therefore focuses only on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. 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 claimant). The Board must assess the credibility and weight of all evidence, so both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (2013). When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against a claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). I. Procedural Duties The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), sets forth VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). a. Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and 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). The United States Court of Appeals for Veterans Claims (Court) has held that 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). All notice under the VCAA should generally 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). However, a delay in timing is "cured" and therefore harmless when a fully compliant VCAA notification letter is followed by readjudication of the claim (such as through the issuance of an SOC or SSOC) after the claimant has had an opportunity to submit additional evidence. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). The appeal of the noncompensable initial rating assigned the Veteran's left knee disability stems from a granted claim of service connection. In initial rating cases, where service connection has been granted and an initial disability rating and effective date assigned, VCAA notice under 38 U.S.C.A. § 5103(a) is no longer required because the purpose that the notice is intended to serve has been fulfilled with the grant of service connection. Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran bears the burden of demonstrating any prejudice from defective (or nonexistent) notice with respect to the "downstream elements" of the degree of disability and effective date assigned. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Here, a December 2009 letter informed the Veteran of the elements of service connection, including VA's general criteria for assigning a disability rating, and also notified him of his and VA's respective responsibilities for obtaining relevant evidence in support of his claim. Therefore, the duty to notify is satisfied. See id.; Quartuccio, 16 Vet. App. at 187. b. Duty to Obtain Records VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as performing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Here, the Veteran's service treatment records and VA treatment records are in the claims file. The Veteran has not identified any other records or evidence that remain outstanding. Thus, the duty to obtain relevant records on the Veteran's behalf is satisfied. See 38 C.F.R. § 3.159(c). c. Duty to Provide an Examination 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, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2013); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a new VA examination must be conducted. See 38 C.F.R. § 3.327(a); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, a VA knee examination was performed most recently in January 2012, with a July 2012 addendum opinion indicating no change in diagnosis after a review of the claims file and medical evidence of record. The examination report and addendum are adequate for rating purposes, as the examiner performed a thorough knee examination, reviewed the claims file, including VA treatment records and prior VA knee examinations, and described the Veteran's disability and resulting functional impairment in sufficient detail to enable the Board to make a fully informed decision on this claim. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994). VA knee examinations were also performed in June 2010 and April 2010. The Veteran has not stated and there is no other evidence indicating that there has been a material change in the severity of his left knee disability since he was last examined in January 2012. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95 (April 7, 1995). Accordingly, VA's duty to obtain a VA examination has been met. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. at 312. d. VCAA Conclusion In sum, VAs duties to notify and assist under the VCAA have been satisfied. The Veteran has had ample opportunity to participate in the development of his claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . . must be considered prejudicial")). Any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication," and no such defect has been alleged. See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, any error in the notice or assistance provided was harmless, and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show that the error was harmful by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) (West 2002) (providing that the Court must take due account of the rule of prejudicial error). Accordingly, the Board may proceed with appellate review. II. Analysis The Veteran's left knee disability has been rated as noncompensable prior to January 26, 2012, and as 10 percent disabling as of January 26, 2012. The Veteran contends that he is entitled to an initial compensable rating for his service-connected left knee disability for the period prior to January 26, 2012, and in excess of 10 percent as of January 26, 2012. He maintains that his left knee disability is more severe than the testing indicates. For the reasons that follow, the Board concludes that a 10 percent rating is warranted for the entire period on appeal, and that a rating higher than 10 percent is not warranted for any period on appeal. VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R., Part IV. 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 (2013). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2013). Otherwise, the lower rating will be assigned. Id. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14 (2013). However, the evaluation of the same disability or its manifestation under various diagnoses, which is known as pyramiding, is to be avoided. Id. In initial rating cases, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). The Veteran's left knee disability is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5260. See 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2013). The additional code is shown after the hyphen. In this case, Diagnostic Code 5299 is used to identify musculoskeletal disabilities that are not specifically listed in the schedule, but are rated by analogy to similar disabilities under the schedule. See 38 C.F.R. §§ 4.20, 4.27. The assignment of Diagnostic Code 5260 shows that the Veteran's service-connected left knee disability is rated as analogous to limitation of flexion, specifically because of objective evidence of painful motion of the left knee, with associated functional limitations. For that reason, the RO rated the Veteran's left knee disability analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related. Under DC 5260, a noncompensable rating is assigned when flexion of the knee is limited to 60 degrees. A 10 percent rating is warranted when flexion is limited to 45 degrees. A 20 percent rating is for consideration when flexion is limited to 30 degrees. A 30 percent rating is applicable where flexion is limited to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. In addition, the intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. 38 C.F.R. § 4.59. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id.; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Further, 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. Moreover, under 38 C.F.R. § 4.45, consideration must also be given to weakened movement, premature or excess fatigability and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria set forth in sections 4.40 and 4.45 are not subsumed by the diagnostic codes applicable to the affected joint). When determining whether a higher rating is warranted for pain, the Court held in Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) that the pain "must actually affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating. See id. at 43. Turning to the evidence of record, the April 2010 VA examination report reflects that the Veteran reported symptoms of left knee pain during running and other exercise. He reported left knee symptoms of giving way, instability, pain, stiffness, weakness, decreased speed of joint motion, swelling, and repeated effusions. He further reported no incoordination, no episodes of dislocation or subluxation, and no locking episodes. He stated that he was unable to stand for more than 15-30 minutes or walk for more than 1/4 mile. Additionally, he stated that he always wore a left knee brace. On examination, the Veteran's left knee exhibited clicks or snaps, but no grinding, instability, patellar abnormality, meniscus abnormality, or other knee abnormalities. The examiner noted the Veteran's clinical history of left knee patellar pain syndrome as indicated by a 2003 abnormal MRI while in active service. The examiner reviewed a November 2004 MRI of the Veteran's left knee which was found to reflect cartilage thinning irregularity and signal abnormality over the lateral patellar articular surface suggesting chondromalacia, while the rest of the articular cartilage was smooth in outline and thickness. The MRI further reflected that the bones demonstrated normal marrow signal, the medial and lateral menisci, cruciate ligaments, collateral ligaments bilaterally, quadriceps and patellar tendon were intact and normal in signal, and there existed no joint effusion. The examiner diagnosed chondromalacia patellae involving the lateral articular surface. The examiner additionally reviewed February 2005 X-rays of the Veteran's left knee which reflected that his medial-lateral compartments were well-maintained with weightbearing and that no acute fracture was seen and no significant capsular distention was identified. Range of motion (ROM) testing showed that left knee flexion was from 0 to 140 degrees. Left knee extension was to 0 degrees. There was no objective evidence of pain following active motion. The examiner found that the Veteran's left knee disability had significant effects on his occupation due to decreased mobility and pain. In terms of daily activities, it had moderate effects on his ability to exercise and play sports and mild effects on his ability to do chores, go shopping, exercise, and engage in recreation. At the June 2010 VA examination, the Veteran reported experiencing sharp pain in his left knee when climbing stairs or rising from a chair, throbbing pain at night, and swelling on a daily basis. He additionally complained of occasional swelling without heat, redness, or tenderness, but denied acute flare-ups resulting in additional limitation of motion or functional impairment. On ROM testing, flexion of the left knee was from 0 to 140 degrees. Left knee extension was to 0 degrees. The examiner noted that the Veteran had crepitance with range of motion, with a grating sound underneath the kneecap consistent with chondromalacia. There was no additional limitation of range of motion after repetitive testing, nor any additional pain, fatigue, incoordination, weakness or lack of endurance. The examiner confirmed the diagnosis of left knee chondromalacia patella. The January 2012 examination report reflects diagnoses of left knee chondromalacia patella and retropatellar pain syndrome. The Veteran reported that since service, his left knee pain had progressively worsened and that he experienced pain upon knee bending, walking, running, and stair climbing. He also reported intermittent swelling and denied flare ups. On examination, Veteran's left knee exhibited bilateral subpatellar crepitus and one plus effusion. ROM testing reflected that left knee flexion was from 0 to 140 degrees. Left knee extension was to 0 degrees. The report reflected no tenderness or pain to palpitation for the joint line or soft tissues, normal muscle strength on flexion and extension, and normal joint stability. Repetitive-use ROM testing showed no additional loss of ROM of the knee and lower leg. Furthermore, after repetition, the examiner found no additional limitation due to weakened movement, premature or excess fatigability, or incoordination. Thus, although the Veteran had pain, the examiner found that it did not limit his ROM. With regard to functional impairment, the January 2012 examiner noted that the Veteran's left knee disability impacted his ability to work in that it rendered him unable to perform duties that require repeated knee bending. Based on the foregoing evidence, the Board finds that with regard to the period prior to January 26, 2012, the criteria for a 10 percent rating have been met. In this regard, because the evidence does not show left knee flexion limited to 45 degrees or less, the criteria for a 10 percent rating based on limitation of motion were not met prior to January 26, 2012. See 38 C.F.R. § 4.71a, DC 5260. Nevertheless, the Veteran's treatment records show credible complaints of left knee pain on bending dating back to 2003, including service treatment records, VA treatment records dating from December 2004, and VA examinations from April 2010 and June 2010. VA regulation provides, in relevant part, that joints which are actually painful due to healed injury should be entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Accordingly, based on the credible evidence of left knee pain and painful motion, the Board finds that a rating of 10 percent but no higher is warranted prior to January 26, 2012. The Board finds that a rating in excess of 10 percent for chondromalacia patella of the left knee is not warranted at any time during the pendency of this claim. The relevant evidence of record shows that the Veteran's left knee disability more nearly approximates the criteria for the 10 percent rating currently assigned. Specifically, his range of motion of the left knee was normal at each of the VA examinations, even after repetitive testing. Indeed, the Veteran himself stated in his July 2011 substantive appeal (VA Form 9) that he has full range of motion of the knee. Thus, the criterion for a 20 percent rating under DC 5260, which requires limitation of flexion to 45 degrees, has not been met. The Board has considered the statements of the Veteran regarding pain and stiffness. However, to the extent these statements conflict with the objective clinical findings on three VA examinations, they do not constitute credible evidence of additional disability. The Board finds that this does not amount to more than the minimum compensable rating in the absence of any objective findings of impairment causing limitation of range of motion. See DeLuca, 8 Vet. App. at 206-07. In this regard, as reflected in the January 2012 and April 2010 VA examination reports, although the Veteran experienced pain, the pain did not limit his range of motion, and the Veteran continued to have normal flexion and extension even with three repetitions of the range-of-motion exercises. See Mitchell, 25 Vet. App. at 42-43 (holding that pain must actually result in functional impairment to warrant a higher rating). Moreover, the Veteran's left knee motion was not further limited by weakness, fatigability, or incoordination on repeat range-of-motion testing. Rather, his left knee continued to exhibit normal range of motion. The 10 percent rating currently assigned compensates him for his left knee pain and associated functional limitations such as decreased ability to stand or walk for prolonged periods and the inability to perform tasks that require repeated bending of his knee. Therefore, a higher rating is not warranted under the Deluca criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca, 8 Vet. App. at 206-07. The Board has considered the application of other DC's pertaining to disorders of the knee. There is no evidence showing that the Veteran has ankylosis of the left knee, recurrent sublaxation or lateral instability, dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint, removal of semilunar cartilage, or limitation of extension of the leg. Therefore, Diagnostic Codes 5256, 5257, 5258, 5259, and 5261 are not applicable. See 38 C.F.R. § 4.71a. There is also no evidence of arthritis of the left knee. Thus, DC's 5003 (degenerative arthritis) and 5010 (traumatic arthritis) are not applicable. See id. Accordingly, the preponderance of the evidence shows that the Veteran's left knee disability has more nearly met the criteria for a 10 percent rating than a 20 percent rating throughout the pendency of this appeal. Thus, a rating in excess of 10 percent is not warranted at any time since the Veteran's claim for an increased evaluation. Therefore, staged ratings are not appropriate for the time frame on appeal. See Hart, 21 Vet. App. at 509-10. The Board has considered whether to the address the issue of a total disability rating based on individual unemployability (TDIU). See 38 C.F.R. §§ 3.340, 4.16 (2013). In Rice v. Shinseki, 22 Vet. App. 447, 453 (2009), the Court held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or as part of a claim for increased compensation. If the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel of that claim for an increased rating is the issue of whether a total rating based on individual unemployability as a result of that disability is warranted. Id. at 455. Here, the Veteran has not stated and the evidence of record does not otherwise suggest that his left knee disability is sufficiently incapacitating as to prevent him from obtaining or maintaining substantially gainful employment. Thus, the Board finds that the issue of entitlement to TDIU has not been raised. See id. The Board has considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2013); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue 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). In Thun, 22 Vet. App. at 115, the Court held that the determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare 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. See id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the claimant's disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Id. Referral for extraschedular consideration is not warranted. A comparison of the Veteran's left knee disability and the rating criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). As shown above, the Veteran's left knee chondromalacia patella is manifested by painful movement but has normal range of motion and stability, even on repetition. Such manifestation is addressed by the rating criteria under 38 C.F.R. § 4.71a, and sections 4.40, 4.45, and 4.59 of the regulations. The Veteran does not have symptoms or functional impairment associated with his left knee disability that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. As noted in Thun, the rating criteria are averages and need not account for each individual circumstance in order to be adequate for evaluation purposes. Therefore, as the evidence does not show that the Veteran's left knee disability is "exceptional" or "unusual" when compared with the rating criteria, the available schedular evaluations are adequate to rate this disability. Thus, the first step of the inquiry is not satisfied. See id. In the absence of this threshold finding, there is no need to consider the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See id. at 118-19 (holding that the Board's "threshold" finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Indeed, in the absence of an exceptional or unusual disability picture under the first Thun factor, interference with employment is not sufficient by itself to warrant extraschedular referral, as the rating schedule "clearly recognizes that the rated disabilities interfere with employment." See VAOPGCPREC 6-96 (August 16, 1996). Accordingly, referral for extraschedular consideration is not warranted. Id. In summary, a rating of 10 percent is warranted prior to January 26, 2012. However, the preponderance of the evidence weighs against assignment of a rating in excess of 10 percent for the Veteran's left knee disability at any point during the pendency of the appeal. Accordingly, the benefit-of-the-doubt rule does not apply, and a rating greater than 10 percent for left knee chondromalacia patella must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102; 4.3; Gilbert, 1 Vet. App. at 55. ORDER Entitlement to a rating of 10 percent, but no higher, for left knee chondromalacia patella for the period prior to January 26, 2012, is granted, subject to the laws and regulations governing payment of monetary benefits. Entitlement to a rating for left knee chondromalacia patella in excess of 10 percent as of January 26, 2012 is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs