Citation Nr: 1336124 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 08-38 928 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to an initial compensable evaluation for right knee patellofemoral syndrome. 2. Entitlement to an initial compensable evaluation for left knee patellofemoral syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran served on active duty from May 1982 to April 2008. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office in Salt Lake City, Utah (RO). In a January 2012 decision, the Board denied an increased rating in excess of 10 percent for lumbar strain, denied initial compensable evaluations for right and left knee patellofemoral syndrome, and granted a 10 percent rating for bilateral mandibular tori. The Veteran appealed the January 2012 decision to the United States Court of Appeals for Veterans Claims (Court or CAVC), only to the extent that it denied compensable evaluations for right and left knee patellofemoral syndrome. In November 2012, the Court granted a Joint Motion for Partial Remand and the part of the Board's decision that denied entitlement to initial compensable evaluations for right and left knee patellofemoral syndrome was remanded for action consistent with the terms of the Joint Motion. The appeal as to the remaining issues was dismissed. FINDINGS OF FACT 1. Right knee patellofemoral syndrome is manifested by chronic, low-grade right knee pain, poor patellar tracking, full extension to 0 degrees without pain, and full flexion to 140 degrees without pain. There were no additional limitations to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. The Veteran had normal x-rays of the right knee with no evidence of arthritic changes. 2. Left knee patellofemoral syndrome is manifested by chronic, low-grade left knee pain, poor patellar tracking, full extension to 0 degrees without pain, and full flexion to 140 degrees without pain. There were no additional limitations to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. The Veteran had normal x-rays of the left knee with no evidence of arthritic changes. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a 10 percent rating, but no more, for right knee patellofemoral syndrome are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2013). 2. Resolving reasonable doubt in the Veteran's favor, for the entire rating period, the criteria for a 10 percent rating, but no more, for left knee patellofemoral syndrome are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist 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), 3.326(a) (2013). The notice requirements of 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, the VA will attempt to obtain. Id. In a claim for increase, the VCAA requires generic notice of type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO issued a February 2008 preadjudicatory notice letter to the Veteran which met the VCAA notice requirements. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that March 2008 and January 2009 VA examinations of record are adequate and addressed all the relevant rating criteria for the knees. For these reasons, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board is also satisfied that VA has made reasonable efforts to obtain relevant records and evidence. VA examinations, lay statements, and a Decision Review Officer (DRO) informal conference report have been associated with the record. VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claims, and to respond to VA notices. The Veteran has not indicated any worsening in his condition since his last VA examination and he and his representative have not identified any outstanding evidence that needs to be obtained. For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Disability Rating Legal Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. 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 life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The United States Court of Appeals for Veterans Claims (Court or CAVC) has held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether a staged rating is warranted. The Board finds that the severity of the Veteran's bilateral knee disability has not changed during the course of the appeal to warrant a staged rating. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2013). Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45 (2013). With any form of arthritis, painful motion is an important factor of disability; therefore, 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. 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 (2013). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2013). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Ankylosis of the knee is evaluated under Diagnostic Code 5256. A 60 percent evaluation is assigned for extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more; a 50 percent evaluation is assigned for flexion between 20 and 45 degrees; a 40 percent evaluation is assigned for flexion between 10 and 20 degrees; and a 30 percent evaluation is assigned for a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5257 (other impairment of the knee) assigns a 30 percent evaluation for severe recurrent subluxation or lateral instability; a 20 percent evaluation for moderate recurrent subluxation or lateral instability; and a 10 percent evaluation for slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a 10 percent evaluation is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, limitation of flexion of the leg is noncompensable where flexion is limited to 60 degrees. A 10 percent evaluation is warranted where flexion is limited to 45 degrees; a 20 percent evaluation is warranted where flexion is limited to 30 degrees; and a 30 percent evaluation is warranted where flexion is limited to 15 percent. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261 (limitation of extension of the leg), a 10 percent rating is warranted where extension is limited to 10 degrees; a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a. VA's Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban, 6 Vet. App. at 262. VA's General Counsel interpreted that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97. In VAOPGCPREC 9-98, VA's General Counsel reiterated that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, the General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 38 C.F.R. § 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004. Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Increased Rating Analysis The Veteran is currently in receipt of noncompensable evaluations for right and left knee patellofemoral syndrome. He contends that initial compensible ratings are warranted for the service-connected right and left knees under the provisions of 38 C.F.R. § 4.59. In November 2012, the Court granted a Joint Motion for Partial Remand, and the part of the Board's decision that denied compensable ratings for right and left knee patellofemoral syndrome was vacated and remanded for action consistent with the terms of the Joint Motion. The Joint Motion provides that the Board erred by failing to consider whether right and left knee disabilities are entitled to compensable evaluations for painful motion under 38 C.F.R. § 4.59, noting the Veteran's complaints of bilateral knee pain on several occasions. A Court remand is meant to entail a critical examination of the justification for the decision. See Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991). After a review of all the evidence, lay and medical, the Board finds that for the entire rating period, service-connected right and left knee patellofemoral syndrome is manifested by chronic, low-grade bilateral knee pain, poor patellar tracking in the bilateral knees, and full extension to 0 degrees and full flexion to 140 degrees in both knees without pain. There were no additional limitations to range of motion on repetition due to pain, fatigue, incoordination, weakness, or lack of endurance. The Veteran had normal x-rays of the right and left knees with no evidence of arthritic changes. During a March 2008 VA examination, the Veteran reported weakness, stiffness, giving way, lack of endurance, fatigability, and intermittent pain in the bilateral knees. Pain was elicited with physical activity and was relieved with rest and ibuprofen. The Veteran had no prosthetic implants. Examination of the bilateral knees revealed no heat, redness, swelling, effusion, or drainage. There was positive J-sign bilaterally consistent with poor patellar tracking and patellofemoral syndrome. Range of motion was normal bilaterally with 0 degrees extension and 140 degrees flexion. Range of motion was not limited by repetitive use, pain, fatigue, weakness, lack of endurance, or incoordination. The VA examiner could not determine any additional limitation in range of motion caused by flare-ups. Medial and lateral collateral ligaments were stable to varus and valgus stress testing. Drawer test and McMurray tests were within normal limits. X-rays of the right and left knee were normal with normal articulating surface of the distal femur and proximal tibia and patella. There were no arthritic changes, fractures or lesions. The Veteran was diagnosed with bilateral patellofemoral syndrome, consistent with examination findings and x-rays. During a January 2009 VA examination, the Veteran reported dull, aching pain or low-grade pain in the bilateral knees which occurred daily. He took Motrin for pain. The Veteran had 145 degrees flexion and 0 degrees extension in the right knee without any pain on range of motion testing. He had 140 degrees flexion and 0 degrees extension in the left knee without any pain on range of motion testing. The Veteran's knees were stable to valgus, varus, and anterior drawer testing. He reported crepitus without pain in the knees on manipulation bilaterally. There was no change in active or passive range of motion during repeat motion testing, and no additional loss of range of motion due to pain, weakness, impaired endurance, fatigue, incoordination or flare-ups. The Veteran was diagnosed with bilateral knee patellofemoral pain syndrome that was intermittent, not worsening on examination that day. In a July 2008 statement, the Veteran reported stiffness and pain in the bilateral knees. During a DRO informal conference hearing, the Veteran reported that his back and knee disabilities limited his physical activities. The Veteran had a dull aching in his knees which was always present. He reported that sleeping was a problem, and that he slept with a pillow between the knees. He reported some giving way in the knees. The Board finds that a compensable evaluation is not warranted under Diagnostic Codes 5260 or 5261 for right knee or left knee patellofemoral syndrome. Evidence of record shows that right and left knee patellofemoral syndrome is characterized by chronic, low-grade knee pain. VA examinations dated in March 2008 and January 2009 reflect full extension in the bilateral knees to 0 degrees without pain and full flexion to 140 degrees without pain. Both VA examinations show that joint function in the bilateral knees was not additionally limited by pain, fatigue, weakness, or lack of endurance after repetitive use, and there was no change in range of motion testing after repetitive use. A 10 percent evaluation under Diagnostic Code 5260 is assigned for flexion limited to 45 degrees and a 10 percent evaluation under Diagnostic Code 5261 is assigned for extension limited to 10 degrees. The Board finds that the Veteran's disability does not approximate 140 degrees flexion or 10 degrees extension in the right or left knee, even with consideration of his functional limitations due to pain and other factors to warrant a 10 percent rating under Diagnostic Code 5260 or 5261. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). In compliance with the November 2012 Court remand and Joint Motion, the Board has considered whether, in the absence of limitation of motion in the knees, whether separate 10 percent evaluations may be granted under 38 C.F.R. § 4.59. Section 4.59 provides, in that the intent of the rating 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. The Veteran is shown to have pain and poor patellar tracking consistent with patellofemoral syndrome as shown by a March 2008 VA examination. He has consistently reported having symptoms chronic pain in the knee joints bilaterally, described as a dull or aching pain, and the Board finds that these reports of pain are credible and consistent with the Veteran's diagnosis of patellofemoral syndrome. A January 2009 VA examination indicated crepitus in the knee without pain. Resolving reasonable doubt in the Veteran's favor, the Board finds that patellofemoral syndrome in both knees approximates actually painful and malaligned knee joints as described Section 4.59, warranting a compensable 10 percent rating for each joint. Resolving reasonable doubt in the Veteran's favor, the Board finds that separate 10 percent evaluations are warranted under for right and left patellofemoral syndrome based on painful motion under 38 C.F.R. § 4.59. See also 38 C.F.R. § 4.71, Diagnostic Codes 5260, 5261. The Board finds that a separate or higher evaluation under Diagnostic Code 5260 or 5261 is not warranted. As discussed above, the Veteran did not meet or approximate the criteria for a compensable rating under Diagnostic Codes 5260 or 5261 based on limitation of motion in the knee, and the 10 percent evaluations assigned under the provisions of 38 C.F.R. § 4.59 were assigned based on painful and malaligned knee joints in the absence of compensable limitation of motion in the left and right knees. VA examinations reflect full range of motion in the knees and the Board finds that the Veteran did not have additional functional loss in the bilateral knees due to flare-ups of pain, fatigability, incoordination, pain on movement, or weakness. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206. Even with consideration of pain and other factors on repetitive use, the Veteran was able to complete 140 degrees flexion and 0 degrees extension bilaterally such that his disabilities do not approximate even a compensable rating under Diagnostic Code 5260 and 5261; thus, the Board finds that higher ratings are not warranted under Diagnostic Code 5260 and 5261. Moreover, the Veteran's symptoms of pain and painful motion have already been considered in assigning his 10 percent evaluations under the provisions of 38 C.F.R. § 4.59. For these reasons, the Board finds that, even with consideration of functional loss due to pain, weakness, and fatigability, and painful motion, service-connected right and left knee disabilities do not more nearly approximate the criteria for separate or compensable ratings based on limited flexion or extension under either Diagnostic Code 5260 or Diagnostic Code 5261. See 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71a. The Board has considered whether separate compensable evaluations are warranted for either the left or right knees under other applicable provisions of the Diagnostic Code. The evidence of record does not reflect ankylosis of the left or right knee to warrant an evaluation under Diagnostic Codes 5256. See 38 C.F.R. § 4.71a. VA examinations show that the Veteran has measurable range of motion in both knee joints without ankylosis. The Board finds that the Veteran does not have recurrent subluxation or lateral instability of either the right or left knee to warrant a compensable evaluation under Diagnostic Code 5257. See 38 C.F.R. § 4.71a. Although the Veteran reported some giving way of the knees, there was no recurrent subluxation or lateral instability shown on objective examination of the knee, and poor patellar tracking noted during the March 2008 examination did not result in subluxation or lateral instability. Both March 2008 and January 2009 VA examinations show that the Veteran's knees were stable to valgus, varus, and anterior drawer testing, and McMurray's test was within normal limits. Although the Veteran is competent to report giving way in the knees; contrary to his report, physical examinations did showed no recurrent subluxation or lateral instability in either knee. The Board finds that physical examinations of the knees showing that the knees were stable on objective testing for subluxation and instability outweigh the probative value of the Veteran's self-report. In the absence of recurrent subluxation and lateral instability in the bilateral knees, pathology in the knees, evidenced by poor patellar tracking, was considered in granting the Veteran's separate 10 percent ratings under 38 C.F.R. § 4.59 on the basis of pain or painful motion in the knee. For these reasons, the Board finds that for the entire rating period, the Veteran's right and left knee disability have not met or more nearly approximated the criteria for separate 10 percent disability ratings under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board finds that the evidence does not show dislocated semilunar cartilage or removal of semilunar cartilage in the right or left knee to warrant an evaluation under Diagnostic Codes 5258 or 5259. See 38 C.F.R. § 4.71a. March 2008 and January 2009 x-rays do not reflect dislocated semilunar cartilage or removal of semilunar cartilage in the knees. The evidence of record does not reflect surgery to the right or left knee at any time, and the Veteran has not otherwise been diagnosed with a meniscal abnormality in the either knee. For these reasons the Board finds that a separate evaluation is not warranted under Diagnostic Code 5258 or 5259. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, 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. 38 C.F.R. 3.321(b)(1). The Board finds that the symptomatology and impairment caused by right and left knee patellofemoral syndrome are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, including Diagnostic Codes 5258, 5259, 5260, and 5261, specifically provide for disability ratings based on limitation of motion and function, instability, or subluxation, and on specific abnormalities, including due to pain and other orthopedic factors. See 38 C.F.R. §§ 4.21, 4.40, 4.45, 4.59 (2013); see also DeLuca. In this case, considering the lay and medical evidence, the Veteran's knee disabilities have been manifested by pain with no limitations to range of motion in the knee or knee function due to pain, and no instability or subluxation. The Veteran's symptoms are contemplated by the schedular rating criteria. The Board has additionally considered ratings under alternate schedular rating criteria as discussed above. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology). Additionally, the Board has considered the Veteran's functional limitations described in lay statements and noted during VA examinations, to include limitations to performing physical activities and avoiding activities that may cause flare-ups of pain. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. The Board finds that the functional limitations imposed by the Veteran's disabilities are specifically contemplated by the criteria discussed above, including the effect of bilateral knee pain and associated limitations on his occupation and daily life. In the absence of exceptional factors associated with the knee disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A 10 percent rating, but no more, is granted for right knee patellofemoral syndrome subject to the law and regulations governing the payment of monetary benefits. A 10 percent rating, but no more, is granted for left knee patellofemoral syndrome subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs