Citation Nr: 1336875 Decision Date: 11/13/13 Archive Date: 11/26/13 DOCKET NO. 08-12 675 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE Entitlement to a higher initial rating in excess of 20 percent for service-connected right knee chondromalacia and retropatellar pain syndrome. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from November 1983 to January 2004, when he retired. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2004 rating decision of the RO in St. Petersburg, Florida which granted service connection and a 10 percent rating for right knee chondromalacia and retropatellar pain syndrome, effective February 1, 2004. The Veteran appealed for a higher initial rating. In a July 2006 decision, the RO granted a higher 20 percent rating for the service-connected right knee disability, effective February 1, 2004. As the highest possible rating was not assigned for the right knee disability, the issue of entitlement to a higher rating remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (a Veteran is presumed to be seeking the highest possible rating unless he expressly indicates otherwise). In November 2012, the Board remanded this case to the RO via the Appeals Management Center (AMC) for additional development, and the case was subsequently returned to the Board. A review of the Veteran's electronic Virtual VA folder reflects that while this case was pending at the AMC, the RO adjudicated other claims, and obtained additional evidence regarding those claims. As this evidence is not relevant to the issue of entitlement to a higher initial rating for a right knee disability, the Board finds that a remand of this appeal for initial RO review in the context of the instant appeal is not required. FINDINGS OF FACT 1. The Veteran's right knee has no more than slight recurrent subluxation or lateral instability. 2. As of December 20, 2012, there has been confirmation of arthritis in the right knee, in addition to the slight recurrent subluxation or lateral instability, although he has continued to have full extension, and flexion limited to no worse than 125 degrees, even with consideration of excess fatigability and pain. CONCLUSIONS OF LAW 1. The criteria are not met for a rating higher than 20 percent for the instability and subluxation component of the Veteran's right knee disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). 2. From December 20, 2012 onwards, the criteria are met for a separate 10 percent rating for arthritis of the right knee. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012); VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997); VAOPGCPREC 9-98 (August 14, 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). This case comes to the Board on appeal from a January 2004 decision that was issued as part of the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. It does not appear that the Veteran was given VCAA notice regarding his initial claim for service connection, prior to the January 2004 rating decision on appeal. However, in cases such as this, where service connection has been granted and initial disability ratings and effective dates have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008). Neither the appellant nor his representative has advanced any such arguments. The provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case (SOC) if the disagreement is not resolved. And this has been done; the Veteran has received both an SOC and supplemental statements of the case, most recently in February 2013, discussing the downstream disability rating element of his claim, citing the applicable statutes and regulations, and discussing the reasons and bases for assigning the initial rating for his service-connected right knee disability. Moreover, additional notice was sent in letters dated in July 2004 and May 2008. Thus, based on the record as a whole, the Board finds that a reasonable person would have understood from the information that VA provided to the appellant what was necessary to substantiate his claim, and as such, that he had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication was not affected. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Here, the appellant's private and VA medical treatment records and private medical records have been associated with the claims file. The appellant was afforded VA medical examinations in April 2005 and December 2012. A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). These examinations were conducted by medical professionals, and the associated reports reflect review of the appellant's prior medical history. The examinations included a report of the symptoms for the right knee and demonstrated objective evaluations. The examiners were able to assess and record the clinical status of the Veteran's right knee disability. Physical examination was accomplished. The Board finds that the examination reports were each sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. In addition, it is not shown that the examinations were in any way incorrectly conducted. Further, the VA examination reports addressed the applicable rating criteria. As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). A Court or Board remand confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, the AMC arranged for a VA medical examination as directed by the Board's November 2012 remand, and VA treatment records were obtained. Therefore, substantial compliance has been achieved. VA has complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. Analysis The Veteran contends that his right knee disability is more disabling than currently evaluated. In his written statements, he asserts that his right knee frequently gives out if he walks briskly, or for an extended period of time. He reports severe pain with bicycle riding or using exercise equipment, and states that he cannot run or jog due to right knee pain. He states that he avoids carrying anything of significant weight or jumping due to right knee pain. In March 2005, he said his ability to climb stairs and carry heavy items was limited by the pain in his right knee. In April 2007, he said his knee sometimes gave way. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. 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 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). 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. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). The basis of disability evaluation 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. Governing law provides that the evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14 (2012). When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). This case arises from an appeal of the initial grant of service connection and assignment of disability ratings for the service-connected right knee disability. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a Veteran appeals his initial rating, VA must consider whether to "stage" the rating to compensate him for times since the effective date of his award when his disability may have been more severe than at others). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Rather, pain may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Throughout the pendency of this appeal, the Veteran's right knee disability (right knee chondromalacia and retropatellar pain syndrome) has been rated as 20 percent disabling, effective from February 1, 2004, the day after his separation from service, under Diagnostic Code 5257. The January 2004 rating decision reflects that the right knee disability was rated under this Code by analogy, based on pain, even though all knee tests were normal. The July 2006 rating decision assigned a 20 percent rating based on the Veteran's lay reports of knee instability. Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, or a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5010, arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Diagnostic Code 5200 etc.). 38 C.F.R. § 4.71a, Diagnostic Code 5003. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5260 concerns limitation of leg flexion. A noncompensable evaluation is assigned where flexion is limited to 60 degrees. A 10 percent rating is warranted where flexion is limited to 45 degrees. A 20 percent evaluation is for application where flexion is limited to 30 degrees. Finally, a 30 percent rating applies where flexion is limited to 15 degrees. Diagnostic Code 5261, pertaining to limitation of leg extension, is also of relevance here. Under that Code section, a noncompensable evaluation is assigned where extension is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent evaluation is for application where extension is limited to 15 degrees. A 30 percent rating applies where extension is limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. Finally, a 50 percent evaluation is warranted where extension is limited to 45 degrees. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (July 1, 1997; revised July 24, 1997). The General Counsel subsequently clarified in VAOPGCPREC 9-98 (August 14, 1998) that for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. VA's General Counsel further explained that, if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. This is because, read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). VA's General Counsel has additionally held that separate rating may also be assigned for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59, 990 (2004). Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same knee, the limitations must be rated separately to adequately compensate him for functional loss associated with injury to his leg and knee. Id. On VA pre-discharge examination in October 2003, the Veteran complained of right knee pain, and said he could no longer run due to the pain. He reported knee pain when he climbed stairs, and when he rode a bike. On examination, range of motion of the right knee was as follows: flexion from 0 to 140 degrees. There was crepitus with patella movement and complaint of pain with patella movement. Lachman's and McMurray's tests were negative, and drawer sign was negative. The Veteran had good varus and valgus stress end points. The examiner opined that the Veteran's right knee with exercise, fatigue, etc. was more likely than not to result in diminished range of motion by 20 to 30 percent and increase in pain by 20 to 30 percent. The diagnosis was right knee injury/chondromalacia patella and retropatellar pain syndrome, with residual. On VA examination in April 2005, the Veteran complained of right knee pain. He did not use an assistive device or brace. He currently worked full time. Flare-ups occurred approximately every other day. On a good day his pain was at a level of 0 on a range of 0 to 10, which increased to level 6 with activity or stairs, as well as pain with jumping. He was not involved in any regular exercise program. He used Motrin for pain. His activities of daily living were impacted in that he did not enjoy running, jumping and climbing stairs as he used to. On examination of the right knee, there was no evidence of infection or effusion. Range of motion was normal, from 0 to 140 degrees. McMurray's and Apley's tests were negative. The anterior cruciate ligament and posterior cruciate ligaments were intact on anterior and posterior drawer test. The collateral ligaments were stable on varus and valgus stress testing. There was mild patellofemoral crepitance. The examiner noted that he reviewed an April 2005 X-ray study, which was normal. The diagnostic impression was chondromalacia patellofemoral joint. The examiner opined that the Veteran did not have any weakened movement. There was excess fatigability with use with repetitive squatting and bending. However, there was no incoordination of the joint or painful motion passively. The examiner opined that with his restrictions of activities of daily living, he had approximately a 10-degree loss of functional range of motion with repetitive exercise. A February 2008 private physical therapy note reflects that the Veteran complained of bilateral knee pain, right greater than left. On examination, active and passive range of motion of the knees was within normal limits. There was pain at the end of flexion of the right knee. VA outpatient treatment records reflect treatment for complaints of right knee pain. He was provided with a knee brace. An October 2008 VA outpatient treatment record reflects that on examination of the extremities, there was no crepitus, no palpable tenderness, and drawer and Lachman's tests were negative. The examiner diagnosed chronic right knee pain. A November 2009 X-ray study of the right knee showed intact bony structures with no evidence of acute fracture, dislocation, lytic or sclerotic lesions. The joint spaces appeared well-preserved. There were no periarticular erosions. The impression was an unremarkable examination. A November 2009 X-ray study of the right patella was also unremarkable. On VA examination in December 2012, the examiner noted that the claims file was reviewed. The Veteran complained of right knee symptoms including pain at a level of 7 out of 10, which was made worse by stair climbing, laxity, with a recent fall, and crepitus. He denied any interval injury or illness involving the right knee. He currently used topical Capsaicin. He reported flare-ups that affected knee function. On examination, range of motion was as follows: flexion to 125 degrees, with no objective evidence of painful motion, and no limitation of extension (i.e., extension was to 0 degrees), with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions, and had no additional limitation of motion of the knee and lower leg following repetitive-use testing. He had no functional loss and/or functional impairment of the knee and lower leg. The examiner indicated that there was no tenderness or pain to palpation for joint line or soft tissues of the right knee. Strength of the right knee was full in both flexion and extension. The right knee was normal (stable) when tested for anterior instability (Lachman test), posterior instability (posterior drawer test), and medial-lateral instability. The examiner stated that there was no evidence of recurrent patellar subluxation or dislocation. The examiner noted that the Veteran had a history of "shin splints" but had no current symptoms from this. The examiner noted that the Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition, and had no other knee surgery. The Veteran regularly used a knee brace. The examiner indicated that arthritis of the right knee had been documented by an X-ray study, and there was no X-ray evidence of patellar subluxation. The examiner indicated that the knee condition did not impact the Veteran's ability to work. The examiner diagnosed chondromalacia of the right knee. A December 20, 2012 X-ray study of the right knee showed no fracture or dislocation. Minimal patellar spurs were noted with degenerative change. There was no joint effusion, and the soft tissues appeared unremarkable. There was a stable appearance since the previous study in November 2009. The diagnostic impression was minimal patellar spur with otherwise unremarkable and unchanged examination. The Board is mindful of the Veteran's lay assertions regarding the severity of his right knee disability and his contention that he has instability of the knee. His statements are competent in regard to reports of symptoms and credible to the extent of the Veteran's sincere belief that his symptoms are more severe than what his current rating reflects. The Board nevertheless must consider these lay assertions along with the other relevant evidence in the file, including the medical evidence as reflected in the results of his objective medical examinations. As to the presence and degree of any instability, the competent and credible lay evidence is outweighed by the competent and credible objective medical opinions of the examiners as they have expertise in evaluating the severity of his knee disability. After a review of all of the evidence of record, the Board finds that the weight of the competent medical evidence does not show that the Veteran has severe recurrent subluxation or instability in the right knee such as to warrant assignment of a higher 30 percent rating under Diagnostic Code 5257. In fact, all of the VA examiners have indicated that there is no laxity or instability of the right knee. Even considering the Veteran's lay statements, the weight of the evidence shows that the Veteran has, at most, slight recurrent subluxation and lateral instability of his right knee (versus moderate or severe). Hence, a higher rating in excess of 20 percent is not warranted under this code throughout the rating period on appeal. After a review of all of the evidence of record, the Board finds that throughout the rating period on appeal, the range of motion findings detailed above do not warrant a compensable rating under the Diagnostic Codes pertaining to limitation of motion, as active range of motion of the right knee was from 0 to 140 degrees (i.e., full range of motion) on VA pre-discharge examination in October 2003, and on VA examination in April 2005. Range of motion was full on private examination in February 2008, even with consideration of pain. Range of motion was from 0 to 125 degrees on VA examination in December 2012, even after repetitive motion. And even accepting that he had less than normal flexion of this knee during that examination, this still far exceeds the flexion limitation required for even the most minimum 0 percent rating under Diagnostic Code 5260 since flexion must be limited to 60 degrees. There was no objective evidence of painful motion, however. The record reflects that the Veteran has consistently reported chronic right knee pain. Functional loss due to pain is rated at the same level as functional loss where motion is impeded. See Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). But, here, the December 2012 VA examiner indicated that the Veteran had no objective evidence of painful motion, no additional limitation of motion of the knee and lower leg following repetitive-use testing, and no functional loss and/or functional impairment of the knee and lower leg. So there was no range of motion loss, i.e., any additional restriction of motion, even with these repetitions. And, again, although pain may cause functional loss, pain itself does not constitute functional loss. Mitchell, supra. Rather, 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.; see also 38 C.F.R. § 4.40. However, with resolution of doubt in the Veteran's favor, and considering his reports of knee pain, the Board finds that as of December 20, 2012, since the Veteran has X-ray evidence of arthritis in the right knee, with associated pain, Diagnostic Code 5003 in combination with 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion - or, in this particular instance, insufficient limitation of motion to warrant a compensable rating under Diagnostic Code 5260 or 5261. See again Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Hence, since he now has osteoarthritis in this knee in addition to the instability, he is entitled to the minimum compensable rating of 10 percent for this arthritis (i.e., additional disability) under Diagnostic Code 5003, aside from the 20 percent rating he already has under Diagnostic Code 5257. See VAOPGCPRECs 23-97 and 9-98. The fact that he continues to have normal extension of this knee, to 0 degrees, precludes also assigning a separate rating as concerning his extension, apart from this additional rating that is being assigned for his flexion limitation on account of his underlying arthritis. VAOPGCPREC 9-2004. Moreover, because there continues to be substantial range of motion of this knee, even considering the arthritic pain and the fact that motion is now from 0 to 125 degrees rather than to the normal 140 degrees, this knee obviously is not ankylosed. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999). Thus, Diagnostic Code 5256 does not apply. Similarly, as the evidence fails to demonstrate nonunion or malunion of the tibia or fibula, a higher rating is not possible under Diagnostic Code 5262. Additionally, as there is no showing of genu recurvatum, Diagnostic Code 5263 is inapplicable. Moreover, as the evidence fails to demonstrate a dislocated semilunar cartilage, or removal of such, Diagnostic Codes 5258 and 5259 are inapplicable. On VA examination in December 2012, there was no meniscus abnormality. There are no other relevant codes for consideration. The Board thus is assigning a separate 10 percent rating for the right knee osteoarthritis under Diagnostic Code 5003 effective December 20, 2012, the date of the VA X-ray study diagnosing arthritis of the right knee. This rating is in addition to the existing 20 percent rating under Diagnostic Code 5257 for the instability and subluxation of this knee which is no more than moderate. The preponderance of the evidence is against granting even greater compensation, however. 38 C.F.R. § 4.3. See also Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Extraschedular Considerations The Board also finds that the circumstances of this case are not so exceptional or unusual as to render impractical the application of the regular schedular standards and warrant referral of this claim to the Director of Compensation and Pension Service or the Under Secretary for Benefits for consideration of an extra-schedular evaluation. 38 C.F.R. § 3.321(b)(1). The schedular rating criteria for the Veteran's right knee disability reasonably describe and contemplate the extent and severity of this disability, including insofar as his specific symptoms (e.g., pain, subluxation, and limitation of motion, etc.) since they are considered in the applicable Diagnostic Codes 5003, 5010, 5257, 5260, and 5261. See Thun v. Peake, 22 Vet. App. 111 (2008). As such, there is no obligation to refer this claim for extra-schedular consideration. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A higher rating in excess of 20 percent for the instability and subluxation component of the Veteran's right knee disability is denied. A separate 10 percent rating is granted as of December 20, 2012, based on arthritis in the right knee, subject to the statutes and regulations governing the payment of VA compensation. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs