Citation Nr: 1337847 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 13-15 445 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for residuals of right knee replacement. 2. Entitlement to a compensable initial rating for right knee scarring. ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from June 1972 to June 1974. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office in Muskogee, Oklahoma (RO). FINDINGS OF FACT 1. The Veteran's service-connected residuals of right knee replacement were as follows: pain, stiffness, weakness, swelling, and crepitus, with a range of motion from zero degrees of extension to between 86 and 90 degrees of flexion, with additional functional loss or additional functional impairment following repetitive range of motion testing due to weakened movement, pain on movement, deformity, and disturbance of locomotion. 2. The Veteran's service-connected right knee scarring was manifested by 5 scars located on various aspects of his right knee, each of which was linear and superficial, with no underlying tissue damage. The scars did not limit the Veteran's motion, and there was no limitation of function due to the scars. The total area of the scars was approximately 7.0 square centimeters, with no one scar accounting for more than 1.9 square centimeters CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for residuals of right knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Code 5055 (2013). 2. The criteria for a compensable initial rating for right knee scarring have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.118, Diagnostic Code 7805 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Because the October 2011 rating decision granted the Veteran's claims of entitlement to service connection, such claims are now substantiated. His filing of a notice of disagreement as to the October 2011 determinations does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2013). Rather, the Veteran's appeal as to the initial rating assignments triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. The March 2013 statement of the case under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," provided notice to the Veteran regarding the applicable diagnostic codes, including a description of the rating formulas and the evidentiary requirements for obtaining higher ratings. Specifically, the notice provided to the Veteran included 38 C.F.R. § 4.71a, Diagnostic Code 5055, which is the diagnostic code used to evaluate knee replacements. He was also provided notice of 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, and 5256, which concern knee range of motion and ankylosis. Further, the Veteran was provided notice of 38 C.F.R. § 4.118, Diagnostic Code 7805, which concerns scars, other, and other effects of scars evaluated under 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, and 7804. The Veteran was, thus, informed of what was needed not only to achieve the next higher schedular rating, but also to obtain all schedular ratings above the ratings that have already been assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve higher ratings for the service-connected disabilities at issue. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Further, there was no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. Indeed, the Veteran submitted a notice response form, dated in June 2011, wherein he indicated that he had no other information or evidence to submit in support of his claims. The Veteran underwent adequate VA examinations in September 2011 and February 2013 in order to ascertain the severity of his service-connected residuals of right knee replacement and right knee scarring. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examiners reviewed the relevant evidence of record, including the Veteran' statements, and administered thorough clinical examinations, which allowed for fully-informed evaluations of the claimed disabilities. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2013). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. This involves a factual determination of the current severity of the disability. Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21. Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). I. Residuals of Right Knee Replacement According to 38 C.F.R. § 4.71a, Diagnostic Code 5055, which governs the rating assigned to impairment arising from the prosthetic replacement of a knee joint, a 100 percent disability rating will be assigned for one year following the implantation of a knee prosthesis. The evidence of record demonstrated that the Veteran underwent right knee replacement on June 2, 2008. He did not file a claim of entitlement to service connection for right knee disability until May 28, 2011. While Diagnostic Code 5055 provides for a 100 percent rating for the year following the date of the knee replacement operation, in the Veteran's case, this spans from June 2, 2008 to June 2, 2009. However, because he did not submit a claim of entitlement to service connection for right knee disability until May 28, 2011, which is more than one year after his right knee replacement surgery, the 100 percent rating is not for application. After this one-year period, the minimum disability rating which may be assigned is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. With intermediate degrees of residual weakness, pain or limitation of motion, adjudicators are instructed to rate by analogy to knee ankylosis, limitation of leg extension, or impairment of the tibia and fibula. 38 C.F.R. § 4.71a, Diagnostic Codes 5055, 5256, 5261, 5262 (2013). Normal flexion of the knee is to 140 degrees, and normal extension of the knee is to 0 degrees. See 38 C.F.R. § 4.71, Plate II (2013). Limitation of knee motion is evaluated as noncompensable if there is more than 45 degrees flexion and less than 10 degrees extension. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. A 10 percent evaluation is warranted when extension is limited to 10 degrees or when flexion is limited to 45 degrees. Id. A 20 percent evaluation is for application when extension is limited to 15 degrees or when flexion is limited to 45 degrees. Id. A 30 percent evaluation is warranted when extension is limited to 20 degrees or when flexion is limited to 15 degrees. Id. A 40 percent rating is warranted when extension is limited to 30 degrees. A 50 percent rating is warranted when extension is limited to 45 degrees. Moreover, separate ratings for knee extension and flexion can be assigned. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). The RO assigned the minimum 30 percent rating to the Veteran's service-connected residuals of right knee replacement, effective May 28, 2011. In order for a higher rating to be assigned, the evidence of record dated after May 28, 2011, must demonstrate ankylosis in flexion between 10 degrees and 20 degrees; or extension limited to at least 30 degrees; or nonunion of the tibia and fibula, with loose motion, requiring a brace. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, 5262. The evidence of record does not demonstrate that the Veteran's right knee was manifested by ankylosis or a nonunion of the tibia and fibula, with loose motion. Further, range of motion testing during the September 2011 March 2013 VA and examinations showed right knee extension to zero degrees. Consequently, a rating in excess of 30 percent for the Veteran's residuals of right knee replacement, on and after May 28, 2011, is not warranted pursuant to Diagnostic Codes 5256, 5261, 5262. Following the one-year, 100 percent rating, the maximum available rating under Diagnostic Code 5055 is 60 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. To warrant a 60 percent rating, the evidence of record must demonstrate chronic residuals consisting of severe painful motion or weakness. Id. The Board observes that the word "severe" is not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). In September 2011, the Veteran underwent a VA examination to ascertain the severity of his residuals of right knee replacement. During the examination, the Veteran reported that he experienced painful motion and weakness since the June 2, 2008 replacement surgery. With respect to functional impairment, the Veteran stated that he had to retire early. Further, he complained of decreased range of motion and difficulty getting in and out of cars, climbing stairs, running, jogging, and prolonged sitting. Physical examination demonstrated that the Veteran walked with a normal gait. There were no signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe-wear pattern. The Veteran did not require an assistive device to ambulate. Range of motion testing revealed abnormal movement and guarding of movement. There were no signs of edema, instability, effusion, weakness, tenderness, redness, heat, deformity, mal-alignment, drainage, or subluxation. The examiner noted the presence of crepitus, but no genu recurvatum or locking pains. Right knee range of motion was from zero degrees of extension to 86 degrees of flexion, with pain at 86 degrees. These measurements remained the same following repetitive range of motion testing. The examiner then stated that the Veteran's right knee function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. A radiological examination of the Veteran's right knee revealed no mal-alignment, and a small osteophytic spur at the superior patella. The diagnosis was status post knee replacement with residual scars and decreased and painful range of motion and a hypertrophic spur at the patella. In February 2013, the Veteran underwent another VA examination to ascertain the severity of his service-connected residuals of right knee replacement. The Veteran reported constant weakness, reduced range of motion, pain, and swelling. Range of motion testing demonstrated a range of motion from zero degrees of extension to 90 degrees of flexion. These findings remained unchanged following repetitive range of motion testing. The examiner then determined that the Veteran did not experience additional limitation in his range of motion following repetitive range of motion testing, but that the Veteran experienced additional functional loss or additional functional impairment following repetitive range of motion testing due to weakened movement, pain on movement, deformity, and disturbance of locomotion. Right knee extension and flexion were scored 5/5 with respect to muscle strength, which is normal. Additionally, stability testing, including anterior, posterior, and medial-lateral, was normal. The examiner found no subluxation. Significantly, the examiner then indicated that the Veteran's right knee replacement residuals were "intermediate degrees of residual weakness, pain, or limitation of motion." The examiner was provided the option of indicating that the Veteran's residuals of right knee replacement constituted "chronic residuals consisting of severe painful motion or weakness," but chose the intermediate level. After the examiner reviewed radiological studies, the assessment was right knee replacement without mal-alignment or acute fracture and mild degenerative irregularity at the superior patella. The examiner then opined that the Veteran's service-connected residuals of right knee replacement impaired his ability to work through the limitation of walking and standing. Based on the above, the Board finds that the Veteran's right knee disability was not manifested by severe painful motion or weakness on or after May 28, 2011. While the Board does not doubt that the Veteran experiences both pain and weakness as residuals of his right knee replacement, the degree of that pain and weakness is the salient issue. The Board finds that the Veteran is both competent and credible to report that he is experiencing pain and weakness. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a veteran's statements are competent evidence of what comes to him/her through his/her senses). However, measuring the severity of symptoms is more suited to the realm of medical, rather than lay expertise. The characterization of the severity of symptoms is too complex for a layperson to proffer a competent opinion, especially in the presence of contraindicating clinical findings such as normal muscle strength. The evidence of record does not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide such opinions. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Thus, the Board is persuaded by the clinical findings from the September 2011 and March 2013 VA examinations and the VA examiners' opinions. Consequently, the criteria for the maximum 60 percent rating under Diagnostic Code 5055 have not been met and, thus, a rating in excess of 30 percent rating is not warranted for the Veteran's residuals of right knee replacement on and after May 28, 2011. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board considered an increased evaluation for the Veteran's right knee disability, on and after May 28, 2011, under other potentially applicable diagnostic codes. Schafrath, 1 Vet. App. at 595. However, a rating in excess of 30 percent is not available under Diagnostic Codes 5257, 5258, 5259, 5260, or 5263. 38 C.F.R. § 4.71a. Consequently, an evaluation in excess 30 percent for the Veteran's right knee disability on and after May 28, 2011 is not warranted under these diagnostic codes. The Board has also considered whether there was any additional functional loss not contemplated in the 30 percent evaluation for the Veteran's right knee disability on and after May 28, 2011. See 38 C.F.R. §§ 4.40, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 205-206 (1995). After repetitive extension and flexion during the September 2011 and February 2012 VA examinations, the Veteran's range of right knee motion remained the same. The September 2011 VA examiner opined that the Veteran's right knee function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The February 2013 VA examination found no additional limitation in the Veteran's range of motion after repetitive use, but that there was additional functional loss or functional impairment due to weakened movement, pain on movement, deformity, and disturbance in locomotion. See Mitchell v. Shinseki, 25 Vet. App. 32, 37-44 (2011) (holding that pain itself is not functional loss, but can cause functional loss to the extent that it affects the normal working movements of the body such as excursion, strength, speed, coordination, or endurance). The February 2013 VA examiner also opined that the Veteran's residuals of right knee replacement impaired his ability to work by limiting his ability to walk and stand. Even with consideration of the Veteran's assertions and the February 2013 VA examiner's findings, the Board finds that the Veteran's right knee symptomatology did not meet or more nearly approximate the criteria for a higher rating under any applicable diagnostic code and, thus, a rating in excess of 30 percent is not warranted. 38 C.F.R. §§ 4.7, 4.40, 4.59, 4.71a, Diagnostic Code 5055, 5256, 5262; DeLuca, 8 Vet. App. at 205-206. II. Right Knee Scarring In the October 2011 rating decision, service connection for the Veteran's right knee scarring was granted and a noncompensable rating was assigned thereto, effective May 28, 2011. The Veteran perfected an appeal of this decision, seeking a compensable initial rating. Given the location of the Veteran's service-connected scarring at issue herein, the right knee, evaluation under 38 C.F.R. § 4.118, Diagnostic Code 7800 (2013), which concerns the head, face, or neck, is inapplicable. Further, the evidence of record does not indicate that the Veteran's scarring is marked by deep, nonlinear, unstable, or painful scars. As such, 38 C.F.R. § 4.118, Diagnostic Codes 7801-7804 (2013) are also inapplicable. Consequently, the Veteran's service-connected right knee scarring most appropriately evaluated pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7805, which requires any disabling effects associated with the Veteran's right knee scarring to be evaluated under the appropriate diagnostic code. Consequently, the Board must ascertain the nature of any disability effects associated with the Veteran's right knee scarring. In September 2011, the Veteran underwent a VA examination. The examiner observed 5 scars located on various aspects of the Veteran's right knee. The examiner described each of these scars as linear and superficial, with no underlying tissue damage. The scars were not painful upon examination; there was no breakdown; no inflammation; no edema; no keloid formation; and none of them were disfiguring. The examiner also stated that the scars did not limit the Veteran's motion and, further, there was no limitation of function due to the scars. The examiner provided the following measurements for the scars: (1) 19.0 centimeters by 0.1 centimeters; (2) 6.0 centimeters by 0.2 centimeters; (3) 6.0 centimeters by 0.2 centimeters; (4) 7.0 centimeters by 0.2 centimeters; and (5) 6.0 centimeters by 0.2 centimeters. In February 2013, the Veteran underwent another VA examination. The examiner observed 5 scars on the Veteran's right knee that were characterized as linear. The examiner provided the following measurements: (1) 19 centimeters; (2) 6.5 centimeters; (3) 6.0 centimeters; (4) 4.5 centimeters; and (5) 7.0 centimeters. After a clinical evaluation, the examiner stated that there no changes in the Veteran's service-connected right knee scarring and, significantly, stated that the scars were asymptomatic. Based on the above, the Board finds that the Veteran's service-connected right knee scarring is not productive of disabling effects warranting evaluation under any specific diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. Despite this, the Board will evaluate the Veteran's right knee scarring by analogy. See 38 C.F.R. § 4.20 (2013) (permitting evaluation, by analogy, where the rating schedule does not provide a specific diagnostic code to rate the disability); see also Schafrath, 1 Vet. App. at 595. Evaluating the Veteran's scars under Diagnostic Code 7802, which concerns superficial, nonlinear scars not of the head, neck, or face, the evidence of record must demonstrate that the scars amount to a total area of at least 929 square centimeters in order to warrant a compensable rating. Similarly, pursuant to Diagnostic Code 7801, which concerns deep, nonlinear scars not of the head, neck, or face, the evidence must demonstrated that the Veteran's right knee scars amount to at least 39 square centimeters in order for a compensable rating to be assigned. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802. However, even using the measurements most favorable to the Veteran from the September 2011 and February 2013 VA examiners, the Veteran's right knee scars have a total area of approximately 7.0 square centimeters, with no individual scar having an area in excess of 1.9 square centimeters. Based on the above, the Board finds that the evidence of record included no basis upon which to grant an initial compensable rating for the Veteran's service-connected right knee scarring. Further, the symptoms associated with the Veteran's service-connected right knee scarring did not more nearly approximate the criteria for a compensable rating under any relevant or analogous diagnostic code. Thus, the Board finds that the claim must be denied. 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7801, 7802, 7805. III. Extraschedular Generally, evaluating a disability using either the corresponding or an analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates then the Veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability pictures are not so unusual or exceptional in nature as to render the assigned ratings inadequate. The Veteran's service-connected residuals of right knee replacement are evaluated as a musculoskeletal disability pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5055, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. Throughout the pendency of this appeal, the Veteran's service-connected residuals of right knee replacement were pain, stiffness, weakness, swelling, and crepitus. Additionally, range of motion testing revealed abnormal movement and guarding of movement. Moreover, right knee range of motion was from zero degrees of extension to between 86 and 90 degrees of flexion. There was no additional limitation of range of motion following repetitive range of motion testing, but the Veteran experienced additional functional loss or additional functional impairment following repetitive range of motion testing due to weakened movement, pain on movement, deformity, and disturbance of locomotion. The evidence of record also demonstrated that the symptoms associated with the Veteran's right knee replacement were normal gait; normal muscle strength; no signs of abnormal weight bearing or breakdown; no callosities; no unusual shoe-wear pattern; no signs of edema; no instability; no tenderness; no redness; no heat; no mal-alignment; no drainage; no subluxation; and no locking pains. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by a 30 percent rating. Ratings in excess of the one already assigned are provided for certain manifestations of residuals of right knee replacement, but the evidence demonstrated that those manifestations are not present here. The criteria for the assigned rating reasonably describe the Veteran's disability level and symptomatology. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.71a, Diagnostic Code 5055; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). The Veteran's service-connected right knee scarring is evaluated as a skin disability pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7805, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by his disability. Id. The evidence of record demonstrated that the Veteran had 5 scars on his right knee, each of which was linear and superficial, with no underlying tissue damage. The scars were not painful; there was no breakdown; no inflammation; no edema; no keloid formation; and none of them were disfiguring. The scars did not limit the Veteran's motion and, further, there was no limitation of function due to the scars. The total area of the scars was approximately 7.0 square centimeters, with no one scar accounting for more than 1.9 square centimeters. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences warrant a noncompensable rating. Compensable ratings are provided for certain manifestations of right knee scarring, but the evidence demonstrated that those manifestations are not present here. The evidence did not demonstrate the Veteran's right knee scarring resulted in any specific disabling effect and were characterized as asymptomatic by the February 2013 VA examiner. Consequently, the Board concludes that a schedular evaluation is adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.118, Diagnostic Code 7805; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749. Even if the Veteran's disability pictures are not adequately addressed by the rating criteria, in order for a referral for extraschedular consideration to be warranted, the evidence must also demonstrate marked interference with employment and/or frequent periods of hospitalizations. Id. The evidence of record demonstrated that the Veteran retired from the U.S. Postal Service prior to undergoing the June 2, 2008 right knee replacement. Although he claimed that he was forced to retire before he wanted to, and despite the February 2013 VA examiner's opinion that Veteran's right knee replacement residuals impaired his ability to work, the Veteran has been retired throughout the pendency of this appeal. As such, the evidence does not support finding that the Veteran's residuals of right knee replacement or right knee scarring resulted in marked interfere with the Veteran's employment at any point during the pendency of this appeal. Id. As for hospitalizations, the Veteran underwent the right knee replacement on June 2, 2008. The evidence of record did not demonstrate that the Veteran was otherwise hospitalized. As such, the Board finds that neither the Veteran's service-connected residuals of right knee replacement nor his right knee scarring resulted in frequent periods of hospitalization. Consequently, even if the Veteran's disability picture is not adequately contemplated by the Rating Schedule, referral for extraschedular consideration is not warranted. Thun, 22 Vet. App. at 115. [CONTINUED ON THE NEXT PAGE] Finally, in reaching these decisions, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against initial evaluations in excess of those already assigned to the Veteran's service-connected residuals of right knee replacement and right knee scarring, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 30 percent for residuals of right knee replacement is denied. Entitlement to a compensable initial rating for right knee scarring is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs