Citation Nr: 1338568 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 04-24 587A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent for the service-connected chondromalacia and patella subluxation of the left knee, status post-tubercle transfer, prior to August 20, 2008. 2. Entitlement to a rating in excess of 30 percent for the service-connected residuals of total left knee arthroplasty from October 1, 2009. 3. Entitlement to a rating in excess of 10 percent for the service-connected degenerative changes of the right knee, status post-patellectomy, prior to June 17, 2009. 4. Entitlement to a rating in excess of 30 percent for the service-connected residuals of total right knee arthroplasty from August 1, 2010. 5. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected knee disabilities. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from September 1972 to June 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that denied increased ratings for the service-connected right and left knee disabilities. In July 2006 the Veteran testified before the undersigned Veterans Law Judge in a hearing at the RO ("Travel Board" hearing). A transcript of the hearing is of record. In August 2012 the Board found that a claim for TDIU due to his knee disabilities had been raised by the rating issues on appeal and added this issue. See Rice v. Shinseki, 11 Vet. App. 447 (2009). The Board's action also remanded the issues shown on the title page to the RO for additional development, which has been accomplished. In July 2013, following the RO's most recent readjudication of the issues on appeal, the Veteran submitted additional evidence directly to the Board, with a waiver of initial RO jurisdiction. The Board has accepted this additional evidence for inclusion into the record on appeal. See 38 C.F.R. § 20.800 (2013). The issue of entitlement to a TDIU based on the combined effects of all service connected disabilities has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Prior to August 20, 2008, the Veteran's left knee disability was generally manifested by painful motion, flexion to 90 degrees or better and extension to 0 degrees, without instability. 2. From August 20, 2008 to September 30, 2009, the Veteran's left knee disability was rated as 100 percent disabling post-surgery. 3. From October 1, 2009, the Veteran's left knee disability has been manifested by prosthetic replacement of the knee joint without severe painful motion or weakness and without intermediate degrees of residual weakness, pain or limitation of motion ratable by analogy under the appropriate diagnostic codes. 4. Prior to June 17, 2009, the Veteran's right knee disability was generally manifested by painful motion, flexion to 90 degrees or better and extension to 0 degrees, without instability. 5. From June 17, 2009 to July 31, 2010, the Veteran's right knee disability was rated as 100 percent disabling post-surgery. 6. From August 1, 2010, the Veteran's right knee disability has been manifested by prosthetic replacement of the knee joint without severe painful motion or weakness and without intermediate degrees of residual weakness, pain or limitation of motion ratable by analogy under the appropriate diagnostic codes. 7. The Veteran's service-connected left and right knee disabilities do not render him unable to obtain and maintain gainful employment consistent with his education, training and work experience. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for chondromalacia and patella subluxation of the left knee, status post-tubercle transfer, prior to August 20, 2008, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261 (2013). 2. The criteria for a rating in excess of 30 percent for residuals of total left knee arthroplasty from October 1, 2009, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2013). 3. The criteria for a rating in excess of 10 percent for degenerative changes of the right knee, status post-patellectomy, prior to June 17, 2009, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261 (2013). 4. The criteria for a rating in excess of 30 percent for residuals of total right knee arthroplasty from August 1, 2010, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2013). 5. The criteria for a TDIU due to service connected bilateral knee disabilities are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify a 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. 38 C.F.R. § 3.159(b) (2013). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran in this case has not alleged any prejudice due to the timing or content of the notice provided. See 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). The record also reflects that service treatment records (STRs), disability records from the Social Security Administration (SSA), and available post-service medical evidence identified by the Veteran have been obtained. The Veteran has been afforded appropriate VA examinations in regard to the disabilities and issues on appeal, most recently in May 2013. The Veteran was afforded a hearing before the Board. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the VLJ identified the issues to the Veteran testified as to the severity of his knee disabilities and the impact his conditions have on his employability. Additionally, the Veteran volunteered his relevant treatment history. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claims, and the Veteran provided testimony relevant to those elements. In addition, the Board held the record open for 60 days to permit the Veteran to submit additional treatment records, which were received the following month. As such, the Board finds that no further action pursuant to Bryant is necessary, and the Veteran is not prejudiced by a decision at this time. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the issues on appeal. Evaluation of Service-Connected Disabilities Applicable Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2013); see also 38 C.F.R. §§ 4.45, 4.59 (2013). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Degenerative or traumatic arthritis is rated under the criteria of 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003. Such arthritis is rated based on limitation of motion under the appropriate DC. When limitation of motion is not compensable under the appropriate DC, but there is objective confirmation that motion is limited by swelling, muscle spasm or satisfactory evidence of painful motion, a rating of 10 percent is applicable for each such joint affected. A note to DC 5003 states that the 10 percent rating will not be combined with ratings based on limitation of motion. Prosthetic implants to the knee are rated under the criteria of 38 C.F.R. § 4.71a, DC 5055. The rating criteria are as follows. A rating of 30 percent is the minimum rating. A rating of 60 percent is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity; intermediate degrees of impairment between the criteria for the 30 and 60 percent ratings are to be rated by analogy to DCs 5256, 5261 or 5262. A rating of 100 percent is assigned for one year following implantation of the prosthesis. Instability and subluxation of the knee is rated under DC 5257. A rating of 10 percent is assigned for slight disability; a rating of 20 percent is assigned for moderate disability; and, a rating of 30 percent is assigned for severe disability. 38 C.F.R. § 4.71a. Limitation of flexion of a leg is rated under DC 5260. A rating of 0 percent is assigned for flexion is limited to 60 degrees; a rating of 10 percent is assigned for flexion limited to 45 degrees; a rating of 20 percent is assigned for flexion limited to 30 degrees; and, a rating of 30 percent is assigned for flexion is limited to 15 degrees. Id. Limitation of extension of a leg is rated under DC 5261. A rating of 0 percent is assigned for extension limited to 5 degrees; a rating of 10 percent is assigned for limitation of extension to 10 degrees; a rating of 20 percent is assigned for extension limited to 15 degrees; a rating of 30 percent is assigned for extension limited to 20 degrees; a rating of 40 percent is assigned for extension limited to 30 degrees; and, a rating of 50 percent is assigned for extension limited to 45 degrees. Id. Normal range of motion (ROM) of the knee is extension to 0 degrees and flexion to 140 degrees. 38 C.F.R. § 4.71a, Plate II. Precedent opinions of the VA's General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 FR 59988 (2004)). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Schedular evaluation of left knee prior to August 20, 2008 The Veteran's request for increased rating was received in February 2001. The Veteran had a VA examination in June 2000 during which the examiner noted the Veteran was wearing knee braces bilaterally. The Veteran's left knee was examined in June 2000 by Dr. Rohan. Range of motion (ROM) was 0-120 degrees without significant instability. X-ray showed some spurring. Dr. Rohan's diagnosis was status post-arthroscopic meniscectomy and patella realignment with some arthritis. The Veteran had a VA examination of the left knee in August 2000 in which he complained of difficulty with squatting, kneeling, weightbearing or climbing stairs. ROM was 0-125 degrees with pain; there was no evident decrease in motion with repetitive activity. There was no clinical evidence of instability. Knee strength appeared to be adequate (5/5) on extension and flexion. The examiner's diagnosis was posttraumatic arthritis of the left knee. In an addendum, the examiner stated that X-ray had not shown a significant amount of arthritis in the left knee. A VA clinical note in March 2001 states the Veteran presented for evaluation of need for knee bracing. Examination showed bilateral knee ligamentous laxity, and the Veteran was ordered to be fitted for knee braces. The Veteran presented to the VA pain clinic for evaluation in May 2001. His pain complaints were neck pain, headache, low back pain and bilateral knee pain. The Veteran had a VA occupational therapy consultation in June 2001 in which he endorsed using a left knee brace 60 percent of the time. His reported pain level was 6.5/10 bilaterally. In June 2002 the Veteran complained of knee pain but denied locking. VA X-ray of the left knee in August 2002 showed an impression of postsurgical changes with screw in the proximal right tibia, with no arthritic changes of note. The Veteran testified before the Board in July 2006 that he has severe bone-on-bone pain standing on the left knee and that he wears a knee brace to prevent hyperextension. He endorsed using a cane and stated he was unable to climb, jump or run. The Veteran presented to the VA orthopedic surgery clinic in May 2007 complaining of bilateral knee pain, left worse than right. ROM of the left knee was 0-90 degrees. There was no instability. The clinical impression was bilateral chondromalacia. During VA examination in August 2007 the Veteran reported that his right knee was worse than his left. He reported constant aching, burning, sharp left knee pain of level 3-7/10. He denied more significant flare-up but endorsed giving out every 2-3 days without locking, subluxing or dislocating. A knee brace kept him from hyper-extending and thus prevented falling. Injections provided some relief. The Veteran reported he was unable to lift a gallon of milk in each hand at the same time, or to tie his own shoes, due to knee pain. He stated he was unable to climb more than 12 steps or to walk more than 15-20 minutes before having to rest his knees. He stated he used a stool in the shower and also while cooking to rest his knees. He was able to drive short distances but avoided doing so because of his pain medications. On examination the Veteran was observed to walk with a broad-based gait using a cane. ROM of the bilateral knees was 0-110 degrees with limitation due to pain and difficulty. Stability tests (Lachlan's, anterior-posterior drawer and McMurray) were negative. Additional limitation due to flare-ups could not be determined. The examiner's diagnosis was bilateral mild osteoarthritis of the knees, as documented on recent X-ray studies. The Veteran presented to the VA orthopedic clinic in March 2008 complaining of continued bilateral knee pain. ROM of the left knee was 0-125 degrees. McMurray test was negative. The Veteran was administered steroid injections into the bilateral knees. The Veteran returned to the VA orthopedic clinic in April 2008 complaining of continued bilateral knee pain, which was not helped by current medications or steroid injections. ROM of the left knee was 0-120 degrees comfortably. McMurray test was negative. Beginning August 21, 2008, the Veteran's left knee disability was rated as 100 percent disabling for knee replacement surgery. Considering the Veteran's left knee symptoms prior to August 21, 2008, the Board finds the Veteran most closely approximated the disability picture associated with the currently assigned 10 percent rating. His ROM was at worst 0-90 degrees (in May 2007), and was in fact significantly better before and after that date (0-110 in June 2000; 0-125 in August 2000; 0-110 in August 2007; and, 0-120 in March 2008). Thus, he did not have limitation of flexion approaching a compensable degree (45 degrees) under DC 5260 or limitation of extension approaching a compensable degree (10 degrees) under DC 5261, even considering any additional limitation of function under DeLuca. Accordingly, the 10 percent rating assigned adequately addresses the pain and functional impairment from the left knee disability. During the period prior to August 21, 2008 the Veteran complained of subjective instability and was issued a knee brace for ligamentous laxity in March 2001, but there is no indication of actual instability on examination that would warrant separate compensation under DC 5257. Private examination in June 2000 and VA examinations in August 2000 and August 2007, all showed affirmatively that the Veteran's left knee was stable. Because the Veteran had a history of remote meniscectomy the Board has considered whether a higher rating may be considered under DC 5258 (dislocated semilunar cartilage). However, as there is no evidence of dislocated semilunar cartilage, DC 5258 is not for application. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence cited above the Board has carefully considered the lay evidence offered by the Veteran in the form of his testimony before the Board, his correspondence to VA and his statements to various medical examiners and providers. Even affording the Veteran with full competence and credibility in reporting his left knee symptoms over time, the lay evidence of record simply does not show that the Veteran's left knee disability met the criteria for a rating higher than the currently-assigned 10 percent during the period under review. The Board has considered whether "staged ratings" are for application, per Hart, 21 Vet. App. 505. However, the Veteran is not shown to have satisfied the criteria for a rating higher than 10 percent during any discrete date range during the period under review, so "staged rating" is not appropriate. Based on the evidence and analysis above, the Board finds that prior to August 20, 2008, the Veteran's left knee disability was generally manifested by painful motion, flexion to 90 degrees or better and extension to 0 degrees, without instability. The Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of his left knee disability. Accordingly, the criteria for a rating higher than 10 percent are not met and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. Schedular evaluation of left knee since October 1, 2009 The Veteran had a VA Physical Medicine and Rehabilitation (PMR) consult in November 2009, shortly after his right knee replacement. In regard to the left knee, which had undergone replacement in August 2008, the Veteran complained of some difficulty with snapping/popping, feeling of looseness and occasional buckling. ROM of the left knee was -5 degrees extension and 130 degrees flexion; quadriceps strength was 5/5. The Veteran's gait was acceptable, and he was able to go from heel strike to foot flat to toe-off without difficulty. The Veteran had a VA examination in January 2011 in which he was noted to walk with a wide-based, antalgic gait and to use a cane. ROM of the left knee after three repetitions was 0-115 degrees with pain; there was no instability. No loss of function with repetitive use was noted; loss of function due to flare-ups could not be estimated. The examiner's diagnosis was left knee disability status post-total knee replacement with moderate functional limitations. The Veteran had a VA examination in May 2013, performed by an examiner who reviewed the claims file. The Veteran complained of new left knee symptoms for the past four months involving a burning sensation with hyperextension or with full weightbearing; this results in pain of 5/10 intensity that resolves with rest within 5 minutes. He stated he had reported these new symptoms to his primary care provider, and that X-rays were taken, but he denied any other treatment since his examination in 2011. He complained both his knees tend to buckle if he reaches out too far. He reported the left knee gives way on a weekly basis, and also complained of intermittent muscle spasms in the calves occurring 3-4 times per week. The Veteran reported flare-ups associated with changes in the weather. Examination showed the Veteran to have normal posture and gait. ROM of the left knee was measured as 0-115 degrees without objective evidence of painful motion; there was also no objective evidence of hyperextension. Repetitive use did not result in additional limitation of ROM but did result in less movement than normal bilaterally and interference with weight-bearing, sitting and standing bilaterally. Muscle strength was 5/5 bilaterally. Both knees had mild anterior instability (1+ to Lachman's test) but posterior stability and varus-valgus stability were normal. There was no indication of recurrent patellar subluxation or dislocation. The Veteran complained of frequent episodes of joint pain bilaterally due to remote meniscectomies. Both knees showed intermediate degrees of residual weakness, pain or limitation of motion following total knee joint replacement. The Veteran's thighs were equal in circumference. The examiner notes surgical scars, but these were clinically insignificant. X-ray of the left knee one month earlier (April 2013) showed status post total knee arthroplasty (TKA) with stable configuration of the prosthesis when compared with previous radiographs and no evidence of fracture or loosening of prosthesis, but some suspicion of small joint effusion. The examiner's diagnosis was left knee total arthroplasty (previously left knee posttraumatic arthritis). Considering the Veteran's left knee symptoms from October 1, 2009, the Board finds the Veteran most closely approximated the disability picture associated with the currently assigned 30 percent rating. A higher rating of 60 percent under DC 5055 requires chronic residuals of severe painful motion or weakness in the affected extremity, but neither circumstance is shown. The Veteran complained of pain of 5/10 severity during examination in May 2013, but such pain was circumstantial (with hyperextension and weightbearing), resolved with rest, and was characterized by the examiner as an "intermediate" degree of pain. Similarly, the Veteran's postoperative weakness was characterized by the same examiner as an "intermediate" degree of weakness, and that examiner noted measured 5/5 strength. Also, the VA examiner in January 2011 characterized the Veteran as having "moderate" functional limitations after surgery. The Board can accordingly not consider the Veteran to have post-surgical "severe pain and weakness" warranting a 60 percent evaluation. Turning to alternative DCs, the Veteran did not have limitation of motion during the period that approached a compensable degree for flexion (45 degrees) under DC 5260 or extension (10 degrees) under DC 5261; ROM was -5 to 130 degrees in November 2009, and 0-115 degrees in January 2011 and in May 2013. Thus, while DC 5055 permits rating by analogy under DC 5256 or 5261 for intermediate degrees of residual weakness, pain, or limitation of motion, such symptoms do not approximate a level higher than the currently-assigned 30 percent rating. In addition to the medical evidence cited above the Board has carefully considered the lay evidence offered by the Veteran in the form of his correspondence to VA and his statements to various medical examiners and providers. 38 USCA § 5107(b); Caluza, 7 Vet. App. 498. The Veteran essentially contends he should be compensated at the 60 percent level due to post-surgical weakness and to evaluations for limitation of motion, instability and other rating factors. The Board notes the Veteran's complaints and functional impairment are adequately addressed under DC 5055, and his symptomatology does not rise to the level warranted for assignment of a 60 percent evaluation under that code. In other lay evidence of record, the Veteran submitted a letter in August 2013 asserting that the examiner in May 2013 had found equal circumference in the thighs (18.5 inches), whereas the VA examiner in July 2003 had found circumference of the left thigh to be 20.5 inches; thus, between 2003 and 2013 he is shown to have lost 2 inches on the left. The Board notes that the VA examiner stated the measurement was being taken "just above the knee," while the VA examiner in November 2003 (not July 2003 as the Veteran cites) does not indicate exactly where on the thigh the measurement was taken. Thus, the two examinations, in and of themselves, do not demonstrate progressive debilitation of the left thigh muscle secondary to the left knee disability. Based on the evidence and analysis above, the Board finds that from October 1, 2009, the Veteran's left knee disability has been manifested by prosthetic replacement of the knee joint without severe painful motion or weakness and without intermediate degrees of residual weakness, pain or limitation of motion ratable by analogy under the appropriate diagnostic codes. Accordingly, the criteria for a rating higher than 30 percent are not shown and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. Schedular evaluation of right knee prior to June 17, 2009 The Veteran had a VA examination of the right knee in June 2000 in which he complained of chronic and significant problems with the right knee, including painful weightbearing and inability to squat or knee. The Veteran endorsed using a cane and knee brace. He was observed to be wearing bilateral knee braces. ROM of the right knee was 0-90 degrees with pain on all range tested. The ligaments were stable to stress. X-rays were not taken. The clinical impression was degenerative changes of the right knee status post-patellectomy. In regard to DeLuca factors, the examiner stated that pain would further limit functional ability with flare-up or with attempts at frequent use, but it would not be feasible to attempt to express any of this in terms of additional limitation of motion as this could not be determined within any degree of medical certainty. The Veteran's right knee was also examined in June 2000 by Dr. Rohan. ROM was 0-110 degrees without significant instability. X-ray showed some spurring. Dr. Rohan's diagnosis was status post-patellectomy with extensor realignment, with some arthritis. The Veteran had a VA examination of the right knee in August 2000 in which he complained of constant pain and episodes of giving way; he also reported difficulty with squatting, kneeling or climbing stairs. He endorsed taking prescription pain medication with minimal relief. The Veteran was observed to walk with a limp, to wear a brace and to use a cane. ROM was 0-125 degrees with pain; there was no evident decrease in motion with repetitive activity. Knee strength appeared to be adequate (5/5) on extension and flexion. There was some slight medial laxity but no evidence of anteroposterior instability. The examiner's diagnosis was posttraumatic arthritis of the right knee. In an addendum, the examiner stated that X-ray had shown mild arthritis and DJD in the right knee, with some medial joint space narrowing. A VA clinical note in March 2001 states the Veteran presented for evaluation of need for knee bracing. Examination showed bilateral knee ligamentous laxity, and the Veteran was ordered to be fitted for knee braces. The Veteran presented to the VA pain clinic for evaluation in May 2001. His pain complaints were neck pain and related headache, low back pain and bilateral knee pain. The Veteran had a VA occupational therapy consultation in June 2001 in which he endorsed using a right knee brace 85 percent of the time. His reported pain level was 6.5/10 bilaterally. In June 2002 the Veteran reported having knee pain but stated the knees were not locking at present. VA X-ray of the right knee in August 2002 showed an impression of postsurgical changes with staple in the proximal right tibia, with no arthritic changes of note. Magnetic resonance imaging (MRI) of the right knee was performed by Panama City Open MRI and Imaging in February 2003. The study showed a small joint effusion and early diffuse chondromalacia. The lateral meniscus was intact, as were the ligaments. In April 2003 the Veteran complained that his right knee had been locking for the past two months. The Veteran had a VA examination of the right knee in November 2003 in which he stated that recent injections into the knee had caused some improvement, although the knee still felt unstable and would "go out" on him. He complained of sensitivity to weather changes, constant aching and throbbing and intermittent shooting pain from the knee to the ankle. He also reported sharp pain with weightbearing and hyperextension with severe pain relating to a sensation of bone-on-bone. Examination showed ROM of 0-90 degrees with pain at the extremes of flexion and extension. There was no swelling or enlargement. Anterior drawer, pivot and McMurray's were positive, but there was no instability of the ligaments. The right quadriceps appeared to be mildly atrophied and measured 1 inch less in circumference compared to the left. Muscle strength was decreased to 4+/5. The Veteran was able to ambulate without cane or brace but he did so with caution. The clinical impression was status post-patellectomy and meniscectomy and diffuse chondromalacia involving the medial and lateral compartments. The Veteran testified before the Board in July 2006 that he has constant aching and burning where his kneecap was removed. He endorsed using a knee brace and strong pain medications, without which his pain and spasms would be intolerable. The Veteran presented to the VA orthopedic surgery clinic in May 2007 complaining of bilateral knee pain, left worse than right. ROM of the right knee was 0-90 degrees. There was no instability. The clinical impression was bilateral chondromalacia and absent patella in the right knee. During VA examination in August 2007 the Veteran reported that his right knee was worse than his left. He reported constant aching, throbbing, burning sharp pain in the right knee of level 3-8/10. He reported no more significant flare-ups or locking, although the knee would give out every 3-4 days without clear subluxation or dislocation. Injections had provided some relief. The Veteran reported he was unable to lift a gallon of milk in each hand at the same time, or to tie his own shoes, due to knee pain. He stated he was unable to climb more than 12 steps or to walk more than 15-20 minutes before having to rest his knees. He stated he used a stool in the shower and also while cooking to rest his knees. He was able to drive short distances but avoided doing so because of his pain medications. On examination the Veteran was observed to walk with a broad-based gait using a cane. ROM of the bilateral knees was 0-110 degrees with limitation due to pain and difficulty. Stability tests (Lachman's, anterior-posterior drawer and McMurray) were negative. Additional limitation due to flare-ups could not be determined. The examiner's diagnosis was bilateral mild osteoarthritis of the knees, as documented on recent X-ray studies. The Veteran presented to the VA orthopedic clinic in March 2008 complaining of continued bilateral knee pain, as well as weakness and loss of motion in the right lower extremity (RLE). ROM of the right knee was 0-110 degrees; McMurray test exacerbated his pain. The right knee also showed weakness, with strength of 4-4+/5. The Veteran was administered steroid injections into the bilateral knees. The Veteran returned to the VA orthopedic clinic in April 2008 complaining that the injections had not reduced his pain. The clinician stated surgical consultation appeared to be warranted. The Veteran had a VA examination in January 2009. He stated that he continued to wear a locking-hinge brace on the right knee with increased confidence and stability but with continued pain, especially with hyperextension. He reported continued sensation of "giving way" and decreased strength related to the removal of his right kneecap. On examination the Veteran's gait was wide-based but not antalgic. ROM of the right knee was extension to 0 degrees without pain and flexion to 110 degrees with pain at that point. There was no instability. The right quadriceps measured 50 cm. as compared to 51 cm. for the left. Additional limitation due to flare-ups could not be estimated. The examiner diagnosed status post-patellectomy of the right knee with minimal degenerative changes consistent with age and body habitus. From June 18, 2009, to July 31, 2010, the Veteran's right knee disability was rated as 100 percent disabling post-surgery. Considering the Veteran's right knee symptoms prior to June 18, 2008, the Board finds the Veteran most closely approximated the disability picture associated with the currently assigned 10 percent rating. His flexion was at worst 90 degrees (in June 2000, November 2003 and May 2007) but was predominantly 110 degrees or better before and after those dates (110 degrees in June 2000; 125 degrees in August 2000; and, 110 degrees in August 2007, March 2008 and January 2009). Thus, he did not have limitation of flexion approaching a compensable degree (45 degrees) under DC 5260. The Veteran's extension was consistently 0 degrees, so limitation of extension did not approach a compensable degree (10 degrees) under DC 5261, even considering any additional limitation of function under DeLuca. During the period the Veteran was noted in August 2000 to have "slight medial laxity) and he was issued a knee brace for "ligamentous laxity" in March 2001, but there is no indication of actual instability on examination that would warrant separate compensation under DC 5257. Private examination in June 2000 and VA examinations in June 2000, November 2003, August 2007 and January 2009 that showed affirmatively that the Veteran's right knee was stable. Because the Veteran had a history of remote meniscectomy the Board has considered whether a higher rating may be warranted under DC 5258 (dislocated semilunar cartilage). As dislocated semilunar cartilage is not shown, DC 5258 is not for application. In addition to the medical evidence cited above the Board has carefully considered the lay evidence offered by the Veteran in the form of his testimony before the Board, his correspondence to VA and his statements to various medical examiners and providers. 38 USCA § 5107(b); Caluza, 7 Vet. App. 498 (1995). Even affording the Veteran with full competence and credibility in reporting his right knee symptoms over time, the lay evidence of record simply does not show that the Veteran's right knee disability met the criteria for a rating higher than the currently-assigned 10 percent during the period under review. The Board has considered whether "staged ratings" are for application, per Hart, 21 Vet. App. 505. However, the Veteran is not shown to have satisfied the criteria for a rating higher than 10 percent during any discrete date range during the period under review, so "staged rating" is not appropriate. Based on the evidence and analysis above, the Board finds that prior to June 17, 2009, the Veteran's right knee disability was generally manifested by painful motion, flexion to 90 degrees or better and extension to 0 degrees, without instability. The Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of his right knee disability. Accordingly, the criteria for a rating higher than 10 percent are not met and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. Schedular evaluation of right knee since August 1, 2010 The Veteran presented for VA physical therapy consult in August 2010 complaining of instability after surgery; he also complained of 4/10 pain. He was observed to walk with decreased stride and decreased cadence. ROM was 0-130 degrees. Quadriceps atrophy was noted on the right; strength was 4/5 bilaterally. Anterior drawer test was positive but varus/valgus stress test was negative. The Veteran presented to the VA physical therapy clinic in September 2010 to begin post-surgical therapy. He was observed to walk with a reciprocal gait pattern, using a cane. He had a brace on his right knee. ROM was 0-130 degrees, and strength was 5/5. The Veteran had a VA examination in January 2011 in which he was noted to walk with a wide-based, antalgic gait and to wear a right knee brace; he continued to use a cane. ROM of the right knee after three repetitions was 0-120 degrees with pain; there was no instability. No loss of function with repetitive use was noted; loss of function due to flare-ups could not be estimated. The examiner's diagnosis was right knee disability status post-total knee replacement with moderate functional limitations The Veteran had a VA examination in May 2013, performed by an examiner who reviewed the claims file. The Veteran complained of weakness in the right knee due to loss of his patella. He stated that his right knee is 1/3 weaker than the left knee and buckles when he takes a step, which is why he wears a brace. Although both knees tend to buckle, his right knee buckles twice as much as the left. The right knee gives way approximately three times per week; he also has intermittent spasms in the calves, mostly at night, 3-4 times per week. Daily right knee pain occurs with walking and is 6-7/10 in severity; pain subsides with rest. The Veteran reported flare-ups associated with changes in the weather. Examination showed the Veteran to have normal posture and gait, and he was observed to be wearing a right knee brace, which he reported using regularly and daily. ROM of the right knee was measured as 0-115 degrees without objective evidence of painful motion; there was also no objective evidence of hyperextension. Repetitive use did not result in additional limitation of ROM but did result in less movement than normal bilaterally and interference with weight-bearing, sitting and standing bilaterally; the examiner also noted deformity to the right knee on repetitive motion testing. The Veteran reported subjective numbness along the anterior right knee after surgery, but muscle strength was 5/5 bilaterally. Both knees had mild anterior instability (1+ to Lachman's test) but posterior stability and varus-valgus stability were normal. There was no indication of recurrent patellar subluxation or dislocation. The Veteran complained of frequent episodes of joint pain bilaterally due to remote meniscectomies. The Veteran's thighs were equal in circumference. The examiner noted surgical scars, but these were clinically insignificant. X-ray of the right knee showed status post-arthroplasty surgery with satisfactory alignment of the prosthesis components without evidence of loosening or infection. The examiner's diagnosis was right knee total arthroplasty (previously right knee DJD status post-patellectomy). Considering the Veteran's right knee symptoms from August 1, 2010, the Board finds the Veteran most closely approximated the disability picture associated with the currently assigned 30 percent rating. A higher rating of 60 percent under DC 5055 requires chronic residuals of severe painful motion or weakness in the affected extremity, but neither circumstance is shown. There is no indication of "severe pain" during the period under consideration. During examination in May 2013 the Veteran's primary complaint was weakness (asserting that the right leg was 1/3 weaker than the left leg), but the examiner noted strength of 5/5. Moreover, service connection for right quadriceps weakness was denied by the RO and was not appealed; thus, this issue is not before the Board. Turning to alternative DCs, the Veteran did not have limitation of motion during the period that approached a compensable degree for flexion (45 degrees) under DC 5260 or extension (10 degrees) under DC 5261; ROM was 0-130 degrees in August and September 2010; 0-120 degrees in January 2011; and, 0-115 May 2013. Thus, while DC 5055 permits rating by analogy under DC 5256 or 5261 for intermediate degrees of residual weakness, pain or limitation of motion, such symptoms do not approximate a level higher than the currently-assigned 30 percent. In addition to the medical evidence cited above the Board has carefully considered the lay evidence offered by the Veteran in the form of his correspondence to VA and his statements to various medical examiners and providers. 38 USCA § 5107(b); Caluza, 7 Vet. App. 498. The Veteran submitted a letter in August 2013 asserting that the examiner in May 2013 had found equal circumference in the thighs (18.5 inches), whereas the VA examiner in July 2003 found the right thigh to have mild atrophy and a circumference of 19.5 inches; thus, between 2003 and 2013 he is shown to have lost 1 inch on the right lower extremity (RLE). The Board notes that the VA examiner in May 2013 stated the measurement was being taken "just above the knee," while the VA examiner in November 2003 (not July 2003 as the Veteran cites) does not indicate exactly where on the thigh the measurement was taken, so no direct comparison is shown. Further, as noted above, the Veteran is already separately compensated at 20 percent for weakness of the RLE. Based on the evidence and analysis above, the Board finds that from August 1, 2010, the Veteran's right knee disability has been manifested by prosthetic replacement of the knee joint without severe painful motion or weakness and without intermediate degrees of residual weakness, pain or limitation of motion ratable by analogy under the appropriate diagnostic codes. Accordingly, the criteria for a rating higher than 30 percent are not shown and the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54-55. Extraschedular consideration The Board has also considered whether the Veteran's bilateral knee disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria, along with consideration of 38 C.F.R. § 4.40, 4.45, and 4.59, reasonably describe the Veteran's disability level and symptomatology and provides for additional or more severe symptoms than currently shown by the evidence; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. Entitlement to TDIU Due to Knee Disabilities Applicable Laws and Regulations It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate, "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU may be assigned if the schedular rating is less than total and the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities or one or both lower extremities, including the bilateral factor if applicable; (2) disabilities resulting from a common etiology or a single accident; (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or, (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director, Compensation and Pension Services, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Consideration may be given to the veteran's education, training, and special work experience, but not to his age or to impairment caused by nonservice-connected disabilities. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Evidence and Analysis The Board previously found the rating decisions on appeal, which concerned the evaluations for the left and right knee disabilities, had raised a claim for TDIU. Rice, 11 Vet. App. 447. Per the instructions in the Board's remand, the RO has considered entitlement to TDIU based solely on the knee disabilities on appeal, and has adjudicated that issue as shown in the SSOC issued in June 2013. The Veteran submitted a VA Form 21-8940 (Veteran's Application for Increased Compensation based on Unemployability) in January 2013, citing unemployability due to his bilateral knee disabilities and also his back disability. The RO has not yet adjudicated this claim for TDIU based on service connected disabilities other than the bilateral knees. Thus, the Board's discussion below will address simply whether the Veteran is rendered unemployable due to his bilateral knee disability. As recorded by a March 2002 VA clinical note, the Veteran's educational level is two years of college with an Associate's Degree in Arts; his occupational background was boat captain (mental health treatment notes specifically show that he was a tugboat captain). A Work Capacities Summary Report, performed by HealthSouth in April 1997, states the Veteran had not worked since May 1995 due to left knee pain, caused by a workplace slip-and-fall injury on a wet deck; he had previously injured the same knee in a shipboard accident in April 1990. The Veteran was paid $135,000.00 by his employer in settlement of the May 1995 workplace injury. The Veteran had a motor vehicle accident (MVA) in December 1997 that resulted in severe injury to the cervical spine. The Veteran was evaluated in November 1999 by Dr. Clell Warriner, a psychologist, in support of his request for SSA disability benefits. Dr. Warriner noted the Veteran's injuries in 1990, 1995 and 1997 cited above. Dr. Warriner stated that these injuries resulted in a stiff and tender neck and dysfunctional legs, which prohibited the Veteran from returning to his primary occupation as boat captain. In May 2000 Dr. Warriner interviewed the Veteran again and affirmed his previous findings. Dr. Warriner also stated the December 1997 MVA had resulted in symptoms of memory loss. A VA mental health clinic note in December 2006 states the Veteran's seagoing career was ultimately ended by injuries received in the December 1997 MVA. During VA examination in August 2009 the Veteran reported that knee pain and low back pain kept him from continuing he had been a tugboat captain. The examiner noted that per review of the file the reason he was not working was an automobile accident and failed physical examination for captain's license after neck fusion. A September 2001 decision by the Social Security Administration (SSA) held the Veteran had been unemployable since July 1999 due to DJD of both knees, cervical disc disease with radiculopathy and lumbar disc disease with radiculopathy. The decision found the Veteran had the residual functional capacity to perform less-than-sedentary exertional work, that he was not able to perform his past relevant work and that there were no jobs the Veteran could perform in the national economy because of his inability to engage in any substantial gainful activity. The Veteran had a VA mental disorders examination in October 2002 in which he reported that in 1995 he was having increasing problems with his knees, which caused difficulty in maintaining his employment as a boat captain. He asserted that because of his physical limitations he was unable to pass the Coast Guard physical examination required for his job. The examiner stated that 50-60 percent of the Veteran's psychiatric impairment was due to depression secondary to pain, while the remainder was due to cognitive impairment from a head injury related to a motor vehicle accident in 1997. The Veteran testified before the Board in July 2006 that he had previously worked in a shipyard but could no longer do so because the job required the ability to lift at least 50 pounds, whereas he could not lift more than 30. He testified that he receives SSA disability primarily due to the knees and back but is also significantly impaired by neurological deficits in the hands, chronic headaches and the effects of prescription-strength pain medications. In December 2011 the Veteran informed a VA social worker that after his May 1995 knee surgery he was unable to pass the physical requirements to continue his work as boat captain. He lost his license in 2001. The Veteran submitted a letter in January 2013 stating that he could not perform duties as a United States Merchant Marine captain because he could no longer meet insurance requirements and the physical requirement of the United States Coast Guard, primarily due to his knees and lower back. Also, the service-connected hearing loss disorder made it difficult to use electronic devices such as telephone, amplified speaker or ship's radio. Further, these physical problems caused depression. The Veteran asserted that employment testing had imposed impossible conditions; orthopedics said he could work at a desk job answering a phone, while audiology stated he could not work at a phone. Meanwhile, mental health had ruled out anything with stress. This left no potential employment when considering the whole person. The Veteran had a VA examination of the bilateral knees in May 2013. The Veteran reported having been unemployed since 1995 due to his knees and low back. The examiner performed a clinical examination of the knees, as noted above. The Veteran reported being essentially independent in activities of daily living, in that he was able to cook, shop, drive, and assist his wife in her volunteer work by picking up and delivering goods; the Veteran was also noted to be computer-literate. The examiner stated an opinion that the Veteran's left and right knee disabilities each imposed moderate function limitation, and that based solely on each knee the Veteran is capable of sedentary duty employment if he so chooses. The Veteran submitted a letter in August 2013 asserting that no company would hire a person 60 years of age whose knees give way when walking, since this would be a "lawsuit waiting to happen." He stated that VA apparently considered him to be capable of working at a desk job (referring to his bilateral knee disability) with only limited sitting (referring to his low back disability) that does not require answering the phone (referring to his hearing loss disability). On review of the evidence above, the Board finds the Veteran is not precluded from obtaining and maintaining gainful employment solely due to his service-connected bilateral knee disability. The Veteran has the educational level to pursue gainful sedentary employment that would not be significantly impeded by his knee disabilities. The VA examiner in May 2013 stated the Veteran's bilateral knee disability does not preclude gainful employment, if the Veteran so chooses. The ultimate question of whether a veteran is capable of substantial gainful employment is an assessment is for the adjudicator. Moore v. Nicholson, 21 Vet. App. 211, 218 (2007), rev'd on other grounds sub. nom. Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). However, the findings of a physician are medical conclusions that the Board cannot ignore or disregard. Willis v. Derwinski, 1 Vet. App. 66 (1991). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The first inquiry is to assess whether a medical expert was fully informed of the pertinent factual premises; the second inquiry involves consideration of whether the medical expert provided a fully articulated opinion, and the third and final factor involves consideration of whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). In this case, the opinion of the VA examiner meets all the element for probative value cited in Nieves-Rodriguez and may be relied upon by the Board. Further, the opinion of the VA examiner is not contradicted by any other medical opinion of record. The opinion of the VA examiner is just one factor that the Board has considered in arriving at its conclusion regarding employability. The Board has also considered the Veteran's occupational and educational background and his functional ability to drive, to reasonably ambulate and to perform activities of daily living despite the impairment imposed by his knee disabilities. The Board notes that the SSA found the Veteran to be incapable of even sedentary employment, but this determination was not limited to occupational impairment imposed by the bilateral knee disability; in any case, the findings of the SSA are not controlling in the adjudication of VA benefits. Murincsac v. Derwinski, 2 Vet. App. 363, 370 (1992). In sum, the Board finds that the Veteran's service-connected bilateral knee disability, alone, does not render him unable to obtain and maintain gainful employment consistent with his education, training and work experience. Accordingly, the criteria for TDIU are not met and the claim is denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER A rating in excess of 10 percent for chondromalacia and patella subluxation of the left knee, status post-tubercle transfer, prior to August 20, 2008, is denied. A rating in excess of 30 percent for residuals of total left knee arthroplasty from October 1, 2009, is denied. A rating in excess of 10 percent for degenerative changes of the right knee, status post-patellectomy, prior to June 17, 2009, is denied. A rating in excess of 30 percent residuals of total right knee arthroplasty from August 1, 2010, is denied. Entitlement to a TDIU is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs