Citation Nr: 1340392 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 09-28 417 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for right knee disability. 2. Entitlement to an initial evaluation in excess of 10 percent for left knee disability. 3. Entitlement to an initial separate evaluation in excess 10 percent for limitation of extension of the right knee, effective August 8, 2011. 4. Entitlement to an initial separate evaluation in excess 10 percent for limitation of extension of the left knee, effective August 8, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from June 1981 to August 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for the Veteran's bilateral knee disabilities and assigned 10 percent evaluations for those disabilities, effective September 1, 2005-the date following the Veteran's discharge from service. The Veteran timely appealed the assigned disability evaluations. The Board notes that in December 2007, the Veteran's bilateral knees were reevaluated by the RO following the association of additional service medical evidence. The Veteran timely appealed the continued 10 percent evaluations; the Board has therefore classified the issues on appeal as an initial evaluation in light of this reassessment and subsequent appeal. This case was last before the Board in November 2010, when it was remanded for further development. During the pendency of that appeal, separate 10 percent evaluations for limitation of extension of his bilateral knees, effective August 8, 2011-the date of his most recent VA examination. In light of the law and regulations respecting the evaluation of knee disabilities, discussed in greater detail below, the Board has taken jurisdiction over those separate evaluation issues on appeal at this time, as part of the initially-appealed increased evaluation claims for the Veteran's bilateral knee disabilities. That development requested in the November 2010 remand having been completed, the case has been returned to the Board for further appellate review at this time. FINDINGS OF FACT 1. Prior to August 8, 2011, the Veteran's extension in both knees was to 0 degrees, and flexion was to 140 degrees, without dislocated semilunar cartilage, effusion or locking symptoms, or instability or recurrent subluxation. 2. Beginning August 8, 2011, extension in each knee has been functionally limited to 20 degrees, and flexion in each knee has been functionally limited to 65 degrees, with no instability or recurrent subluxation. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003, 5010, 5019, 5257, 5258, 5260 (2013). 2. The criteria for an evaluation in excess of 10 percent for a left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003, 5010, 5019, 5257, 5258, 5260 (2013). 3. The criteria for a 30 percent evaluation for limitation of extension of the right knee, effective August 8, 2011, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5261 (2013). 4. The criteria for a 30 percent evaluation for limitation of extension of the left knee, effective August 8, 2011, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5261 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant 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 claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's increased evaluation claims for his bilateral knee disabilities arise from an appeal of the initial evaluations following the grants of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims herein decided. Finally, the Board acknowledges that the Veteran's bilateral knee claims were the subject of a November 2010 Board remand, which instructed that the Veteran be asked to provide information regarding any private treatment he had sought for his bilateral knee disabilities and to afford him another VA examination of his knees. The Board was asked for information regarding treatment in a November 2010 letter and subsequently provided a release authorization for Dr. F.B.; Dr. F.B.'s records were obtained and associated with the claims file. The Veteran underwent a VA examination of his bilateral knees on August 8, 2011. Therefore, the Board finds that its remand order has been substantially complied with, and it may proceed to adjudicate upon the merits of this case. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Background Review of the Veteran's service treatment records show that he was treated in September 1984 for knee sprain with contusions. He later injures both knees playing sports. In June 2002, the Veteran was diagnosed with chondromalacia level II of both knees and he was given physical therapy. In a June 25, 2002 record, the Veteran's left knee demonstrated crepitus, but he did not have swelling and a Lachman's test was negative. A left knee x-ray performed at that time indicated a normal left knee. In September 2002, a left knee Magnetic Resonating Imaging (MRI) scan indicated that there was Grade II chondromalacia in the patella, but was otherwise an unremarkable MRI of the left knee. In October 2002, the Veteran was taking medication for pain associated with his bilateral knees. On examination at that time no instability of either knee was shown on examination, though he had mild crepitus bilaterally and some edema was noted as well. In February 2003, the Veteran was seen for a follow-up for his knees, at which time he reported continued trouble cycling as well as negotiating steps. On examination at that time, the Veteran was shown to have a normal gait. With regards to his right knee, it was tender to palpitation at the intersection of the IT band with the LCL. He denied pain at that time. He was positive for patellar grind. The Veteran's left knee demonstrates similar findings. He was diagnosed with bilateral chondromalacia and IT band syndrome at that time and prescribed physical therapy. In April 2003, he was put on a limited physical profile for his bilateral knees, which generally consisted of no cycle or ergo, running or jumping. The Veteran was later allowed to do upper body workouts and to participate in team sports as able, but he remained on the physical profile due to his knees until discharge in August 2005. In May 2003, the Veteran reported having bilateral knee pain for 20 years and that he had a left knee instability sensation for the last month. He also noted that his left knee would collapse and swell with little activity. His knees were examined, at which time he had range of motion from 0 to 145 degrees bilaterally, without any effusion. He there was no laxity noted bilaterally, and McMurray's testing was negative; however, the Veteran had +1 Lachman's testing bilaterally. In October 2003, the Veteran had began light jogging and complained of increased pain and symptoms in his left knee. On examination, the Veteran's left knee has a range of motion from 0 to 140 degrees and had patellar grinding. There was no effusion noted at that time, and he had a negative Lachman's test. It appears that between that time and December 2003, the Veteran had a steroid injection in his left knee. Similar findings of the left knee as noted in October 2003 were demonstrated in December 2003 and February 2004 treatment records. Again, in April 2004, the Veteran complained of dull throbbing/constant pain in his left knee, which was exacerbated by walking or prolonged sitting. On examination, the Veteran's left knee was tender to palpitation on the MCL, with a range of motion from 0 to 140 degrees. He did not have effusion at that time; x-rays and Lachman's testing was negative. He was prescribed a hinged knee brace at that time. In May 2004, the Veteran was seen for a follow-up secondary to his bilateral knee pain due to degenerative joint disease (DJD). He had a normal gait at that time, with a full active range of motion from 0 to 140 degrees, bilaterally. He did not have any effusion or erythema at that time. In a February 2005 assessment, the Veteran again complained of bilateral knees, particularly with running, spinning or ergo. The Veteran was noted as participating in soccer or volleyball at that time, however. Active range of motion for the Veteran's bilateral knees at that time was 0 to 140 degrees. There was positive patellar grind but no effusion bilaterally. He had negative Lachman's testing bilaterally, though his joint lines were tender to palpitation. He was diagnosed with bilateral knee pain, DJD and chondromalacia that time. In a March 2005 Report of Medical Assessment, the Veteran noted that he was on a profile for his legs and knees. The doctor noted at that time that he had bilateral knee problems with subjective complaints of "intermittent buckling" for 20 years. There was no history of surgery of either knee and it was noted that the Veteran was on a profile due to these problems. The doctor additionally noted that the Veteran had received 3 or 4 steroid injections for his left knee condition. In June 2005, the Veteran again was noted as having positive MRI scans for his bilateral knees and having bilateral knee pain. Approximately 3 weeks after discharge from service, the Veteran underwent a VA examination of his bilateral knees in September 2005. At that time, the Veteran reported having bilateral knee pain 2 to 3 times a week, but that it was mild. He was noted that he was running 1-2 miles at that time and playing soccer as tolerated. He was also doing physical therapy for his bilateral knees at home. He used bilateral knee braces as necessary. The Veteran did not report any surgical procedures at that time. With respect to his "bilateral knees, he [was] functioning well. If at all during his work it bothers him, [he] just slows down the pace of work, gets up, weight shifting is done." The Veteran avoided squatting, crawling, kneeling or going up and down stairs, however; if such activities are necessary, he does them within the limits of his tolerance. On examination, the Veteran's gait was normal without evidence of limping, listing, foot-drop or foot-drag; he did not need assistive devices for ambulation. He had normal weightbearing bilaterally. Neurological and reflex testing of the Veteran's bilateral knees, including Babinski's testing, was normal. There was no swelling bilaterally and his knees were noted as "stable, medial/lateral still within normal, drawer signs are negative, Lachman's/McMurrays's test negative." The Veteran's range of motion was noted as 0 to 140 degrees, bilaterally, which remained the same without any evidence of impaired endurance. In fact, it appears that the Veteran performed flexion and extension more than 6 times with 5-pound resistance; pain was noted in the retropatellar pain syndrome zone area. There was no locking or giving way of the knees observed, however. The Veteran was diagnosed with left knee chondromalacia patella and right knee retropatellar pain syndrome with episodic pains bilaterally. In his November 2008 notice of disagreement, the Veteran indicated that he initially sought treated in service for instability, which is what led to the diagnosis of his knee problems in the first place. The Veteran indicated that he had presented with clicking and catching of his knee and loss of stability, as well as with significant pain in his knees since June 2002. He took over-the-counter pain relievers and anti-inflammatories with limited success. The Veteran documents his significant history of treatment for his knees throughout service, much of which is noted above, but noted that it was unsuccessful in aiding his instability issues. He noted that currently he was "constantly in pain, do[es] not have consistent stability when walking, standing, or exiting seats, vehicles, etc.; [he is] unable to remain seating or standing for extended periods of time, and experience extreme discomfort when walking for greater than ten minutes." The Veteran's August 2009 substantive appeal, VA Form 9, is essentially a copy of the Veteran's notice of disagreement. Private treatment records from Dr. F.B. in December 2010 demonstrate that the Veteran was attempting to walk and swim for exercise, but that walking caused him significant pain. On examination, the Veteran had normal strength and patellar reflexes bilaterally. He had anterior patellar pain bilateral medial to lateral, with pain over the tibial tubercle and IT band. He also had pain and complaints of compression of the knee. He was diagnosed with mild DJD of the bilateral knees, and was sent for x-rays and MRI's of his knees in order to rule out meniscal tears. X-rays of his bilateral knees taken the same day as the examination were normal. And MRI of the left knee taken in December 2010 demonstrated mild periarticular soft tissue edema, slight excess joint fluid suggesting a minimal joint effusion, mild osteoarthritic changes of the patellofemoral and femorotibial joints, and slight intrasubstance degenerative changes within the menisci, though no tears were identified. There was a benign-appearing lesion noted, however, and a follow-up MRI was performed in June 2011. The June 2011 MRI of the left knee confirmed that there was a benign chondral rest at the metadiaphyseal junction of the distal femur and that no further evaluation was necessary. The Veteran also had an MRI of the right knee taken in December 2010, which revealed slight periarticular soft tissue edema, slight degenerative changes of the knee joints, and minimal intrasubstance degenerative changes of the menisci, though no tears were identified; the right knee was otherwise unremarkable in appearance. Finally, the Veteran underwent a VA examination of his bilateral knees on August 8, 2011. Since his last VA examination, the Veteran reported no hospitalizations or surgeries for his knees. For treatment, the Veteran took two over-the-counter Aleve every morning, which is helpful. The Veteran is also currently employed full-time in a management position. He reported not missing working due to his knee conditions within the past year; though, if he has to travel on an airplane for his job, he has to flight first-class in order to have more room to stretch out his legs. The Veteran further reported that he was independent with his activities of daily living; he is able to drive, though he had to switch to an automatic transmission due to his left knee causing him to be unable to properly work the clutch. He has bilateral knee pain getting into and out of the vehicle. Furthermore, he is limited to standing for 10 minutes, sitting for 60 minutes and walking to 20 minutes due to either pain, stiffness or both. He can no longer tolerate riding a bicycle or recumbent bicycle. His pain is exacerbated by going up and down stairs; he also has to hold onto the railing when navigating stairs because "he does not trust his knees." He does not wear any braces or use any assistive devices for ambulation. He avoids kneeling and squatting due to pain and "perceived instability." He fly-fishes occasionally, but has to be careful and watches his footing in the water. Since the last examination in September 2005, the Veteran reported progressive worsening of his knee disabilities. He reported constant bilateral pain that is 7 out of 10 in severity, as well as constant bilateral knee stiffness that is worse in cold weather. He reported intermittent locking, particularly during stair-climbing, bending and squatting. His knees will also intermittently swell, which he treats with cryotherapy which is helpful. He also reported that he felt his knees were "unstable and weak," particularly when climbing stairs, kneeling or squatting. The Veteran is followed by private physicians, who gave him bilateral Synvisc injections which relieve the pain for 3 months time. He also stated that he intermittently walked with a limp, favoring his left or right side depending on which side is more bothersome that day. He finally reported experiencing a flare-up of pain, stiffness and swelling approximately once a month which lasted 48 hours. He uses ice to decrease the swelling during flares. The flare-ups further limit his standing and walking. The examiner noted reviewing the claims file, including specifically listing many of the above documents. On examination, the Veteran ambulated with a normal gait without the use of an assistive device or brace. He did not currently limp, though he was slow from going from a sitting to standing position and in moving about the examination room. He appeared to use caution when pivoting and turning around corners. He could only perform half of a normal squat due to bilateral knee pain, and "audible pops" were heard at the left and right knees on squatting. Squatting caused obvious discomfort, with grimacing and crying out in pain. The Veteran's left knee demonstrated mild anterior swelling, though there was no anterior, posterior, medial or lateral instability. There was no laxity with application of varus or valgus stress. Lachman and McMurray tests were negative. Alignment was normal and he was tender to palpitation along the medial and lateral borders of the patella, over the patellar tendon, and along the medial and lateral joint lines. He reported pain with patellar compression and passive patellar deviation. There was a moderate amount of crepitus. Range of motion testing indicated that he lost 10 degrees of extension due to pain; flexion was from 10 degrees to 95 degrees, with pain beginning at 65 degrees. The Veteran's right knee demonstrated the exact same findings. The examiner further noted that after repeated testing against resistance, he noted an additional loss of 10 degrees in extension for both the right and left knees, due to pain. There was no additional loss of range of motion due to weakness, impaired endurance, incoordination, or instability. X-rays of the left knee demonstrated joint effusion, mild spurring at the tibial tuberosity, and minimal spurring of the lateral aspect of the patella, though joint spaces were maintained and there were no acute bony abnormalities; minimal degenerative changes were assessed. The right knee x-rays demonstrated no joint effusion or acute bony abnormalities; joint spaces were maintained and there was no appreciable osteophytosis. The right knee was assessed as normal. The examiner diagnosed the Veteran with left knee DJD and right knee chondromalacia patella; she noted that x-rays of the right knee did not reveal degenerative changes at that time. Neither knee showed objective evidence of instability. In summary, the examiner noted that the Veteran's knees lacked 10 degrees of extension bilaterally due to pain and that flexion was from 10 to 95 degrees with pain at 65 degrees. "Due to pain and pain-on-use following repetitive testing against resistance, an additional loss of 10 degrees of extension is recommended bilaterally, based on clinical measurements and observation. There is no additional loss of bilateral knee range of motion due to weakness, incoordination, or excess fatigability. There is no recurrent instability or lateral subluxation" of the bilateral knees. Analysis The Board has reviewed all of the evidence in the Veteran's claims file. 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 Veteran or obtained on his 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). 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 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 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 (2013); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2013); 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 (2013); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2013). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, 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). 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 (2013). Currently, the Veteran's bilateral knees are assigned a 10 percent evaluation, effective September 1, 2005, under Diagnostic Code 5019, bursitis, which redirects the Rater to evaluate the disability under the applicable arthritis and/or limitation of motion codes, as appropriate. Separate 10 percent evaluations have been assigned for limitation of extension under Diagnostic Code 5261, effective August 8, 2011. Under Diagnostic Code 5010, traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. The 10 and 20 percent evaluations based on X-ray evidence may not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. With any form of arthritis, painful motion is an important factor. It is the intention of the rating schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X-ray findings and no actual limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Where compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable. The Board notes that the normal range of motion of the knee is to 0 degrees (full extension) to 140 degrees (full flexion). See 38 C.F.R. § 4.71a, Plate II. When flexion of the knee is limited to 45 degrees, a 10 percent rating may be assigned. When flexion is limited to 30 degrees, a 20 percent evaluation may be assigned. A 30 percent rating may be assigned when flexion of the leg is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. When extension of the knee is limited to 10 degrees, a 10 percent evaluation may be assigned. When extension is limited to 15 degrees, a 20 percent evaluation may be assigned. When limited to 20 degrees, a 30 percent rating may be assigned. When extension is limited to 30 degrees, a 40 percent evaluation is assignable. A 50 percent evaluation may be assigned when extension of the leg is limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Slight recurrent subluxation or lateral instability warrants a 10 percent evaluation. A 20 percent rating requires moderate recurrent subluxation or lateral instability. A 30 percent rating requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Based on the foregoing evidence, the Board finds that an evaluation in excess of 10 percent for the Veteran's bilateral knees is not warranted, but that beginning August 8, 2011, the Veteran's separate evaluations for his limitation of extension are increased to 30 percent evaluations. The Board additionally finds that separate evaluations for instability of the Veteran's knees are not warranted. The reasoning is as follows. Based on the findings prior to August 8, 2011, the Veteran's bilateral knee flexion is shown to be to 140 degrees, or normal, throughout that period of time. Likewise, the Veteran's bilateral knee extension is shown to be to 0 degrees, or normal, throughout that period of time. Accordingly, no evaluations in excess of 10 percent are for application due to limitation of flexion or extension during that period of time. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Moreover, the Board finds that there is no evidence of any dislocation of his semilunar cartilage of the bilateral knees during that period of time. While there is some intermittent evidence of some effusion in the joints during the Veteran's service, it does not appear that such symptomatology was predominantly present throughout the period prior to August 8, 2011, nor that such evidence caused any locking of the bilateral knee joints. The Veteran's notice of disagreement noted some "clicking and catching" of his bilateral knees, but the overall objective evidence does not demonstrate any locking of the bilateral knees throughout that period of time. A 20 percent evaluation under Diagnostic Code 5285 is therefore not for application in this case. See 38 C.F.R. § 4.71a, Diagnostic Code 5258. In this case, it appears that the Veteran's 10 percent evaluations have been assigned under the arthritic diagnostic codes. A 20 percent evaluation is not for application as each knee joint is a single major joint affected by arthritis in this case. As a second major joint or two or more minor joints-which the Board notes does not exist in the knee-is not affected, the Board is unable to assign a higher evaluation for the Veteran's bilateral knees under those applicable diagnostic codes. See 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5010. With respect to the Veteran's separate evaluations for his extension, the Board finds that 30 percent evaluations are warranted beginning August 8, 2011. In the VA examination conducted on that date, the Veteran's initial extension was shown to be limited to 10 degrees. However, following repetitive testing, the examiner noted that the Deluca factors in this case warranted an additional 10 degrees of loss in extension. After factoring in this additional loss, the Board finds that the Veteran's bilateral knees are shown, beginning August 8, 2011, to have loss of 20 degrees of extension. Such 20 degrees of loss of range of motion in extension commensurates to a 30 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. With respect to the Veteran's flexion, his bilateral knee flexion is shown to be to 95 degrees with pain beginning at 65 degrees. Even if the Board were to factor in the noted pain, the Veteran still demonstrates 65 degrees of flexion during the period beginning August 8, 2011. Such flexion does not commensurate to a compensable evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. For the period beginning August 8, 2011, with respect to Diagnostic Code 5258, the Board notes the Veteran's 30 percent evaluation for extension commensurates to a higher evaluation than 20 percent and therefore, that Diagnostic Code is no longer applicable. See 38 C.F.R. § 4.71a, Diagnostic Code 5258. With respect to the Veteran's assigned 10 percent evaluation under Diagnostic Code 5019, which is still currently in effect as of August 8, 2011, the Board notes that the Lichtenfels rule does not apply when an evaluation of a joint has been assigned for limitation of motion, such as in this case. Thus, the Board must deny an evaluation in excess of 10 percent, because in short, such evaluation should not have been continued beginning August 8, 2011. The Veteran has been assigned a 30 percent evaluation for his knees due to his loss of extension during this period, but his loss of flexion is noncompensable, the Board notes that such compensation under Diagnostic Codes 5003 and 5010 for arthritis would be considered pyramiding with respect to his bilateral knees. See 38 C.F.R. § 4.14 (2013); see also Lichtenfels, supra. As the Veteran is not currently entitled to an evaluation under Diagnostic Codes 5019-5003/5010 and 5019-5261, but is currently in receipt of those two evaluations, the Board finds that an evaluation in excess of 10 percent for the Veteran's bilateral knees must be denied at this time. See 38 C.F.R. §§ 4.14, 4.71a, Diagnostic Codes 5003, 5010, 5019; see also Lichtenfels, supra. Finally, the Board finds that separate evaluations for recurrent subluxation or lateral instability are not warranted on the basis of the evidence of record. Initially, the Board acknowledges that the Veteran is competent to state that throughout the appeal period he has had subjective feelings of instability, giving way, or buckling of the knees. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). The Board additionally acknowledges the singular objective finding in May 2003 of a +1 Lachman's test, which correlates with at least a less-than-normal knee with respect to lateral stability; the Board also acknowledges the substantial amount of subjective complaints of instability and buckling of his bilateral knees, both in service and after military service. Significantly, however, throughout the records closer to the Veteran's separation from service and in the s post-service treatment records, the Board notes the numerous findings of normal McMurray's and Lachman's testing. This includes the most recent VA examination in August 2011, during which the examiner emphatically noted that there was no evidence of recurrent subluxation or lateral instability. There is no objective evidence in the wealth of treatment records in the claims file that corroborate the Veteran's subjective complaints of instability during the appeal period, with the exception of that sole May 2003 service treatment record; the Board finds that May 2003 finding to be an isolated and attenuated finding. Overwhelmingly, the objective evidence of record, including the September 2005 VA examination and the most recent VA examination in August 2011, weighs against a finding of recurrent subluxation and/or lateral instability of the Veteran's bilateral knees. The probative value of the sole May 2003 finding and the repeated but uncorroborated subjective complaints of lateral instability do not bring the evidence into relative equipoise when weighed against the significant probative weight of the objective evidence and clinical findings in this case. Accordingly, the Board must find that separate evaluations for recurrent subluxation or lateral instability of the Veteran's bilateral knees are not warranted on the evidence of record in this case. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. In summary, the Board finds that for the period prior to August 8, 2011, the Veteran's flexion and extension of the bilateral knees was normal and separate evaluations for compensable evaluations under the applicable Diagnostic Codes were not warranted. Neither was there evidence of any dislocated cartilage for that period, which created locking or effusion. The Veteran's knees are a single major joint and therefore a higher evaluation under the applicable arthritic Diagnostic Codes are not for application during that appeal period. Beginning August 8, 2011, however, the Veteran's separate evaluation for limitation of extension is increased to 30 percent disabling as the overall limitation of motion and functional impairment demonstrated on examination and estimated by the VA examiner, when including the Deluca factors, demonstrates a limitation of extension to 20 degrees bilaterally. The Veteran's flexion bilaterally, however, does not commensurate to a compensable evaluation for that appeal period. Application of an additional 10 percent evaluation under the arthritic Diagnostic Codes would be pyramiding and is inappropriately assigned at this time; thus, an evaluation in excess of 10 percent for the bilateral knees must be denied at this time. Finally, the Board finds that separate evaluations for recurrent subluxation and/or lateral instability are not warranted for the Veteran's bilateral knees throughout the appeal period, as the objective evidence does not corroborate his subjective complaints in this case. Accordingly, the Board must deny evaluations in excess of 10 percent throughout the appeal period, but does allow an increased evaluation for the Veteran's separate evaluations for limitation of extension to 30 percent disabling, bilaterally. See 38 C.F.R. §§ 4.7, 4.14, 4.71a, Diagnostic Codes 5003, 5010, 5019, 5257, 5258, 5260, 5261. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2013). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is adequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected bilateral knee disabilities, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorders. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. Finally, the Board has also considered whether a remand is necessary in order to determine whether the Veteran is entitled to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In this case, the evidence of record does not indicate that the Veteran is currently unemployed due to his bilateral knee disabilities. In fact, the Veteran is shown to be employed full-time in a management position during his most recent VA examination. No evidence of record refutes this evidence or indicates that the Veteran has since become unemployed due to his bilateral knee disabilities since that VA examination. As there is not any evidence of record that the Veteran's bilateral knee disabilities cause him to be unable to secure and follow substantially gainful employment, the Board finds that a remand for such an opinion is not required in this case. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In so reaching the above conclusions, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER An evaluation in excess of 10 percent for right knee disability is denied. An evaluation in excess of 10 percent for left knee disability is denied. A 30 percent evaluation for a separate evaluation for limitation of extension of the right knee, effective August 8, 2011, is granted. A 30 percent evaluation for a separate evaluation for limitation of extension of the left knee, effective August 8, 2011, is granted. ____________________________________________ THOMAS H. O'SHAY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs