Citation Nr: 1340976 Decision Date: 12/12/13 Archive Date: 12/20/13 DOCKET NO. 10-20 268 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased disability rating for service-connected chondromalacia, status post arthroscopy and meniscectomy (right knee disability), currently rated as 10 percent disabling. 2. Entitlement to a separate initial rating in excess of 10 percent for mild instability associated with the right knee disability. 3. Entitlement to extended temporary total ratings based on periods of convalescence after surgery for the service-connected right knee disability, currently in effect from April 2, 2007 to June 30, 2007; and from September 17, 2007 to October 31, 2007. 4. Entitlement to an initial compensable rating for residual scars associated with the right knee disability. 5. Entitlement to an earlier effective date for the grant of service connection for residual scars associated with the right knee disability effective November 17, 2010. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Heneks, Counsel INTRODUCTION The Veteran served on active duty from October 1994 to October 1998. These matters come before the Board of Veterans' Appeals (BVA or Board) on appeal from January and November 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The January 2008 rating decision assigned a temporary evaluation of 100 percent for the service-connected right knee disability effective April 2, 2007 based on surgical or other treatment necessitating convalescence; a 10 percent rating effective July 1, 2007; a 100 percent rating for convalescence effective September 17, 2007; and a 10 percent rating effective November 1, 2007. In an April 2008 notice of disagreement (NOD), the Veteran disagreed with the 10 percent rating assigned for the right knee disability and requested an extension of the periods of convalescence. A November 2008 rating decision denied the request for an extension of the period of convalescence as well as entitlement to a higher rating. Thereafter, a September 2012 rating decision assigned a 100 percent rating for convalescence effective November 17, 2010; a 10 percent rating effective February 1, 2011; granted a separate 10 percent rating for the mild instability of the right knee effective March 25, 2011; and granted a non-compensable rating for residual scars of the right knee effective November 17, 2010. The Board observes that the Veteran did not dispute the length of the convalescence rating assigned following his November 17, 2010 surgery. Accordingly, this period of convalescence will not be addressed. The Board will address the July and September 2007 post-surgery convalescence periods as the Veteran specifically disagreed with them and the RO also addressed them in the November 2008 rating decision. The Board will also address whether the Veteran is entitled to a higher rating, or earlier effective date, for the grant of the 10 percent rating for mild instability and non-compensable rating for residual scars because these ratings were assigned during the course of an appeal wherein the Veteran was seeking an increased rating for his underlying service-connected right knee. Accordingly, the issues have been characterized as reflected above. FINDINGS OF FACT 1. The Veteran's right knee disability is primarily manifested by pain and some limitation of motion, but with flexion greater than 60 degrees and extension limited to no more than 5 degrees. 2. From March 25, 2011, the Veterans' right knee instability is no more than slight in severity. 3. As a result of the April 2, 2007 surgery, the Veteran did not require convalescence, have severe postoperative residuals, or require immobilization of a major joint after June 30, 2007. 4. As a result of the September 17, 2007 surgery, the Veteran did not require convalescence, have severe postoperative residuals, or require immobilization of a major joint after October 31, 2007. 5. The Veteran's right knee scars are not deep or nonlinear, do not affect an area of 144 square inches or greater, are not unstable or painful, and do not cause functional loss. 6. Right knee scars related to the service-connected right knee disability are shown April 2, 2007, but no earlier. CONCLUSIONS OF LAW 1. The criteria for a rating 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. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.10, 4.71a, Diagnostic Code 5020 (2013). 2. From March 25, 2011, the criteria for an initial rating in excess of 10 percent for instability associated with a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.10, 4.71a, Diagnostic Code 5257 (2013). 3. The criteria for extension beyond June 30, 2007 of a temporary total rating for a right knee disability based on surgical or other treatment necessitating convalescence are not met. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 4.30 (2013). 4. The criteria for extension beyond October 31, 2007 of a temporary total rating for a right knee disability based on surgical or other treatment necessitating convalescence are not met. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 4.30 (2013). 5. The criteria for an initial, compensable rating for residual scars associated with a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Code 7806 (2013). 6. The criteria for an effective date of April 2, 2007 for the award of service connection for residual scars associated with a right knee disability have been met. 38 U.S.C.A. §§ 5107, 5110 (West 2002); 38 C.F.R. § 3.400 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to notify with respect to the claim for an increased rating for the service-connected right knee disability was satisfied by a letter sent to the Veteran in October 2007, which was before the rating decisions on appeal. The claims related to the mild instability of the right knee and residual scars are being considered by the Board as they are part and parcel to the increased rating claim. As such, the October 2007 letter satisfies the duty to notify regarding these claims. Although the Veteran did not receive a notice letter specific to how to extend an assigned convalescence rating under 38 C.F.R. § 4.30, the Board concludes that any failure to do so was harmless. Specifically, the Veteran indicated that he was aware of the criteria for a temporary total rating in his April 2008 NOD wherein he asserted that he should have received six months of convalescence because he was off work for six months. Additionally, the November 2008 rating decision explained why the requests for longer convalescence periods were denied. The Board finds that a reasonable person would be aware of what was necessary for entitlement to a total rating following surgery for a service-connected disability after reading this rating decision. Accordingly, the Board finds that the Veteran was not prejudiced by the lack of a notice letter specific to the temporary total rating and will proceed with a decision on this matter. Shinseki v. Sanders, 556 U.S. 396 (2009). In addition, the duty to assist the Veteran has also been satisfied in this case. All available VA medical records and all relevant private medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. The Veteran was afforded VA examinations in October 2007, April 2010, and August 2012. The Board finds that the examinations are adequate upon which to base a determination, as they are based on a physical examination of the Veteran, address the rating criteria to include range of motion findings, and address the impact of his right knee on his daily activities and ability to work. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The record reflects that during the March 2013 hearing, the undersigned explained the issues, focused on the elements necessary to substantiate the claim, and sought to identify any further development that was required to help substantiate the claim. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). There is no indication that there is any additional relevant evidence to be obtained by either VA or the Veteran. Therefore, the Board determines that VA has made reasonable efforts to the assist the Veteran in obtaining the evidence necessary to substantiate his claims. Law and Analysis I. Convalescent Ratings During the appeal, the Veteran was assigned temporary 100 percent ratings for convalescence following right knee surgeries on April 2, 2007 and September 17, 2007 under 38 C.F.R. § 4.30. He was awarded 10 percent ratings following those periods of convalescence effective July 1, 2007 and November 1, 2007, respectively. In an April 2008 statement, the Veteran disagreed with the length of the 100 percent convalescence ratings assigned after his April and September 2007 surgeries, stating that he should have been compensated for six months, as he did not return to work until October 2007. A total disability rating is warranted if treatment of a service-connected disability resulted in surgery necessitating at least one month of convalescence; surgery with severe postoperative residuals to include incompletely healed surgical wounds, therapeutic immobilization of one major joint or more, the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or immobilization by cast of one major joint or more, without surgery. See 38 C.F.R. § 4.30(a)(1)-(3). On April 2, 2007, the Veteran underwent open osteochondral allograft transplantation with adjacent microfracture chondroplasty. An April 17, 2007 private treatment record from Orthopedic Specialty Associates (O.S.A.) reflected that the Veteran was in for his first postoperative visit. (The Board notes that all the private treatment discussed herein is from O.S.A. unless otherwise indicated.) It was noted that his pain was controlled, he was wearing a brace and using crutches, he was going to therapy, and he was not working. He was to remain non-weight bearing until he returned to O.S.A. for follow-up treatment. A May 2007 record indicated that the Veteran was six weeks out from surgery and was walking without his brace and crutches. He also had very little swelling. A June 2007 record stated that the Veteran had taken some time off to study for the corporal's test at the police department where he worked. He cut his therapy back to one day a week and continued to ride a stationary bike daily. It appears that in May 2007, the Veteran no longer met the criteria for convalescence as he was walking without his brace and crutches, reflecting that regular weight-bearing was no longer prohibited. Importantly, the June 2007 record indicates that the Veteran was not prohibited from returning to work by physician's order, but had voluntarily decided to take time off to study for a test. Thus, it appears that the Veteran was no longer entitled to convalescence under the rating criteria effective June 1, 2007. However, the RO assigned his 10 percent rating effective July 1, 2007, which will not be disturbed. On September 17, 2007, the Veteran underwent anterior internal debridement, resection of medial and lateral femoral condyle exostoses, and limited lateral femoral condyle chondroplasty. A September 25, 2007 record noted that it was the Veteran's first postoperative visit and that he was in therapy and on crutches as directed. The Veteran was to remain on crutches until three weeks postoperative and was to return to work on light duty the following week. An October 2007 record stated that the Veteran was doing really well and was going to continue light duty at work. As noted above, the evidence of record reflected that the Veteran remained on crutches due to his surgery for his service-connected right knee until the middle of October 2007. Thereafter, the evidence of record does not reflect that treatment for his service-connected disability resulted in any of the circumstances outlined under 38 C.F.R. § 4.30(a)(1)-(3). Thus, the RO properly concluded that the Veteran's 100 percent convalescence rating should end on November 1, 2007, the first day of the month following the October 2007 notation that he was doing well and was going to continue working. In conclusion, as the preponderance of the evidence is against these issues, the Board finds that the Veteran is not entitled to an extended convalescence period in connection with his April 2, 2007 or September 17, 2007 surgeries. 38 C.F.R. § 4.30. II. Increased Ratings The Board finds that the Veteran is not entitled to increased ratings for his service-connected right knee. The Veteran is currently assigned a 10 percent rating under Diagnostic Code (DC) 5020, which provides for a rating based on limitation of motion of the affected parts, as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5020. Diagnostic Code 5003, degenerative arthritis, provides that when limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Pursuant to VAOPGPREC 9-98 (August 14, 1998), a separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. In the absence of limitation of motion, a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. During the period on appeal, right leg flexion was not shown to be limited to 60 degrees, which is required for a non-compensable rating. 38 C.F.R. § 4.71a, DC 5260. Right leg extension limited to 5 degrees for a non-compensable rating was shown. 38 C.F.R. § 4.71a, DC 5261. A 10 percent rating was appropriately assigned by the RO because a non-compensable limitation of extension under DC 5261 was shown and there was satisfactory evidence of painful motion. 38 C.F.R. §§ 4.59; 4.71a, DC 5003. However, there was no evidence showing that extension was limited to 10 degrees, which is required for a higher evaluation under DC 5261. In this regard, August 2007 records reflected that, at the worst, the Veteran's right knee had grinding symptoms along his lateral knee that were getting worse and painful. He had lateral joint line pain and increasing difficulty getting around. Upon examination, the range of motion was 5 to 130 degrees, and there was moderate patellofemoral crepitation and a painful lateral joint line. His gait was normal. A September 2007 MRI scan of the right knee reflected minor degenerative changes per the radiologist. The Veteran complained of persistent pain along the lateral joint line. The recommendation was to place the Veteran on crutches to allow the edema to resolve and to have an arthroscopy. During his October 2007 VA examination, the Veteran complained of pain, swelling, and loss of full extension of the right knee. He reported no periods of flare-up. He did not use braces or assistive devices at the time of the examination. He estimated that he lost six months of work in the past year due to his knee. His activities of daily living were affected in that weight bearing activities increased his pain and he was unable to participate in sports. Upon physical examination, the Veteran had a normal gait and range of motion from 5 to 140 degrees with pain in the medial and lateral joint lines throughout that range. The knee was tender in the medial and lateral joint lines. There was small effusion, but no instability to varus or valgus stress and a negative Lachman's test. The only additional limitation following repetitive use was increased pain. There were no flare-ups, or effects of incoordination, fatigue, weakness, or lack of endurance on his joint function. The summary of his symptomatology was continued pain, swelling, and loss of 5 degrees of flexion. In November 2007, the Veteran still reported joint effusion and lateral joint line pain and discomfort. The Veteran was given permission to return to full duty. In December 2007, the Veteran reported that he was doing well and was working full duty. In a February 2008 treatment record, the Veteran reported that following his Hyalgan injection series, his joint effusion had largely resolved. He still had lateral knee pain and could not run well, jump well, or do anything else that required a load on the lateral compartment. He could stand, flex, and extend the knee with recurrent popping sensation. Upon examination, his gait was normal, his range of motion was full, there was no joint effusion, and his lateral joint line was mildly painful. In June 2008, the Veteran reported that he could ride a stationary bike and use an elliptical without much difficulty but it was hard to run on the street. It was also hard for him to do a single leg squat and weight train. Upon examination, his gait was normal, there was no joint effusion, range of motion was full, and the lateral joint line was mildly painful. A July 2008 record noted that the Veteran's gait was normal, there was no joint effusion, his range of motion was full, lateral joint line was slightly painful, and medial joint line was not painful. In an October 2008 record, the Veteran reported that he had good days and bad days. Good days meant he had some pain with everyday activity but was able to work out in the gym without too much trouble. A bad day meant his knee was sore with everything he did. The private examiner reported that his examination was essentially normal. The Veteran had a VA examination in April 2010. The Veteran reported pain of 7/10 that was located mostly along the lateral aspect of the right knee. He had swelling that was activity dependent and complained of painful clicking and popping. There was no locking, giving way, unsteadiness, or falling. The Veteran complained of pain going up and down stairs. He reported that he occasionally used a brace with activities. He reported flare-ups that were activity dependent, but could not quantitate how often they occur. The Veteran's daily activities were not affected other than by pain, and he reported pain with going up and down stairs or climbing ladders. His job was affected in that "there is a physical test that he is unable to do." He also complained of pain during foot pursuits. His walking and standing were not affected. The Veteran did not notice any heat or redness. Upon physical examination, the Veteran's gait was normal. There was palpable crepitus on range of motion testing but no swelling. Strength testing was 5/5. Anterior and posterior drawer testing were both negative. Lachman's and McMurray's tests were also negative. The knee was stable to varus and valgus stress testing. The range of motion was 0 to 130 without pain. The Veteran did not exhibit any functional loss due to pain, weakness, lack of endurance, or incoordination on repetitive motion testing. An x-ray showed moderate degenerative joint disease of the patellofemoral and lateral compartments and no effusion. A January 2011 worker's compensation work status report noted that the Veteran could perform all duties required of a detective except for running, jumping, and fighting. The Veteran had another VA examination in August 2012. The Veteran reported that his right knee was worse than at the time of his last VA examination. The Veteran was on full duty as a police officer but was doing supervisor duties because of his knee. He reported constant 7-8/10 pain over his right knee. The Veteran denied that flare-ups impact the function of his knee. Flexion was to 120, with objective evidence of painful motion at 100 degrees, and extension was to 0 degrees without objective evidence of painful motion. After three repetitions, right knee flexion was limited additionally at 120 degrees and 0 degrees extension. Instability in the right knee was also shown. There was tenderness or pain to palpation for the joint line. Muscle strength testing was 4/5, active movement against some resistance, on both knee flexion and extension. Lachman's test was normal, Posterior drawer test was normal, and medial-lateral instability was 1+ (0-5 millimeters). There was no evidence or history of recurrent patellar subluxation or dislocation. It was noted that the Veteran had a meniscal tear with frequent episodes of joint locking, pain, and effusion. Following his meniscectomy, he continued to have pain and limitation of motion. There was no x-ray evidence of patellar subluxation. The Veteran reported that he was out of work for about one to two weeks during the last year. In a January 2013 private treatment record, the Veteran reported that he no longer weight trains at all with his lower extremity. If he sits with his knee bent and then straights it, he asserted that "something catches." His knee was very stiff. Upon examination, his gait was normal; there was decreased flexion and extension, and a markedly painful lateral joint line. The Veteran has also been assigned a separate 10 percent rating, effective March 25, 2011, for mild instability associated with the right knee disability under DC 5257. A separate rating based on instability is not warranted prior to this date, and a rating in excess of 10 percent is not warranted at any time since March 25, 2011. Diagnostic Code 5257 is used for rating other impairment of the knee and allows for 10, 20, and 30 percent ratings for recurrent subluxation or lateral instability that is slight, moderate, and severe, respectively. 38 C.F.R. § 4.71a. The evidence in this case reflects that the Veteran did not have right knee recurrent subluxation or lateral instability prior to March 25, 2011. For example, during VA examination in October 2007 there was no right knee instability to varus or valgus stress and a negative Lachman's test. During examination in April 2010, the Veteran reported unsteadiness or falling, and physical examination revealed negative anterior and posterior drawer tests as well as negative Lachman's and McMurray's tests. The examiner specifically noted that the knee was stable to varus and valgus stress testing. In fact, in August 2012 an examiner specifically noted that there was no evidence or history of recurrent patellar subluxation or dislocation. In sum, prior to March 25, 2011, the evidence does not reflect instability of the right knee. Since March 25, 2011, the evidence reflects that the Veteran did not have recurrent subluxation and lateral instability that was more than slight in degree. During examination in August 2012 instability in the right knee was shown; however, Lachman's test was normal and posterior drawer test were normal. While there was medial-lateral instability, the examiner described such instability as 1+ (0-5 millimeters). The Board finds that the most nearly approximates slight instability. A higher level of instability has not been shown by the evidence. Indeed, there were levels above 1+ (such as 2+ or 3+) for the examiner to rate the right knee instability; however, the clinician determined that such levels were not shown upon physical examination. In conclusion, the criteria for a rating in excess of 10 percent based on limitation of motion have not been met. See 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a DCs 5003, 5260, 5261. The Board has considered the tenants of DeLuca v. Brown, 8 Vet. App. 202 (1995) and finds that the current rating, to the extent present, contemplates such factors. See August 2012 VA examination report (noting no flare-ups and that the Veteran was able to perform repetitive use testing); April 2010 VA examination report (noting that the Veteran did not exhibit any functional loss due to pain, fatigue, weakness, lack of endurance, or incoordination upon repetitive testing); October 2007 VA examination report (noting no flare-ups or effect or incoordination, fatigue, weakness or lack of endurance on his joint function). The criteria for a rating in excess of 10 percent based on instability have not been met. Further, the criteria for a 10 percent rating based on instability were not met prior to March 25, 2011. See 38 C.F.R. §§ 4.7, 4.71a DC 5257. The Board has also considered whether an increased evaluation would be in order under other DCs relevant to the knee. However, the Board finds that higher, or separate ratings, are not for application. A rating under DC 5256 is not for application because ankylosis (or its equivalent) has not been shown. Although some effusion was noted during the appeal period, diagnostic testing of the right knee did not reveal any dislocated cartilage. There is also no evidence of tibia or fibula impairment or genu recurvatum. Thus, ratings cannot be assigned under DCs 5256, 5258, 5262, or 5263. See 38 C.F.R. § 4.71a. Even if the criteria for a 10 percent rating based on symptomatic removal of semilunar cartilage were met for part of the appeal period, a rating under DC 5259 cannot be assigned as it would constitute pyramiding with the ratings already assigned for the right knee disability. See 38 C.F.R. § 4.14 (2013); see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran's symptoms demonstrated by his service-connected right knee have already been compensated by his current ratings. III. Scars As noted in the Introduction, the Veteran was assigned a non-compensable evaluation for residuals scars related to his right knee surgeries under DC 7806. 38 C.F.R. § 4.118. The September 2012 rating decision assigned the effective date of November 17, 2010, the "date of hospitalization treatment which reflected findings to establish entitlement to service connection." However, the evidence of record indicates that an earlier effective date for the non-compensable evaluation for scars can be granted. In this regard, on the April 2010 VA examination, the examiner noted that the Veteran had several well-healed anterior arthroscopic portals. There was also an anterior linear scar that measured 12.5 centimeters (cm) by 0.3 cm and a lateral scar that measured 4 cm by 1 cm. The scars were all highly mobile and not adherent to the underlying tissue. There was no subcutaneous tissue loss, no keloid formation, no hypertrophy, and no motion restriction. The scars were nontender, flat, and of normal tone and texture. After resolving all reasonable doubt in favor of the Veteran, the Board concludes that an effective date of April 2, 2007, the date of his initial surgery for his service-connected right knee during the course of his appeal, is assigned. An April 2007 private treatment record recorded that following his surgery, the Veteran's incision sites were noted to be clean and dry and that staples were in place. It seems reasonable to conclude that even though the characteristics of the scars were not reported until April 2010, the Veteran had scars on his right knee from the date of his April 2, 2007 surgery. Accordingly, entitlement to a non-compensable rating for residual scars is warranted effective April 2, 2007. See 38 C.F.R. § 3.400(b)(2). However, the criteria for a compensable rating for the residual scars are not met at any point during the appeal period. During the August 2012 VA examination, the examiner noted that there was one midline scar, one lateral patellar scar, five port for arthroscopy scars, and one superomedial to the patella. The superficial non-linear scars were 15 cm by 1 cm; 6 cm by 1 cm; 1 cm by 1 cm; and 2.5 cm by 1 cm. There was a superficial non-linear scar with total approximate area of 65 square cm. The scars did not affect his ability to work. Although the Veteran's scars covered an area greater than 39 square cm but less than 77 square cm, they were not described as deep to warrant a 10 percent rating under DC 7801. Although his scars were described as superficial and nonlinear, they were not described as covering an area of at least 929 square cm for a 10 percent rating under DC 7802. The Veteran's scars were not found to be painful or unstable for a 10 percent rating under DC 7804. Further, they did not cover at least 5 percent of his entire body, or require systemic therapy or other immunosuppressive drugs for a rating under DC 7806. Lastly, the scars did not cause any disabling effects to warrant consideration of a rating under another DC. 38 C.F.R. § 4.118, DC 7805. IV. Extraschedular consideration The above determinations are based upon application of the pertinent provisions of VA's rating schedule. The Board finds that the record does not reflect that the Veteran's right knee disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). 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 Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). In this case, the Board finds that the rating criteria to evaluate his right knee disability reasonably describe the Veteran's disability level and symptomatology and he has not argued to the contrary. First of all, the Veteran's scars do not manifest in any symptomatology. Their size and shape are fully contemplated by the applicable rating criteria as discussed above. The Veteran's service-connected right knee disability is manifested by signs and symptoms such as pain, limitation of motion, difficulty squatting, and instability, which impairs his ability to climb stairs and run. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the knee and leg provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (providing ratings on the basis of limited flexion and extension). In summary, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in his ability to run and climb stairs. In short, there is nothing exceptional or unusual about the Veteran's right knee disability because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the evidence of record does not suggest that his right knee disability has caused him to miss work or has resulted in any hospitalizations beyond the assigned periods of convalescence that have already been considered and contemplated under 38 C.F.R. § 4.30. The Board observes that the Veteran has contended that his right knee limitations have caused him to choose sedentary work at the police station, which is limiting his ability to advance his career. He also testified that he cannot wear a knee brace with his uniform and has taken time off from work in connection with his knee. This does not rise to the level of marked interference with employment and is contemplated by the current ratings. The Board finds, therefore, that the Veteran's service-connected right knee disability does not result in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, referral for extraschedular consideration is not warranted. ORDER Entitlement to an increased disability rating for service-connected right knee disability, currently rated as 10 percent disabling, is denied. Entitlement to an initial rating for service-connected mild instability, associated with the right knee disability, in excess of 10 percent disabling, is denied. Entitlement to a compensable disability rating for residual scars associated with the right knee disability is denied. Entitlement to a temporary total rating beyond June 30, 2007, based on a period of convalescence after the April 2, 2007 surgery for the service-connected right knee disability, is denied. Entitlement to a temporary total rating beyond October 31, 2007, based on a period of convalescence after the September 17, 2007 surgery for the service-connected right knee disability, is denied. Entitlement to an effective date of April 2, 2007 for the grant of service connection for residual scars associated with the right knee disability is granted. ____________________________________________ Paul Sorisio Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs