Citation Nr: 1342390 Decision Date: 12/23/13 Archive Date: 12/31/13 DOCKET NO. 10-48 728 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome, right knee (right knee disability). 2. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome, left knee (left knee disability). REPRESENTATION Veteran represented by: Timothy E. Burns, Attorney ATTORNEY FOR THE BOARD Michael J. Adams, Associate Counsel INTRODUCTION The Veteran had active service from March 2004 to December 2004. These matters come to the Board of Veterans' Appeals (Board) from an October 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In an October 2010 correspondence, the Veteran's representative requested an extension of time to submit additional medical evidence. This request was made during the 60 day period following the issuance of the September 2010 statement of the case. The Board finds that this correspondence qualifies as a substantive appeal and is therefore timely. Furthermore, the RO treated the Veteran's appeal as timely without objection. See Percy v. Shinseki, 23 Vet. App. 37, 46 (2009) (holding that VA waives any objection to the timeliness of a substantive appeal by taking actions that would lead an appellant to believe that the appeal was perfected.) As such, the October 2009 rating decision is currently on appeal before the Board. FINDINGS OF FACT 1. Left knee patellofemoral pain syndrome is manifested by flexion limited to no less than 110 degrees with pain, and 100 degrees after repetition for the entire period on appeal; no additional functional loss due to fatigue, weakness, incoordination, or lack of endurance with repetitive use; there also was no evidence of arthritis, recurrent subluxation or lateral instability. 2. Right knee patellofemoral pain syndrome is manifested by flexion limited to no less than 110 degrees with pain, and 100 degrees after repetition for the entire period on appeal; no additional functional loss due to fatigue, weakness, incoordination, or lack of endurance with repetitive use; there also was no evidence of arthritis, recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for an evaluation in excess of 10 percent for right knee patellofemoral pain syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5024(2013). 2. For the entire period on appeal, the criteria for an evaluation in excess of 10 percent for left knee patellofemoral pain syndrome have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5024(2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims 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, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the RO provided notice to the Veteran in July 2009, prior to the initial adjudication of the claim in October 2009. The Veteran was notified of the evidence not of record that was necessary to substantiate the claims, as well as of VA's and the Veteran's respective duties for obtaining evidence. The July 2009 notice letter also informed the Veteran how disability ratings and effective dates are assigned. Thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of his claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA treatment records, VA examination reports, private treatment records, and lay statements. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in October 2010, March 2012 and March 2013. Prior to the March 2012 VA examination, the Veteran asserted that his service-connected bilateral knee disabilities had worsened. VA's General Counsel has interpreted that, when a veteran asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. See VAOPGCPREC 11-95; see also, e.g., Caffrey v. Brown, 6 Vet. App. 377, 381 (1995); Green v. Derwinski, 1 Vet. App. 121, 124 (1991); 38 C.F.R. § 3.327 (2013). Accordingly, the Veteran was afforded another VA examination in March 2012 and March 2013. The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran, fully reviewed all medical evidence of record, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes. Moreover, neither the Veteran nor his representative have challenged the adequacy of the examinations. The Veteran was offered the opportunity to testify at a hearing before the Board, but withdrew his request through written correspondence submitted in March 2013. As such, the request for a hearing is considered withdrawn. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Ratings for Right and Left Knee Disabilities Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2013). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether a staged rating is warranted; however, as will discuss in more detail below, the Board finds that staged ratings for any of the Veteran's knee disabilities is not appropriate in this case. The Diagnostic Codes relevant to this case are 5003, 5010, 5024, and 5256-5263. The VA General Counsel has interpreted that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97. Likewise, the VA General Counsel has also interpreted that, when X-ray findings of arthritis are present and a veteran's knee disability is evaluated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable evaluation under Diagnostic Code 5003 if the arthritis results in limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Furthermore, to warrant a separate rating for arthritis based on X-ray findings and limited motion under Diagnostic Codes 5260 or 5261, the limited motion need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Veteran is in receipt of a 10 percent disability rating for the right knee and a 10 percent disability rating for the left knee rated under Diagnostic Code 5024 (rating for tenosynovitis). Diagnostic Code 5024 is rated based on limitation of motion pursuant Diagnostic Codes 5003, 5260, and 5261. The Veteran contends that his right and left knee disabilities have manifested by more severe symptomatology than that contemplated by the respective 10 percent ratings assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5024 for the entire rating period. Specifically, the Veteran contends that his right and left knee disabilities are manifested by instability, with episodes of locking and buckling, and should be rated under Diagnostic Code 5257. The Veteran has reported other symptoms of knee impairment that pertain to a separate rating for knee arthritis, namely, pain and limitation of motion. In an October 2009 notice of disagreement, the Veteran stated that he has limited motion, constant pain, and that his knees were weak and felt as if they would buckle. He also reported that he was not examined properly at a February 2009 VA examination. While there appears to be a corresponding VA treatment note, the record is negative for any VA examinations during that time. In a February 2012 correspondence, the Veteran, through his representative, contended that his bilateral knee disabilities are severe enough to warrant increased evaluations. Instability Diagnostic Code 5257 contemplates impairment of the knee manifested by recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where instability is severe, moderate and slight, disability evaluations of 30, 20, and 10 percent are assigned, respectively. 38 C.F.R. § 4.71a. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6 (2013). Having reviewed all the evidence of record, both lay and medical, the Board finds that the Veteran does not have bilateral knee instability and therefore Diagnostic Code 5257 is not for application. The Veteran has reported that he experiences right and left knee instability manifested by difficulty running, locking, popping noises, buckling sensation brought on by weakness, and occasional use of a right knee brace. VA treatment reports during the period on appeal are negative for any objective findings of bilateral instability, although they do indicate that the Veteran's knees make a popping sound when bent. At the October 2010 VA examination, the examiner specifically reported that there was no instability in both knees. The report from the March 2012 VA examination also reflects that no objective instability was observed on examination in either the right or left knee. Joint stability tests were also normal at the March 2013 VA examination. Additionally, the March 2012 and 2013 reports note that there was no subluxation of either knee. The Veteran reported that he experienced locking during ROM testing at his March 2013 VA examination. It was noted that he proceeded to jump off the table and do deep knee bends to a full squat position to relieve the sensation. The examiner reported that there were no clinical signs of locking upon examination however. It was also noted that the Veteran used a right knee brace on occasion when the weather made his pain flare up. A private examination report from August 2009 also reflects that the Veteran's knees demonstrated no clinical signs of instability. X-rays taken at that time also appeared normal bilaterally. A VA treatment note from February 2009 reflects that the Veteran had normal X-rays of both knees from February, 2009, December 2008, and October 2007. Based on the above, the evidence of record does not establish that the Veteran's bilateral knee disability warrants an evaluation under Diagnostic Code 5257 for any period on appeal as the weight of the evidence does not establish that the Veteran's bilateral knee disability is characterized by any instability. As noted above, the Veteran has reported that he has instability in both knees characterized by episodes of locking and a sensation of buckling, the occasional use of a knee brace, and difficulty sitting for prolonged periods; however, all three VA examination reports, along with the private examination report, note no mechanical instability, locking or subluxation in either knee. Additionally, the March 2012 and 2013 VA examination reports note that imaging studies performed on the knees reflect no X-ray evidence of patellar subluxation. Furthermore, the Veteran reported wearing his knee brace only occasionally and in response to increased pain during periods where the weather causes a flare-up. Knee Arthritis and Limitation of Motion The Board has also considered whether assignment of separate evaluations under any other of the applicable diagnostic codes is appropriate in this case. The Board finds that, for the entire rating period on appeal, the criteria for a disability rating in excess of 10 percent under Diagnostic Code 5024, based on limitation of motion, for the service-connected right and left knee disabilities, including painful motion, is not supported by the evidence in this case. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261. The provisions of Diagnostic Code 5003 set forth that degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if 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 authorized if 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. Id., Diagnostic Code 5003. For the purpose of rating disabilitiy from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f) (2013). Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Notes (1) and (2). The Diagnostic Codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. Id. For disabilities of the musculoskeletal system, the Board also considers whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Having reviewed the evidence of record, both lay and medical, the Board finds that the criteria for a disability rating in excess of 10 percent, each, for the service-connected right and left knee disabilities, based on painful motion limited to a noncompensable (less than 10 percent) degree have not been met under Diagnostic Code 5003. Throughout the entire rating period on appeal, the Veteran's bilateral knee disabilities have been manifested by symptoms of painful motion and tenderness that is productive of noncompensable limitation of motion as required for 10 percent ratings under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Objective range of motion testing at the three VA examinations (October 2010, March 2012, March 2013) along with the August 2009 private examination revealed slightly limited range of motion in both knees with flexion in both knees limited to no less than 110 degrees with pain on flexion. Extension was to zero degrees at all 4 examinations. Upon repetition, objective range of motion testing found an increase in pain, but no fatigability, lack of endurance, weakness, or incoordination. The March 2012 and 2013 VA examination reports, as well as the private examination report, reflect that the Veteran experienced no additional loss of range of motion on repetition. However, the October 2010 VA examination noted that the Veteran's flexion after repetition was limited to 100 degrees. Both the March 2012 and 2013 VA examination reports note that imaging studies show no traumatic or degenerative arthritis for both knees. As discussed, the Veteran has also asserted that weather can cause his knee pain to flare up. However, no evidence of flare-ups was noted at any of the examinations. Based on the evidence above, the Board finds that the Veteran's bilateral knee disability most nearly approximates the criteria for separate 10 percent disability ratings, but not higher, through the entire appeal period under Diagnostic Code 5024 based on painful, but noncompensable, limitation of motion. Specifically, the Board finds that the Veteran's right and left knee disabilities have been productive of painful motion with no X-ray evidence of arthritis, and noncompensable limitation of flexion or extension for the entire rating period, even with considerations of additional limitations due to pain and reported flare ups of the knee disabilities. The Veteran has not endorsed, and the evidence does not otherwise show additional limitation of motion due to pain and tenderness, including during flare ups, that meets the level of a compensable limitation (e.g., limited to 45 degrees in flexion or 10 degrees in extension). 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. See DeLuca; see also 38 C.F.R. §§ 4.40, 4.59. The Board has applied 38 C.F.R. §§ 4.40 and 4.45 and DeLuca, supra for the entire appeal period in reaching its finding that the Veteran has limitation of motion to a noncompensable degree. Although all 4 examination reports note that the Veteran experienced pain, such findings do not provide for a higher disability rating than 10 percent in this case. The weight of the evidence shows that the major limiting factor for the Veteran is pain alone. While increased pain was reported, no fatigue, incoordination, weakness, or lack of endurance was noted upon examination following repetition. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (pain must affect some aspect of normal movement in order to constitute functional loss under 38 C.F.R. § 4.40). The Veteran has asserted that he experiences flare-ups of pain during weather changes; however, he has not asserted that these flare-ups incapacitate him and has dealt with them through the occasional use of a knee brace. He has also reported that prolonged sitting or prolonged standing results in knee pain. At the October 2010 VA examination the Veteran reported moderate impairment of daily activities including chores, shopping, exercise, recreation, traveling, and driving. He reported he was unable to participate in sports. The August 2009 private examination report reflects that the Veteran's knee disabilities have a mild affect on his condition. At the March 2012 VA examination the Veteran reported that his knee pain required him to take breaks at work to stretch but that he would go back to working. Additionally, a VA occupational consult report from May 2012 reflects that the Veteran does not have any physical functional limitations impeding his ability to lift, carry, reach, pull, push, walk, bend, stand for up to 2.5 hours, or sitting for up to 2 hours. It was noted that he had functional issues with kneeling. While the Veteran does appear to experience some functional impairment brought on by knee pain, the evidence of record more closely approximates a 10 percent disability rating for each knee. The weight of the evidence demonstrates that the Veteran's knee disabilities result predominantly in painful motion with mild interference on his daily social and occupational activities. It has not been shown that the Veteran's knee disabilities result in abnormal motion of the knee joint and range of motion throughout the majority of the period on appeal has been close to normal. In this regard, as noted above, the Veteran had near full range of motion during the appeal period even with consideration of pain that limits motion. The range of motion for extension was 0 degrees at all 4 examinations for both knees, which does not warrant a compensable rating based on extension. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. The evidence also reflects that the range of motion for flexion was no less than 110 degrees, initially and no less than 100 degrees upon repetition, for both knees during the period on appeal. None of the range of motion measures warrant a compensable rating based on flexion. See id., Diagnostic Code 5260. The Board finds that the multiple range of motion tests are highly probative evidence that the Veteran has not experienced limitation of flexion to a compensable degree. Additionally, the Veteran has not alleged that he has limitation of flexion to 30 degrees to warrant a rating in excess of 10 percent. During the entire appeal period, the limitation of motion did not more nearly approximate extension limited to 15 degrees or more, or flexion limited to 30 degrees or less, as needed for a 20 percent evaluation, even with consideration of the additional limitation due to pain. The evidence also does not show compensable limitation of motion of extension (10 degrees) and limitation of motion of flexion (45 degrees) to warrant separate compensable ratings for both limitation of extension and limitation of flexion. See VAOPGCPREC 09-04 (separate ratings may be awarded for compensable limitation of flexion and limitation of extension of the same knee joint). Therefore, a higher disability rating in excess of 10 percent is not warranted under Diagnostic Codes 5260 or 5261 for limitation of extension and flexion. 38 C.F.R. § 4.71a. Thus, the evidence demonstrates entitlement to separate 10 percent evaluations, but no higher, for painful motion of the right and left knees under Diagnostic Code 5024 (rated under arthritis) throughout the rating period on appeal. The Board also finds that no other higher or separate rating is warranted under any of the other diagnostic codes pertaining to the knee. For point of explanation, ankylosis is "[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint." Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (quoting from Stedman's Medical Dictionary 87 (25th ed. 1990)). As there is no lay or medical evidence of ankylosis, the Board finds that Diagnostic Code 5256 does not apply. There is no evidence the Veteran has undergone a knee replacement, so Diagnostic Code 5055 is also inapplicable. 38 C.F.R. § 4.71a. Diagnostic Codes 5262 and 5263 do not apply, as there is no evidence of impairment of the tibia or fibula, and no evidence of genu recurvatum. Diagnostic Code 5258 also does not apply as imaging studies during the period on appeal reveal normal meniscus bilaterally. The Board acknowledges that the Veteran asserts he experiences locking, however, there is no clinical evidence of locking on any of the range of motion examinations. Based on the clinical evidence to include the 4 examinations and imaging studies, the Board finds that the weight of the evidence is against a finding that the Veteran has any semilunar cartilage manifested by locking or dislocation. As such, Diagnostic Code 5258 is not for application. Finally, the Board notes that the Veteran has undergone arthroscopic surgery on his right knee. However, the evidence reflects that he does not have any residual surgical scars. The March 2012 and 2013 VA examination reports note that the Veteran does not have any scars associated with his prior surgery. Therefore, the Board finds that the Veteran is not entitled to a separate compensable rating under Diagnostic Codes 7800 through 7805. 38 C.F.R. § 4.118. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for the right or left knee disabilities. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's right and left knee disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's right and left knee disabilities have been manifested by limitation of motion, including due to pain. The schedular rating criteria specifically provides ratings for instability (Diagnostic Code 5257); such noncompensable limitation of motion due to pain (Diagnostic Code 5003, 38 C.F.R. § 4.59); and contemplate ratings based on limitation of motion (Diagnostic Codes 5260, 5261), including motion limited to orthopedic factors such as pain, weakness, and fatigue (38 C.F.R. §§ 4.40, 4.45, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of the bilateral knee disabilities to the rating schedule, the degree of disability of each throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the left or right knee disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when such claim is expressly raised by a veteran or reasonably raised by the record. While an April 2011 VA treatment note reflects that the Veteran reported he could no longer work his landscaping job due to his knee pain, he has also indicated that he is currently in college to become a mechanic. (See March 2013 VA examination report). A VA occupational consult report from May 2012 reflects that the Veteran does not have any physical functional limitations impeding his ability to lift, carry, reach, walk, or utilize hands frequently. It was noted that he had functional issues with kneeling but that he could compensate with a low-level seat. Moreover, the Veteran has not asserted that he is unemployable due to his knee disabilities. Thus, the Board finds that Rice is inapplicable since there is no evidence of record of unemployability due to the Veteran's service-connected right or left knee disabilities, and the Veteran has not asserted TDIU due to service connected knee disabilities. ORDER Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome, right knee, is denied. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome, left knee, is denied. ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs