Citation Nr: 1400035 Decision Date: 01/02/14 Archive Date: 01/16/14 DOCKET NO. 10-04 644 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for left knee patellofemoral pain syndrome with mild degenerative joint disease. 2. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral pain syndrome with mild degenerative joint disease prior to May 10, 2012. 3. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral pain syndrome with mild degenerative joint disease from May 10, 2012. 4. Entitlement to a separate disability rating for right knee instability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Castillo, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1979 to August 1999. This matter is before the Board of Veterans' Appeals (Board) on appeal of an August 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. FINDINGS OF FACT 1. Throughout the appeal, the Veteran's left knee patellofemoral pain syndrome has manifested with pain, flexion limited to no less than 45 degrees and limitation of extension to 5 degrees; and without any objective evidence of instability, subluxation, or ankylosis. 2. Prior to May 10, 2012, the Veteran's right knee patellofemoral pain syndrome manifested with pain, flexion limited to no less than 95 degrees and limitation of extension to 0 degrees, including on repetition; and without ankylosis. 3. From May 10, 2012, flexion was limited to 30 degrees in the right knee. 4. Throughout the appeal, there have been credible subjective complaints of right knee instability, but without clinical evidence of instability or subluxation. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for left knee patellofemoral pain syndrome with mild degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5003, 5257, 5261 (2013). 2. Prior to May 10, 2012, the criteria for a disability rating in excess of 10 percent for right knee patellofemoral pain syndrome with mild degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.7, 4.71a, DCs 5003, 5260, 5261 (2013). 3. Resolving doubt in the Veteran's favor, from May 10, 2012, the criteria for a 20 percent disability rating for right knee patellofemoral pain syndrome with mild degenerative joint disease have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.59, 4.7, 4.71a, DCs 5003, 5260 (2013). 4. Resolving doubt in the Veteran's favor, from May 10, 2012, the criteria for a separate disability rating for right knee instability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, DC 5257 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. 38 U.S.C.A. § 5103(a) (West 2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. A June 2009 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). This letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was informed of the need to show the impact of disabilities on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claim was subsequently readjudicated, most recently in a May 2013 supplemental statement of the case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.); see also Mayfield, 444 F.3d at 1333-34. The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c)(2). VA examinations were conducted in July 2009, April 2010, and May 2012. The Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. The VA examination reports are adequate for the purposes of deciding the claim because the examiners conducted clinical evaluations, reviewed the medical history, and described the disability in sufficient detail so that the Board's evaluation is an informed determination. 38 C.F.R. § 3.159(c)(4); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claim file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Sanders, 129 S. Ct. 1696; see also Dingess/Hartman, 19 Vet. App. at 486. General Rating Principles Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). Rating the Knee Diagnostic Code 5003 provides that degenerative arthritis is to be rated on the basis of limitation of motion of the affected joint under the appropriate diagnostic code for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint group or minor joint group affected by limitation of motion. In the absence of limitation of motion, a 20 percent evaluation is provided where there is X-ray evidence of involvement of two or more major joints, or two of more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003 (2013). The knee is considered a major joint. 38 C.F.R. § 4.45(f) (2013). Under DC 5257, the criterion for a 10 percent rating is slight recurrent subluxation or lateral instability of the knee. A 20 percent rating requires moderate recurrent subluxation or lateral instability. A 30 percent rating, the maximum rating for this Diagnostic Code requires severe recurrent subluxation or lateral instability. Under DC 5260, flexion limited to 60 degrees is noncompensable. The criterion for a 10 percent rating is flexion limited to 45 degrees. The criterion for the next higher rating, 20 percent, is flexion limited to 30 degrees. The criterion for the maximum rating under this Diagnostic Code, 30 percent, is flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, extension limited to 5 degrees is noncompensable. The criterion for a 10 percent rating is extension limited to 10 degrees. The criterion for a 20 percent rating is extension limited to 15 degrees. The criterion for the next higher rating, 30 percent, is extension limited to 20 degrees. The criterion for the next higher rating, 40 percent, is extension limited to 30 degrees. The criterion for the maximum rating under this Diagnostic Code, 50 percent, is extension limited to 45 degrees. 38 C.F.R. § 4.71a. Normal knee motion is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Under 38 C.F.R. § 4.71a, there are other diagnostic codes that may potentially be employed to evaluate impairment resulting from service-connected knee disorders. Diagnostic Code 5258 provides a 20 percent evaluation for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. Diagnostic Code 5259 grants a 10 percent evaluation for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a, DC 5259. Additional rating criteria are found under DCs 5256 (ankylosis of the knee), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum acquired, traumatic, with weakness and insecurity in weight-bearing objectively). 38 C.F.R. § 4.71a, DC 5256, 5262, 5263. A knee disability rated under DC 5257 or DC 5259 warrants a separate rating for arthritis based on X-ray findings and limitation of motion under DC 5260 or DC 5261; limitation of motion need not be compensable, but must at least meet the criteria for a zero-percent rating under those codes. A separate rating for arthritis may also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59 and DC 5003. VAOPGCPREC 9-98 (1998). Separate ratings are also available for limitation of flexion and limitation of extension under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Facts At VA examination in July 2009, the Veteran complained of bilateral knee pain, stiffness, and locking, that was treated with medication. He denied subluxation and episodes of dislocation. He reported that he works as a mail handler at the post office, and that he has had to take 3-4 days of sick leave per month because of knee pain. He denied a history of knee surgery. On physical examination, the VA examiner reported that knee flexion was limited to 130 degrees and extension to 0 degrees bilaterally with objective evidence of pain following repetitive motion, but no additional limitations after repetition. Varus/valgus testing of the medial, lateral, collateral ligaments was normal bilaterally. Anterior and posterior cruciate ligaments were normal bilaterally. McMurray's Test was negative bilaterally. The Veteran's gait was normal and there was no evidence of abnormal weight-bearing. There was no objective evidence of instability, edema, effusion, weakness, or abnormal guarding. The VA examiner diagnosed degenerative joint disease and patellofemoral pain syndrome, bilaterally. A November 2009 VA treatment record reflects a complaint of right knee instability and weakness. An April 2010 private treatment record shows that the Veteran complained of pain and occasional locking at about 15 degrees of extension. He reported that his knee felt like it gives-way, but he denied any episodes of clear dislocation. Physical examination showed no edema and negative anterior and posterior drawer tests. On VA orthopedic consultation in April 2010, the Veteran complained of knee pain, and right knee buckling. He was unsure if he had locking versus stiffness in the right knee. He denied left knee locking. He denied a history of surgery. On physical examination, flexion of the right knee was limited to 95 degrees with pain and flexion of the left knee was limited to 130 degrees without pain. Extension was to 0 degrees in the right knee and 5 degrees in the left knee. No laxity was noted with stressing of medial and lateral, collateral ligaments and anterior and posterior cruciate ligaments. At VA examination in April 2010, the Veteran complained of instability of the right knee and bilateral knee stiffness and pain, which were treated with a right knee brace, cane, and medication. He reported that he still worked as a mail handler, and that he had to take 3 days of sick leave per month due to knee pain. Functional limitation was pain with prolonged standing or walking. On physical examination, the VA examiner reported that flexion was to 140 degrees and extension was to 0 degrees bilaterally, with objective evidence of pain following repetitive motion, but no additional limitations after repetition. No obvious deformity of either knee, such as warmth or edema, was noted. Stability was intact bilaterally with negative Lachman's test and negative McMurray's sign. The VA examiner noted that the Veteran walked with an exaggerated antalgic gait that was inappropriate to his physical examination and X-ray findings. Ankylosis was not present. The VA examiner diagnosed mild degenerative joint disease of the right knee and retropatellar pain syndrome of the left knee. With respect to the subjective complaint of right knee occasional give way, the VA examiner noted the Veteran is a diabetic that is chronically ill and deconditioned. He stated that diabetic peripheral neuropathy may contribute to the Veteran's leg weakness. An October 2010 private treatment note shows the Veteran had no laxity, effusion, or swelling of either knee on clinical evaluation. Mild crepitus was present and knee alignment was normal. At VA examination in May 2012, the Veteran complained of pain and giving way, which were treated with a right knee brace, cane, medication, and steroid injection in the right knee. He reported that he has changed his occupational duties, from mail handler to desk job, due to knee pain. On physical examination, the examiner reported that right knee flexion was limited to 30 degrees and extension was to 0 degrees with no objective evidence of pain. Left knee flexion was limited to 45 degrees and extension was to 0 degrees with no objective evidence of pain. Following repetitive motion, there was no additional limitation of motion in either knee. However, there was additional functional impairment due to less movement than normal. Joint stability tests revealed medial, lateral, and collateral ligaments and anterior and posterior cruciate ligaments were normal. No evidence of recurrent subluxation or dislocation. The examiner noted there was no history of meniscal surgery or of recurrent subluxation or dislocation. Significantly, the VA examiner expressed the opinion that the Veteran's symptoms and decreased active range of motion are far out of proportion to the physical findings and the X-ray findings of mild degenerative joint disease of the knees, which are consistent with normal findings of the knees of a 58 year old male. The examiner further explained that the orthopedic consultation in April 2010 showed an active range of motion of the knees with right knee flexion to 95 degrees and left knee flexion to 130 degrees. Analysis Left Knee The Veteran is currently in receipt of a 10 percent rating for left knee patellofemoral pain syndrome with mild degenerative joint disease, pursuant to 38 C.F.R. § 4.71a, DCs 5003-5257. A rating of 10 percent is warranted for painful movement of an arthritic joint even if no compensable loss of motion is shown; see VAOPGCPREC 09-98 (August 14, 1998), citing Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991); see also Burton v. Shinseki, 25 Vet. App. 1 (2011). The knee is a single major joint; hence a higher rating under DC 5003 is not warranted for either knee. See 38 C.F.R. § 4.45(f); 4.71, DC 5003 (2013). The evidence does not support a higher rating under DC 5257 for left knee instability. That is, moderate instability is not shown by the record. The objective medical findings have consistently failed to any show clinical evidence of instability with stressing of medial and collateral ligaments and anterior and posterior cruciate ligaments. McMurray's, Drawer, and Lachman's Tests have all been negative at every VA examination. On VA examination in July 2009, the Veteran denied subluxation and episodes of dislocation. The private and VA outpatient treatment records also failed to reveal clinical evidence of left knee instability or recurrent subluxation during this appeal. The Board further notes that while the Veteran would be competent to report symptoms of left knee instability and give way; he has not done so. Rather, he has complained of right knee instability. The 10 percent disability rating that is in effect for the patellofemoral pain syndrome of the left knee was assigned pursuant to the hyphenated Diagnostic Code 5003-5257. Use of this hyphenated code accounts for any subjective complaints of left knee instability and give-way. In the absence of any objective evidence of left knee instability or subluxation that is of moderate severity, a higher rating of 20 percent is not warranted. The criteria for a higher rating under DC 5260 or 5261, for limited flexion and/or extension have also not been met at any time during the appeal. See 38 C.F.R. § 4.71, Diagnostic Codes 5260 and 5261; see also VAOPGCPREC 9-2004. A 20 percent rating requires knee flexion limited to 30 degrees and extension limited to 15 degrees, respectively. Here, with the exception of the May 2012 VA examination findings, left knee flexion has not been shown to have been less than 95 degrees and extension has been to no less than 5 degrees, including upon repetition. See, the July 2009 and April 2010 VA examination reports. The May 2012 range of motion findings of left knee flexion limited to 45 degrees and extension to 0 degrees also does not warrant a higher rating under DCs 5260 and/or 5261, including with consideration of functional limitation. Significantly, the examination report showed there was no additional limitation of motion following repetitive motion. Therefore, even considering any functional limitation, the Veteran's ranges of motion did not meet or more nearly approximate that required for higher rating of 20 percent for limitation of flexion or a separate 10 percent for limitation of extension, even with consideration of the DeLuca precepts. The Veteran has reported episodes of pain, swelling and locking in the left knee joint. Thus, the Board has also considered whether separate or higher evaluations are warranted under 38 C.F.R. § 4.71a, DCs 5258 and 5259. As indicated, a 20 percent rating is warranted under DC 5258 when there is semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. There is no evidence of dislocated semilunar cartilage in this case to support a higher rating under DC 5258. Accordingly, this diagnostic code is not for application. DC 5259 is also inapplicable as there is no evidence of removal of semilunar cartilage, which is symptomatic. There are no other diagnostic codes which would provide higher or separate ratings for the Veteran's left knee disability. The left knee disability is not productive of ankylosis or complete immobility of the knee joint; malunion or nonunion of the tibia and fibula, therefore Diagnostic Codes 5256 and 5262 are not applicable. Right Knee The service-connected right knee patellofemoral pain syndrome with mild degenerative joint disease, is currently rated at 10 percent pursuant to 38 C.F.R. § 4.71a, DC 5003-5260, for painful motion of a major joint. The knee is a single major joint; hence a higher rating under DC 5003 is not warranted for the right knee. See 38 C.F.R. § 4.45(f); 4.71, DC 5003 (2013). Throughout the appeal, the Veteran has reported instability in his right knee. His complaints have been consistent in this regard and are considered credible. The Board notes that the objective medical findings consistently fail to show clinical evidence of instability with stressing of medial and collateral ligaments and anterior and posterior cruciate ligaments, but nonetheless finds that the Veteran's credible and competent complaints support the assignment of a separate compensable rating for slight right knee instability. The evidence does not, however, support a higher rating of 20 percent under DC 5257 for moderate right knee instability. In the absence of any objective findings of instability or subluxation, the Board finds that moderate instability is not shown and a 20 percent rating is not warranted. The Board further finds that the symptoms of right knee disability has met the criteria for a higher rating of 20 percent under DC 5260 (for limited flexion), but only from May 10, 2012. Prior to May 2012 VA examination, right knee flexion was not shown to have been less than 95 degrees, including upon repetition. See, the July 2009 and April 2010 VA examination reports. The private and VA treatment records did not reflect range of motion findings that showed right knee flexion limited to at least 30 degrees. The May 2012 VA examination report showed right knee flexion was limited to 30 degrees. The Board notes that the VA examiner stated that the Veteran's decreased active range of motion was far out of proportion to the physical findings. However, the Board also notes that throughout the appeal, the Veteran has credibly reported experiencing significant pain and impaired function due to his right knee disability, more so than his left. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is resolving all doubt in the Veteran's favor to find the May 2012 finding of right knee flexion to 30 degrees to be probative. This range of right knee motion meets the criteria for a higher evaluation of 20 percent. As flexion limited to 15 degrees has not been demonstrated on objective testing, including upon repetition; the criteria for an even higher rating of 30 percent are not met, even with consideration of the DeLuca precepts. The Board has also considered whether a separate, compensable rating may be assigned for right knee limitation of extension pursuant to VAOPGCPREC 9-2004. A compensable evaluation for limitation of extension requires knee extension to be limited to 10 degrees or greater. See 38 C.F.R. § 4.71a, DC 5261. Here, right knee extension has been full to 0 degrees, including on repetition, at every evaluation during the appeal. Based on these findings, a separate, compensable rating for limitation of right knee extension is not warranted for the entire period under review, even with consideration of the DeLuca precepts. The Veteran has reported episodes of pain, swelling and locking in the right knee joint. Thus, the Board has also considered whether separate or higher evaluations are warranted under 38 C.F.R. § 4.71a, DCs 5258 and 5259. As indicated, a 20 percent rating is warranted under DC 5258 when there is semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. There is no evidence of dislocated semilunar cartilage in this case to support a higher rating under DC 5258. DC 5259 is also inapplicable as there is no evidence of removal of right knee semilunar cartilage, which is symptomatic. There are no other diagnostic codes which would provide higher or separate ratings for the Veteran's right knee disability. The right knee disability is not productive of ankylosis or complete immobility of the knee joint; malunion or nonunion of the tibia and fibula, therefore Diagnostic Codes 5256 and 5262 are not applicable. The Board has considered whether "staged" ratings are appropriate for the service-connected left and right knee disabilities and associated residuals. See Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the record does not support assigning higher ratings than currently assigned in this decision during the appeal period. Extraschedular and TDIU Consideration In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that neither the first nor second Thun element is satisfied here. The Veteran's service-connected left and right knee disabilities are both manifested by signs and symptoms such as pain, stiffness, locking, and limited motion, which impairs his ability to stand and walk for long periods. 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 5256, 2560, 5261 (providing ratings on the basis of ankylosis and limited flexion and extension). For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased, or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet.App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet.App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in standing and walking for long periods. In short, there is nothing exceptional or unusual about the Veteran's left and right knee disabilities because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet.App. at 115. Even if the Board were to find that step one of Thun had been satisfied, extraschedular referral would still not be warranted because the Board also finds that Thun step two is not satisfied. See Johnson v. Shinseki, 26 Vet.App. 237, 247 (2013) (en banc) (error in Thun step one analysis is harmless were Board makes an adequate finding that Thun step two is not satisfied). With respect to the second Thun element, there is no evidence of frequent hospitalization or marked interference with employment caused by either disability. The rating criteria are therefore adequate to evaluate the Veteran's disabilities and referral for consideration of an extraschedular rating is not warranted. Finally, the Board has considered whether a claim of total disability based on individual unemployability is inferred in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran is currently employed. The record shows that he switched from a mail handler to a sedentary desk job to accommodate his knee disabilities. As there is no evidence of unemployability due to either service-connected knee disability; the question of entitlement to a TDIU is not raised. ORDER A disability rating in excess of 10 percent for left knee patellofemoral pain syndrome with mild degenerative joint disease is denied. Prior to May 10, 2012, a disability rating in excess of 10 percent for right knee patellofemoral pain syndrome with mild degenerative joint disease is denied. Resolving doubt in the Veteran's favor, from May 10, 2012, a 20 percent disability rating for right knee patellofemoral pain syndrome with mild degenerative joint disease is granted subject to the laws governing the grant of monetary benefits. Resolving doubt in the Veteran's favor, a separate disability rating for right knee instability is granted subject to the laws governing the grant of monetary benefits. ____________________________________________ D. JOHNSON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs