Citation Nr: 1452909 Decision Date: 12/02/14 Archive Date: 12/10/14 DOCKET NO. 12-14 403 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increase in excess of 10 percent for the service-connected chondromalacia patella of the left knee. 2. Entitlement to an increase in excess of 10 percent for the service-connected chondromalacia patella of the right knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Nelson, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1985 to January 1988 and from December 1990 to August 1991. This matter come before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, that continued a 10 percent disability rating for chondromalacia patella of the left knee and a 10 percent disability rating for chondromalacia patella of the right knee, both under Diagnostic Codes 5260-5010. In May 2012, the Veteran notified the Board that he did not want a Board hearing. FINDINGS OF FACT 1. For the entire increased rating period, the Veteran's chondromalacia patella of the left knee is manifested by pain and noncompensable limitation of flexion ranging from 125 degrees to 130 degrees, without evidence of limitation of extension, ankylosis, recurrent subluxation or lateral instability, semilunar cartilage dislocation, impairment of the tibia and fibula, or genu recurvatum. 2. For the entire increased rating period, the Veteran's chondromalacia patella of the left knee is manifested by pain and noncompensable limitation of flexion to 130 degrees, without evidence of limitation of extension, ankylosis, recurrent subluxation or lateral instability, semilunar cartilage dislocation, impairment of the tibia and fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. For the entire increased rating period, the criteria for a disability evaluation in excess of 10 percent for chondromalacia patella of the left knee are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2014). 2. For the entire increased rating period, the criteria for a disability evaluation in excess of 10 percent for chondromalacia patella of the right knee are not met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Duty to Assist 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VA notice letters must also include notice of a disability rating and an effective date for award of benefits if service connection is granted. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, the RO provided a notice letter to the Veteran in October 2010, prior to the adjudication of the instant claim. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claim for an increased rating, what information and evidence must be provided by the Veteran, and what information and evidence would be obtained by VA. The Veteran was told to inform VA of any additional information or evidence that VA should have, and was told to submit evidence to the RO in support of his claims. The letter also provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective dates. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The Veteran's claim for higher ratings for the service-connected chondromalacia patella of the left knee and right knee are downstream issues, which were initiated by the notice of disagreement. The Court has held that, as in this case, once a notice of disagreement from a decision establishing service connection and assigning the rating and effective date has been filed, the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 control as to the further communications with the appellant, including as to what "evidence [is] necessary to establish a more favorable decision with respect to downstream elements..." Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Thus, there is no duty to provide additional notice in this case with respect to the service-connected chondromalacia patella of the left knee and right knee. The record establishes that the Veteran has been afforded a meaningful opportunity to participate in the adjudication of his claim. The Board notes that there has been no allegation from the Veteran or his representative that he has been prejudiced by any of notice defects. See Shinseki v. Sanders, 556 U.S. 396 (2009). Thus, there is no prejudice to the Veteran in the Board's considering this case on its merits. The Board finds that the duty to notify provisions have been fulfilled, and any defective notice is nonprejudicial to the Veteran and is harmless. The Board further finds that all relevant evidence has been obtained with regard to the Veteran's claim, and the duty to assist requirements have been satisfied. All available service treatment records (STRs) were obtained. VA medical records dated from 1994 to July 2013 are associated with the claims file. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claim. The Veteran underwent VA examinations in November 2010 and June 2013 to obtain medical evidence regarding the etiology and severity of the claimed disability. The Board finds the VA examinations adequate for adjudication purposes. Treatment records were reviewed, the Veteran's history was taken, and complete examinations with clinical measures were conducted. Conclusions reached and diagnoses given were consistent with the examination reports. The Board finds that for these reasons, the Veteran has been afforded adequate examinations. The Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the duties to notify and assist the Veteran have been met, so no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Pertinent Law and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). It is essential that the examination on which ratings are based adequately portray the anatomical damage and functional loss with respect to all these elements. Id. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. The Court instructed that in applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. The Court held that pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. Mitchell v. Shinseki, 24 Vet. App. 32, 33, 43 (2011). Although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Id. The Court explained in Mitchell that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). 38 C.F.R. § 4.71a, Diagnostic Codes (DC) 5256 through 5263 set forth the relevant provisions for disabilities of the knee. DC 5256 governs ankylosis of the knee, and provides a 30 percent rating for knee ankylosis in a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is provided for knee ankylosis in flexion between 10 and 20 degrees. A 50 percent rating is provided for knee ankylosis in flexion between 20 degrees and 45 degrees. A 60 percent rating is provided for knee ankylosis that is extremely unfavorable, in flexion at an angle of 45 degrees or more. The Schedule provides that the normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. DC 5257 governs other impairment of the knee, providing respective ratings of 10, 20, and 30 percent for slight, moderate, or severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a. DC 5258 provides for a maximum 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Id. DC 5259 provides a maximum 10 percent rating for removal of semilunar cartilage that is symptomatic. Id. DC 5260, which governs limitation of leg flexion, provides a zero percent rating for flexion limited to 60 degrees, 10 percent for flexion limited to 45 degrees, 20 percent for flexion limited to 30 degrees, and a maximum of 30 percent for flexion limited to 15 degrees. Id. DC 5261, which governs limitation of leg extension, provides a zero percent rating for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and a maximum of 50 percent for extension limited to 45 degrees. Id. DC 5262 provides that impairment of the tibia and fibula characterized by malunion with slight knee or ankle disability warrants a 10 percent evaluation, malunion with moderate knee or ankle disability warrants a 20 percent evaluation, and malunion with marked knee or ankle disability warrants a 30 percent rating. Impairment of the tibia and fibula manifested by nonunion with loose motion, requiring a brace, warrants a maximum 40 percent rating. Id. DC 5263 provides a maximum 10 percent rating for genu recurvatum that is acquired and traumatic, with weakness and insecurity in weight-bearing objectively demonstrated. Id. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, DCs 5003, 5010. DC 5010 (traumatic arthritis) directs that arthritis be rated under DC 5003 (degenerative arthritis), which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The 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, X-ray evidence of arthritis involving two or more major or minor joint groups will warrant a 10 percent rating, and two or more major or minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The 10 percent and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, DC 5003 Note 1. The VA General Counsel has issued a precedential opinion holding that "separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg." See VAOPGCPREC 9-2004 (September 17, 2004). In addition, a Veteran may be assigned separate ratings for arthritis with limitation of motion under Diagnostic Code 5260 or 5261 and for instability under Diagnostic Code 5257. See VAOPGCPREC 23-97 (July 1, 1997). Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C.A. § 7104(a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. Analysis The Veteran's chondromalacia patella of the left knee and chondromalacia of the right knee have been rated under DCs 5260-5010 for limitation of flexion and traumatic arthritis. Hyphenated DCs are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four digits, 5260, represent the DC used to rate limitation of flexion of the leg. The second four digits after the hyphen, 5010, represent the DC for rating traumatic arthritis. The Veteran contends that that increased disability ratings for his chondromalacia patella of left and right knees are warranted because his knees have gotten worse over the years. The Veteran asserts that the pain and limited range of motion in his knees has gotten worse, which prevents him from performing many daily activities. See the October 2014 statement; May 2012 VA Form 9. The Board has carefully reviewed the evidence of record and finds that, for the entire increased rating period, the record does not demonstrate the requisite manifestations for a rating in excess of 10 percent for the service-connected left knee chondromalacia patella disability, or a rating in excess of 10 percent for the service-connected right knee chondromalacia patella disability. For a 20 percent rating under Diagnostic Code 5260, the evidence must show that for the period of appeal, forward flexion more nearly approximates limitation to 30 degrees. In this case, the weight of the competent and credible evidence shows that for the period of the appeal, flexion of the left knee ranged from 125 degrees to 130 degrees with pain on motion, and flexion of the right knee was 130 degrees with pain on motion. The Board finds that, based on measures of range of motion of both knees, neither the left knee disability nor the right knee disability more nearly approximate limitation of flexion to 30 degrees. In a November 2010 VA joints examination, range of motion for the left knee showed flexion to 125 degrees with pain on motion. Range of motion for the right knee showed flexion to 130 degrees with pain on motion. Extension was normal, with zero degrees of hyperextension, bilaterally. The Veteran's knees showed symptoms of bilateral swelling and tenderness, but no left or right knee instability, stiffness, weakness, incoordination, decreased speed of joint motion, locking episodes, effusions, or flare-ups of joint disease. Regarding functional impairments, the report indicates that the Veteran was able to stand for up to one hour and that the examiner could not opine on the Veteran's functional limitations of walking, but that the Veteran had a normal gait. The examiner found that there was no ankylosis, crepitation, clicks or snaps, grinding, patellar or meniscus abnormalities, or abnormal tendons or bursae. X-rays showed mild right knee patellar spurring, with no evidence in either knee of fracture, dislocation, bony destruction, or other significant bony abnormality. The examiner reported that the bilateral medial and lateral knee compartments were normal, and there was no soft tissue abnormality. In a December 2010 VA treatment record, the Veteran reported having no pain in his knees and could bend and stretch without any problem. Upon examination, the examiner noted that the Veteran's knees were not swollen or red. In a June 2012 VA treatment record, the Veteran reported feeling intermittent, vague bilateral knee pain. He further reported taking ibuprofen periodically, which relieved his discomfort. In April 2013, the Veteran requested that VA X-ray his knees. The reviewing physician reported that the X-ray results indicated very minimal medial compartment tibiofemeral narrowing bilaterally and left patellar enthesophyte. The physician further indicated that the above findings meant a very mild arthritic change, that the Veteran was already taking ibuprofen for pain, and that no further treatment was indicated. In a June 2013 VA examination, range of motion for the left knee showed flexion to 130 degrees with pain on motion. Range of motion for the right knee also showed flexion to 130 degrees with pain on motion. Extension was normal, with zero degrees of hyperextension, bilaterally. After repetitive-use testing with three repetitions, range of motion showed flexion to 130 degrees, bilaterally. Regarding functional impairments, the report indicates that the Veteran had less movement than normal and pain on movement. The examiner reported that the Veteran did not have tenderness or pain to palpitation for joint lines or soft tissues of either knee. The Veteran had normal bilateral muscle strength on flexion and extension. The examiner found no evidence in either knee of joint instability, patellar subluxation or dislocation, meniscal conditions, medial tibial stress syndrome (shin splints), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairments. X-rays showed no degenerative or traumatic arthritis, or evidence of patellar subluxation. The Board has considered whether a higher disability rating than 10 percent for the left knee or right knee is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40 , 4.45, 4.59; see also Mitchell, Burton, and DeLuca, supra. In this case, the Board notes that the Veteran reported having daily knee pain and increased pain with prolonged standing and walking. The Board observes, however, that the current 10 percent ratings for limitation of flexion under DCs 5260-5010 for the chondromalacia patella of the left knee and the chondromalacia patella of the right knee contemplates the effects of any complaints of pain, fatigue, swelling, weakness, or lack of endurance. As discussed above, the November 2010 and the June 2013 VA examinations considered functional loss and additional limitation in range of motion after repetitive-use testing due to factors including pain on movement, weakened movement, excess fatigability, and incoordination. The examination reports both indicate that flexion of the left knee has been between 125 and 130 degrees, which is noncompensable, and flexion of right knee has consistently been 130 degrees, which is also noncompensable. See 38 C.F.R. § 4.71a, DC 5260. Both reports also reflect specific findings of no additional limitation of motion with repetitive use. The November 2010 report indicates that there was no left or right knee instability, weakness, or incoordination, and the June 2013 report indicates that the Veteran showed now weakened movement, excess fatigability, incoordination, or instability. DC 5010 mandates that limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or painful motion. Accordingly, consideration of other factors of functional limitation does not support the grant of any higher rating than the initial rating already assigned. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. The Board has also considered whether a separate disability rating was warranted under Diagnostic Code 5261. See VAOPGCPREC 9-2004 (September 17, 2004). In this regard, however, the record reflects that extension of both knees has consistently been assessed as normal. Even factoring in pain, the Veteran's extension exceeds the extension limited to 10 required for a compensable evaluation. The Board also considered whether separate evaluations may be warranted for instability or subluxation. In this regard, while the Veteran reported giving way during the November 2010 VA examination, he denied instability or episodes of dislocation or subluxation. Furthermore, clinical examination on that date reflected no instability. Additionally, the June 2013 VA examination noted that the bilateral knees were normal on anterior instability (Lachman), posterior instability (Posterior drawer) and medial lateral instability (varus/valgus) testing. The June 2013 VA examiner further noted no evidence of recurrent subluxation or dislocation. A higher rating under Diagnostic Code 5010-5003 is also not warranted as there is no evidence of occasional incapacitating exacerbations. While the Veteran has reported pain, he never indicated the pain resulted in incapacitating episodes. Accordingly, the next higher rating of 20 percent based on an absence of compensable limitation of motion is not warranted. 38 C.F.R. § 4.71a , DC 5003. Consideration has also been given to the potential application of the other diagnostic codes for knee disabilities. See 38 C.F.R. § 4.71a, DC 5256-5263. However, the Board finds no basis upon which to assign an evaluation in excess of 10 percent for the Veteran's left knee disability and 10 percent for the right knee disability for the time period of the appeal. In this regard, the Board notes there is no medical evidence of in either the left or right knee of ankylosis, dislocated semilunar cartilage with frequent episodes of "locking" pain and effusion into the joint, removal of semilunar cartilage, limitation of leg extension, malunion or nonunion of the tibia and fibula, or genu recurvatum that would support a higher evaluation under the criteria set forth in DCs 5256, 5258, 5259, 5261, 5262, and 5262. 38 C.F.R. § 4.71a. Finally, the Board has considered whether referral for an extraschedular evaluation is warranted. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2014). 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 the service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate a veteran's level of disability and symptomatology and is found inadequate, it must determine whether the veteran'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 veteran'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 Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence fails to show unique or unusual symptomatology regarding the Veteran's service-connected chondromalacia patella of the left and right knees that would render the schedular criteria inadequate. The Veteran's symptoms, including pain and limitation of flexion, are contemplated in the rating assigned; thus, the application of the Rating Schedule is not rendered impractical. Additionally, the regulations and caselaw also mandate consideration of painful motion, and the effects of repetitive motion, weakness, fatigability, swelling, and atrophy. 38 C.F.R. § 4.40, 4.41, 4.44, 4.45, 4.46, and 4.59. Moreover, the Veteran has not argued that his symptoms are not contemplated by the rating criteria; rather, he merely disagreed with the assigned disability rating for his level of impairment. In other words, he did not have any symptoms from his service-connected disabilities that are unusual or different from those contemplated by the schedular criteria. Moreover, the Veteran has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Accordingly, the Board finds that referral for consideration of an extraschedular rating is not warranted, as the manifestations of the Veteran's disabilities are considered by the schedular rating assigned. 38 C.F.R. § 3.321; Thun, 22 Vet. App. 111. For all of the above reasons, the Board concludes that, for the entire period of appeal, an increase in excess of 10 percent for the service-connected chondromalacia patella of the left knee is not warranted. In addition, for the entire period of appeal, an increase in excess of 10 percent for the service-connected chondromalacia patella of the right knee is not warranted. ORDER Entitlement to a disability rating in excess of 10 percent for chondromalacia patella of the left knee is denied. Entitlement to a disability rating in excess of 10 percent for chondromalacia patella of the right knee is denied. ____________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs