Citation Nr: 1509430 Decision Date: 03/04/15 Archive Date: 03/17/15 DOCKET NO. 10-28 620 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to a rating in excess of 10 percent for service-connected status post release of medial plica with low grade chronic infrapatellar tendonitis and mild degenerative joint disease of the right knee. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dustin Ware, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1983 to June 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. This decision continued the 10 percent disability rating in effect for the Veteran's service-connected right knee disability. The Veteran provided testimony at a hearing conducted at the RO by the undersigned Veterans Law Judge in March 2011. The transcript of this hearing has been associated with the Veteran's claims folder. This case was brought before the Board in December 2012, at which time the claim was remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran in the development of his claim, specifically obtaining VA treatment records and providing him a more recent VA examination. The requested development having been completed, the case is once again before the Board for appellate consideration of the issue on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. During the appeals period, the evidence of record does not support a finding of right knee instability that the Board would characterize as "moderate" or "severe." Furthermore, there is no subjective or objective medical evidence of ankylosis, dislocation or removal of semilunar cartilage, impairment of the tibia or fibula, ankylosis, or genu recurvatum. 2. During the appeals period, the Veteran's right knee disability has been manifested by objective findings of, at worst, extension limited to 0 degrees and flexion limited to 120 degrees, but with functional limitation that is objectively confirmed by findings of pain on movement. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for status post release of medial plica with low grade chronic infrapatellar tendonitis and mild degenerative joint disease of the right knee have not been met. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. §§ 4.3, 4.20, 4.40, 4.49, 4.71a, Diagnostic Codes 5024, 5256-5259, 5262-5263 (2014). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for a separate rating of 10 percent, but not higher, for status post release of medial plica with low grade chronic infrapatellar tendonitis and mild degenerative joint disease of the right knee have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.3, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist When VA receives a complete or substantially complete application for benefits, it 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. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA's duty to notify was satisfied prior to the rating decision on appeal through a January 2010 letter sent to the Veteran that fully addressed all notice elements. The letter informed the appellant of what evidence was required to substantiate his increased rating claim, and of the Veteran's and VA's respective duties for obtaining evidence. In light of the above, the Board finds that the Veteran was provided all required notice and that no useful purpose would be served by delaying appellate review to send out additional notice letters. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2014). Service treatment records are associated with the claims file. All post-service VA and private treatment records identified by the Veteran have also been obtained. The Veteran has not identified any additional records that should be obtained prior to a Board decision. Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. See 38 U.S.C.A. § 5103A(d); see also 38 C.F.R. § 3.159 (c)(4) (2012); Wells v. Principi, 327 F. 3d 1339, 1341 (Fed. Cir. 2002). In February 2013, the Veteran was afforded a VA examination in conjunction with his increased evaluation claim. Moreover, the Veteran was provided a VA examination in May 2014 for a left knee claim not presently before the Board; however, this examination contains substantive information about the right knee. These examinations are adequate for the purposes of evaluating the Veteran's disability, as they involve a review of the Veteran's pertinent medical history as well as a clinical evaluation of the Veteran, and provide an adequate discussion of relevant symptomatology. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Prior to both of these examinations the Veteran received a VA examination in March 2010. At his March 2011 Board hearing the Veteran raised multiple issue with the adequacy of the resulting VA examination report. The adequacy of this examination will be discussed further in the Analysis section. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Analysis I. Rating Criteria The Veteran contends that he is entitled to a rating in excess of 10 percent for his service-connected status post release of medial plica with low grade chronic infrapatellar tendonitis and mild degenerative joint disease of the right knee. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as in the present case, entitlement to compensation has already been established and an increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 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 and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2014). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing is related considerations. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40 (2014); DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2014). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 (2014), however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Throughout the appeal period, the Veteran's right knee disability has received an evaluation of 10 percent pursuant to Diagnostic Code 5024-5257. Hyphenated diagnostic codes 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 (2014). The first four numbers reflects the diagnosed disability. The second four numbers after the hyphen identifies the criteria used to evaluate that disability. Diagnostic Code 5024 pertains to tenosynovitis. Diagnostic Code 5257 pertains to recurrent subluxation or lateral instability. In considering the applicability of other Diagnostic Codes, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5259 (symptomatic removal of semilunar cartilage), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable in this instance, as the medical evidence does not show that the Veteran has any of those conditions. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5259, 5262, 5263 (2014). Diagnostic Code 5003 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. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2014). In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2014). These ratings will not be combined with rating based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1 (2014). Furthermore, the 20 percent and 10 percent ratings based on X-ray findings will not be utilized in rating condition listed under diagnostic codes 5013 to 5024. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Court also has held that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. The intent of the schedule is to recognize painful motion with joint or periarticular 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 that joint. 38 C.F.R. § 4.59 (2014). Read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 deem painful motion of a major joint or a minor joint group caused by degenerative arthritis, where the arthritis is established by X-ray, to be limited motion and entitled to a minimum 10-percent rating under Diagnostic Code 5003, even though there is no actual limitation of motion (i.e., even though a range of motion may be possible beyond the point when pain sets in). Hicks v. Brown, 8 Vet. App. 417, 420-21 (1995) (citing Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991)). Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of a knee, and assigns a 10 percent rating for a "slight" impairment, 20 percent rating for a "moderate" impairment, and 30 percent rating for a "severe" impairment. Diagnostic Code 5257 is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Diagnostic Code 5258 directs that when semilunar cartilage is dislocated with frequent episodes of locking, pain, and effusion into the joint a 20 percent rating is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5260, limitation of flexion of the leg, a noncompensable rating is assigned when flexion is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the leg, a noncompensable rating is assigned when extension is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a (2014). For VA purposes, normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II (2014). The Board notes that separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Additionally, VAOPGCPREC 23-97 held that a claimant who has both arthritis and instability of the knee may receive two separate disability ratings under Diagnostic Codes 5003-5010 and Diagnostic Code 5257 (or under Diagnostic Codes 5258-9) without violating the prohibition of pyramiding of ratings. It was specified that, for a knee disorder already rated under Diagnostic Code 5257, a claimant would have additional disability justifying a separate rating if there is limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261. Turing to the evidence of record, the Veteran was provided a VA examination in March 2010. The VA examiner noted right knee symptoms that included pain, crepitus, tenderness, clicks or snaps, stiffness, incoordination, swelling, and decreased speed of joint motion. Symptoms the Veteran was specifically noted not to have included deformity, giving way, grinding, effusion, instability, weakness, or episodes of dislocation, subluxation, or locking. The Veteran was reported to have severe knee flare-ups every one to two months that lasted three to seven days at a time. The resulting impairment is the Veteran has to rest and elevate his legs. Constant use of a knee brace was noted. The Veteran was show to have a very mild limp on the right as a result of weight-bearing issues with the right knee joint. The VA examination report describes the Veteran as having well healed post arthroscopy surgical scars that are non-tender. The Veteran's range of motion of the right knee was extension to 0 degrees and flexion to 130 degrees with objective evidence of pain with active motion. No additional limitation of motion or objective evidence of pain on motion was found following three repetitions of range of motion. The Veteran's right knee disability impacted his occupational activities through decreased mobility and pain. The Veteran missed 12 weeks of work in the previous 12 months related to his right knee surgery. At the time of the examination the Veteran reported increased knee pain was caused by sitting for long periods, driving, walking on uneven ground, and having to kneel down for work or chores. The Veteran also noted he is no longer able to hunt as this required walking on uneven ground. In March 2011, the Veteran submitted statements from his wife and three associates. The Veteran's wife notes the Veteran's knee is painful, pops, swells, and locks. She went on to note the Veteran cannot get on his knees, walk on uneven ground, or drive for very long. She also stated that the Veteran has trouble sleeping because of knee pain. She concluded her statement by mentioning that almost every day the Veteran says he wishes someone would cut off his right leg. G.S., a coworker of the Veteran, reported that the Veteran had to be reassigned at work in a different location to avoid regular climbing up and down stairs to help him with his knee pain. B.C. states that he has known the Veteran for three years. When they first met, thought the Veteran had knee problems, he could get around fine. Now he looks like he is in constant pain. He has problems climbing stairs or standing for a very long time. B.C. observed that standing on hard surfaces appears to aggravate the Veteran's knee more than soft. T.B. described having to drive the Veteran home from a VA medical center because of limping and pain. At his March 2011 Board hearing the Veteran noted multiple issues with the March 2010 VA examination. First, he indicated that the VA examiner did not review the claims file as indicated by the examination report. Furthermore, the Veteran discussed that the VA examiner noted the frequency of his severe flare-ups but failed to note that he has minor flare-ups every day. The Veteran described these flare-ups as causing immobility. Other concerns were the fact that the examiner noted the Veteran could stand for one to three hours while he says that half an hour to an hour is more accurate. The VA examiner manually manipulated the Veteran knee and leg during range of motion testing the Veteran did not move it for her. Also, the VA examiner appeared to estimate by eye the degree of motion instead of using a goniometer. Turing to symptoms the Veteran described at the hearing, the Veteran reported his right knee pops and when it pops it is so painful he does not want to move it. He notes he has problems on uneven surfaces and cannot do work on his knees. He says that while his knee brace provides some pain relief it does little to truly relieve the pain. Overall, he indicates that though his rating is for mild symptoms he feels they are better described as moderate. The Veteran submitted a May 2011 radiology report from Humboldt General Hospital. The report's findings were "[a] small joint effusion is evident. Only minimal degenerative changes are evident. The cruciate and collateral ligaments appear to be intact. The quadriceps tendon and patellar ligament are unremarkable. Increased signal in the posterior horn of the medial meniscus extends to the articular surface, consistent with a meniscal tear." The impression was "[t]ear of the posterior horn of the medial meniscus. Small joint effusion." The Veteran was provided another VA examination in February 2013, following Board remand. The VA examination report indicates the Veteran's right knee pops generating pain especially in the medial and posterior parts of the knee. The Veteran's right knee symptoms including painful squatting, walking, and climbing all of which interfere with daily life and work. These symptoms are increased by flare-ups. The Veteran gets some day time support and relief from his knee brace that helps with stability. Range of motion testing indicated flexion to 135 degrees with objective evidence of painful motion starting at 135 degrees and extension to 0 degrees with objective evidence of painful motion at 0 degrees. Repetitive use testing produced the same results. Contributing factors to functionale loss and/or functional impairment were less movement that normal; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. There was pain to palpation for joint line or soft tissue of the right knee. All joint stability tests were normal. No patellar subluxation or dislocation, tibial or fibular impairment, or genu recurvatum was reported. At the time of the examination the Veteran had developed a semilunar cartilage condition, specifically a meniscal tear, subsequent to his previous partial lateral meniscectomy in May 2009. The VA examiner reported the condition resulted in frequent episodes of pain and effusion but no locking. The Veteran was observed to have scars associated with his right knee condition. However, the scars were not painful, unstable, or a total area of 39 square centimeters. The VA examiner indicated that imaging studies revealed no degenerative or traumatic arthritis. A description of how the Veteran's disability affects his work indicates he cannot do sustained physical work but with the help of a knee brace could do his present light physical work. This includes occasional deep knee bends, careful climbing of ladders to access trucks, standing, moving, and sitting. It was also noted he could do sedentary work if allowed to move occasionally. In May 2014, the Veteran was provided a VA examination in regards to a service connection claim for a left knee disability not presently before the Board. The VA examination report shows that the Veteran's right knee was also examined at this time. The results of range of motion testing of the Veteran's right knee were flexion to 135 degrees with objective evidence of painful motion starting at 135 degrees and extension to 0 degrees with no objective evidence of painful motion. Repetitive use testing produced the same results. In regards to the right knee, contributing factors to functional loss and/or functional impairment were pain on movement and disturbance of locomotion. There was pain to palpation for joint line or soft tissue of the right knee. All joint stability tests were normal. No history of patellar subluxation or dislocation was report. The VA examination report does indicate a history of shin splints and lower leg stress fractures but no current problems. At the time of the examination the Veteran continued to have the semilunar cartilage condition, i.e.meniscal tear, that was discussed in the February 2013 VA examination. At this time the condition was reported to result in frequent episodes of joint pain but no effusion or locking. The Veteran was observed to have scars associated with his right knee condition. However, the scars were not painful, unstable, or a total area of 39 square centimeters. The Veteran was described as still using a brace to assist with his right knee disability. The VA examiner indicated that imaging studies revealed degenerative arthritis, dating the diagnosis to August 2009. The Veteran's right knee disability was observed to have no impact on the Veteran's ability to work. Finally, the VA examiner was asked whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. The examiner responded "it is feasible that, during flare-ups or when the joint is used repeatedly over time, the Veteran could suffer a limitation in the functional ability of the bilateral knees." The examiner continued stating that the expected result would be further loss of range of motion but to quantify the extent of this limitation of motion would be mere speculation. Also included in the claims file are VA treatment records from throughout the appeals period. These treatment records include the operation report for the Veteran's May 2009 microfracture to the right medial femoral condyle plus partial lateral meniscotomy. These records show regular complaints of right knee pain and treatment of this with medication. In regards to the right knee, these treatment records reveal a disability picture similar in nature to the one present by the VA examination, Veteran's testimony, and lay statements already discussed. The Board does note that in June 2009 range of motion was reported as flexion to 130 degrees and extension to 0 degrees and in March 2014 as flexion to 120 degrees and extension to 0 degrees. A January 2014 treatment note observes a grinding sense with range of motion. Returning to the diagnostic codes, the Board finds the Veteran's right knee disability does not warrant an increased rating pursuant to the Diagnostic Code 5024-5257, which the Veteran is currently rated under. For the Veteran's right knee to warrant an increased rating pursuant to this diagnostic code the Veteran's disability picture needs to more nearly approximate "moderate" or "severe" instability. The terms "slight," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R § 4.6 (2014). The Board acknowledges the Veteran's contention that his right knee instability more nearly approximates "moderate" or "severe" instability. Board Hearing Transcript page 9. However, all VA examinations during the appeals period found either no instability or reported normal stability test results. In regards to the severity of the Veteran's right knee instability, the Board finds the results of medical testing more probative than the Veteran's assertion of moderate to severe instability. Therefore, a rating in excess of 10 percent is not warranted under 38 C.F.R. § 7.41a, Diagnostic Code 5024-5257. As discussed, a claimant who has both arthritis and instability of the knee may receive two separate disability ratings under Diagnostic Codes 5003-5010 and Diagnostic Code 5257. The May 2014, VA examiner indicated imaging studies revealed degenerative arthritis as far back as August 2009. Degenerative arthritis is rated pursuant to Diagnostic Code 5003. This diagnostic code instructs the rating be assigned based on limitation of motion. During the appeals period, at worst, the Veteran has exhibited flexion to 120 and extension to 0 degrees. Such range of motion warrants no more than a noncompensable rate under Diagnostic Codes 5260 and 5261 for limitation of motion. Nevertheless, the medical evidence of record also indicates the presence of objectively confirmed findings of pain on movement as a contributing factor to functional impairment on use of his right knee joint. Thus, resolving all reasonable doubt in the Veteran's favor, the assignment of a minimum compensable rating of 10 percent for the right knee is warranted under Diagnostic Code 5003 and 38 C.F.R. § 4.59. Hence, a separate rating of 10 percent is therefore warranted for status post release of medial plica with low grade chronic infrapatellar tendonitis and mild degenerative joint disease of the right knee. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003. Additionally, the Board has considered, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness pursuant to 38 C.F.R. §§ 4.40 , 4.45, 4.59 (2014); DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). Here, the medical evidence on examination reveals that upon repetitive motion, the Veteran did not have additional functional loss or change in range motion due to pain, weakened movement, excess fatigability, or incoordination of the knees. While the May 2014 examiner noted that with "flare-ups or when the joint is used repeatedly over time, the Veteran could suffer a limitation in the functional ability of the bilateral knees" he could not quantify such limitation. Thus, even considering the possible additional loss of range of motion noted by the VA examiner, objectively confirmed findings of pain on movement, and the Veteran's complaints of popping the evidence does not show that the right knee is limited in motion to 15 degrees extension or 30 degrees flexion, i.e., the requirements for 20 percent ratings under Diagnostic Codes 5260 and 5261, and thus the requirements for increased ratings under these diagnostic codes are not met. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202. Next, the Board takes note of the fact that the Veteran currently has a meniscal tear resulting in frequent episodes of joint pain and effusion. Nevertheless, the medical evidence of record shows no semilunar cartilage dislocation thus an increased rating of 20 percent is not warranted under 38 C.F.R. § 7.41a, Diagnostic Code 5258. Moreover, Diagnostic Code 5258 also requires frequent episodes of locking, pain, and effusion. The evidence of record supports a find of frequent episodes of pain and effusion but no locking. While the Veteran's wife asserted that the Veteran's right knee locks physical examination did not reveal locking thus the weight of the evidence is against a finding of right knee locking. Therefore, even if the Veteran's meniscal tear was considered a semilunar cartilage dislocation an increased rating would not be warranted as it does not result in frequent episodes of locking. Also, the VA examination reports indicate the Veteran has scars related to treatment of his right knee condition. However, these scars are described as not being painful or unstable, or totaling an area greater than 39 square centimeters. As such, a sperate compensable rating for scars is not warranted under 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7804, or 7805. Finally, at the March 2011 Board hearing the Veteran testified about the many reasons why the March 2010 VA examination report should be considered inadequate. The Board notes that even if it was to afford no probative value to that VA examination, and base its findings only on the other evidence of record, its final determination would be no different as there is plenty of other evidence of record to support the Board's findings. In sum, a rating in excess of 10 percent is not warranted under Diagnostic Code 5024-5257 as the weight of the evidence does not support a finding that the Veteran's right knee instability most nearly approximates what the Board would consider "moderate" or "severe." Furthermore, a rating in excess of 10 percent is not warranted under Diagnostic Codes 5256 through 5259, 5262, or 5263. Nevertheless, the Veteran's does have degenerative arthritis of the right knee allowing for a separate rating under Diagnostic Code 5003. A compensable rating is not warranted for limitation of motion, thus, resolving all reasonable doubt in the Veteran's favor, a separate rating of 10 percent under Diagnostic Code 5003 and 38 C.F.R. § 4.59 for painful motion is warranted. This conclusion is reached in light of objectively confirmed findings of pain on movement as a contributing factor to functional impairment on use of his right knee joint. II. Other Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2014). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's right knee disability with the criteria used in rating this disability show that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the rating criteria provides for evaluation based on instability and limitation of motion that takes consideration of the Veteran's pain. As the first prong of Thun has not been satisfied, the Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Finally, the Board notes that entitlement to a total disability evaluation based on individual unemployability (TDIU) is an element of all increased rating claims. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). However, the evidence of record does not show that the Veteran's disabilities markedly interfered with employment such that a remand or referral of a claim for TDIU is appropriate. The evidence does show that the Veteran's right knee disability has an effect on his ability to work. Nevertheless, the VA examinations along with other evidence of record reveal that the Veteran's employer provides adequate accommodations and the Veteran continues to work. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A rating in excess of 10 percent for status post release of medial plica with low grade chronic infrapatellar tendonitis and mild degenerative joint disease of the right knee is denied. In recognition of painful motion, a separate rating of 10 percent, but no higher, for status post release of medial plica with low grade chronic infrapatellar tendonitis and mild degenerative joint disease of the right knee is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs