Citation Nr: 1510182 Decision Date: 03/11/15 Archive Date: 03/24/15 DOCKET NO. 07-27 736 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an evaluation higher than 20 percent for patellofemoral syndrome of the left knee. 2. Entitlement to an evaluation higher than 10 percent for patellofemoral syndrome of the right knee. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Fussell INTRODUCTION The Veteran had active service from January to October 1994. This matter arises before the Board of Veterans' Appeals (Board) from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which confirmed and continued a 20 percent rating for left patellofemoral syndrome (PFS) and 10 percent for right PFS, both rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (previously rated under DC 5257). In February 2010, the Veteran testified at a Travel Board hearing in front of the undersigned. The transcript of the hearing has been reviewed and is of record. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of an electronic record. In April 2010, in July 2011, and again in November 2013 this case was remanded for additional development. The case has been returned to the Board and is ready for further review. In the 2010 Board remand it was noted that a claim for service connection for a hip disorder, as secondary to service-connected knee disorders, had been raised and was referred to the RO for appropriate action. Contained in Virtual VA is a January 2013 rating decision which denied service connection for a left hip disorder. However, the Veteran has not appealed the January 7, 2013, notification of that decision. In the December 2014 Appellant's Post-Remand Brief, entered into VBMS in February 2015), it was stated that waiver of initial RO consideration of additional evidence associated with the record since the January 2014 Supplemental Statement of the Case (SSOC) was waived. Contained in Virtual VA is a February 2015 rating decision which reflects that a temporary evaluation of 100 percent was assigned effective August 18, 2014, based on surgical or other treatment necessitating convalescence; an evaluation of 20 percent for left PFS was resumed from December 1, 2014. Thus, the schedular 20 percent and 10 percent ratings for the left and right knee disabilities, respectively, remain the same and, since these are his only service-connected disorders, the combined disability rating remained 30 percent. FINDINGS OF FACT 1. The left PFS is manifested by no instability, full extension, and flexion to not less than 100 degrees. 2. The right PFS is manifested by no instability, full extension, and flexion to not less than 120 degrees 3. The Veteran is service-connected only for left PFS, rated 20 percent, and right PFS rated 10 percent, and his combined disability rating is 30 percent. 4. The Veteran has a high school education and work experience driving a tractor-trailer and in machine maintenance, at which he is currently employed with the U.S. Post Office, but the combined effect of his service-connected disabilities does not preclude obtaining or retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an evaluation higher than 20 percent for left PFS are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 3.159, 3.321, 4.1, 4.7, 4.21, 4.40, 4.45, 4.59, 4.71, Table II, 4.71a, Diagnostic Codes 5003 - 5260 (2014). 2. The criteria for an evaluation higher than 10 percent for right PFS are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.3, 3.159, 3.321, 4.1, 4.7, 4.21, 4.40, 4.45, 4.59, 4.71, Table II, 4.71a, Diagnostic Codes 5003 - 5260 (2014). 3. The criteria for a TDIU rating are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.15, 4.16 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide notification to the Veteran with respect to establishing entitlement to benefits, and a duty to assist with development of evidence under 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159(b). VA must provide notification that to substantiate an increased rating claim the claimant should provide or ask VA to obtain medical or lay evidence demonstrating a worsening or increase in a disability's severity and the effect thereof on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). See also Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), affm'd in part by Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed.Cir. 2009). Here, the Veteran was provided with initial notice of how to substantiate his claim for higher ratings by RO letter in August 2006. He was provided information on how disability ratings were assigned by RO letter in May 2008, in compliance with the holding in Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). He was provided notice of how to substantiate the TDIU claim by letter in January 2008. And all this, at a minimum, was prior to the most recent readjudication of the claims in the January 2014 SSOC. See generally Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (while VCAA notice was intended to be provided prior to initial adjudication any such timing error may be corrected by providing notice and a subsequent readjudication, e.g., in an SSOC). As to the duty to assist, all reasonable efforts have been made to obtain all relevant information and evidence. The Veteran's service treatment records (STRs) are on file. Also, all his available VA treatment records are on file. The Board notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the appellant's claims called Virtual VA, in which some of the Veteran's medical records have been associated. As noted in the 2010 Board remand, VA Form 21-4142, signed in August 2006, indicated that the Veteran had received treatment from the VA, at Massachusetts facilities located in Brockton, West Roxbury, and Jamaica Plains, and from the VA in Providence, Rhode Island, and the Veteran testified at his February 2010 BVA hearing that he had been receiving treatment for his knees at a VA facility in Ellenton Community-Based Outpatient Clinic in Florida. The Board remanded this case in 2010 and 2011 to obtain these records. Following the April 2010 Board remand, by letter of June 10, 2010, the Veteran was notified that VA treatment records since 2005 at Providence and Jamaica Plains could not be obtained and he was requested to submit such records if he had them in his possession. However, an April 2011 SSOC the Veteran responded that he had no additional information or evidence to submit. In a July 2011 Report of General Information the Veteran indicated that all of his VA treatment since March 2005 had been at VA facilities in Florida. An August 2011 report of a telephone conversation indicates that all such VA treatment in Florida had been at the Bay Pine VA facility. By letter of January 20, 2012, he was informed that his records from the Bay Pine VA facility had been received. As confirmed in the December 2012 SSOC VA treatment record from 1995 to 1997 from the Providence VA facility, from 1996 to 2000 from a Boston VA facility, and from 2005 to 2012 from the VA Bay Pines facility are on file. The Veteran has been afforded multiple VA examinations in this case. In the October 2007 Statement of Accredited Representative, In Lieu of VA Form 646, it was noted that the August 2006 VA rating examination was done without the benefit of review of the claim file and it was alleged that the amount of time spent by the VA examiner was too little and, so, that examination was inadequate for rating purposes. However, "the Court has never decided that in every case, a medical examiner must review all prior medical records before issuing a medical opinion or diagnosis." Snuffer v. Gober, 10 Vet. App. 400, 404 (1997) (emphasis omitted). The Court has made clear that medical examiners and VA adjudicators, such as the Board, have specific and different responsibilities. "The medical examiner provides a disability evaluation and the rating specialist interprets medical reports in order to match the rating with the disability." Moore v. Nicholson, 21 Vet. App. 211, 218 (2007). "It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the element of disability present." 38 C.F.R. § 4.2; see Moore, supra. Moreover, the Veteran was also afforded additional VA examinations of his knees (his only service-connected disorders) in 2008, 2010, 2013, and 2014. The Veteran and his representative have not challenged the adequacy of those examinations. The Board may assume the adequacy of VA examinations unless challenged. See Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed.Cir. 2010). Overall, the multiple VA examinations and the other evidence of record have provided sufficient information and evidence to allow the Board to make informed decisions in this case. Moreover, the extensive evidentiary development in this case has been in full compliance with the Board's remands. See generally Stegall v. West, 11 Vet. App. 268 (1998). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), it was held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2) which consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. However, these duties do not require preadjudication of a claim. Here, the questioning and testimony at the hearing focused on the elements for claim substantiation. Even if not all elements required for claim substantiation are explicitly set forth at a hearing, if those matters are developed by VA, there is no indication of any outstanding additional evidence or information, and particularly if any VA examination was conducted to address such matter, the purpose of 38 C.F.R. § 3.103(c)(2) if fulfilled. See Bryant v. Shinseki, 23 Vet. App. 488, 498-99 (2010). Also, neither the Veteran nor his representative have alleged that there was any deficiency with respect to the hearings in this case, much less any violation of the duties set forth in 38 C.F.R. § 3.103(c)(2). As there is neither an indication that the Veteran was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board concludes that there has been full VCAA compliance. Background A December 1994 rating decision granted service connection for PFS of each knee, with each assigned an initial noncompensable disability rating under 38 C.F.R. § 4.71a, DC 5257. However, a 10 percent rating was assigned under 38 C.F.R. § 3.324 (for multiple noncompensable service-connected disabilities which impact upon function). Contained in VBMS is a report of VA general medical examination in November 1994 which found that the Veteran's gait was within normal limits and his muscle strength was 5/5 throughout. On a special orthopedic examination at that time there was no muscle atrophy and he had full range of motion of each knee, with mild crepitation on motion in the right knee. There was mild tenderness of the lateral aspect of the left knee on varus and valgus maneuvers. There was no laxity or other abnormality of those joints. VA X-rays in November 1994 found no soft tissue or bony abnormality of the knees. Contained in VBMS is a report of X-rays in December 1994 of the Veteran's left knee which revealed mild joint space narrowing and mild joint effusion. Contained in VBMS is a report of VA orthopedic examination in May 1995 which revealed full extension of each knee and flexion in the left knee to 116 degrees and in the right knee to 128 degrees. The knees were of equal circumference and there was no measurable atrophy of the thighs. Both knees were stable but there was some pain on manipulation of the left patella. He reported that the left knee would lock after exercising. Grind test was slightly positive in the left knee. It was reported that the Veteran's complaint of pain on climbing was suggestive of chondromalacia and the complaint of locking was suggestive of internal derangement, probably a frayed left lateral cartilage, and that these conditions would undoubtedly progress. A June 1995 rating decision confirmed and continued a noncompensable rating for right PFS but assigned a 10 percent rating for left PFS, each being rated under DC 5257. Contained in VBMS is a report of VA orthopedic examination in January 1996 which revealed that the Veteran had some tenderness on movement of the left patella and on grind test he had some grating under the right patella. He had full extension of each knee and flexion was to 128 degrees in the right knee and to 136 degrees in the left knee. While the knees were of equal circumference, there was some slight atrophy of the left thigh, the left being 1/2 inch smaller. There was no ligamentous instability. A February 1996 rating decision confirmed and continued the 10 percent rating for the left knee disorder but assigned a 10 percent rating for the right knee disorder, both under DC 5257. A VA operative report in March 1997, in VBMS, shows that, in part it was suspected that the Veteran might have nerve entrapment in the left knee, and he underwent a repair of an ACL tear and some shaving of a lateral meniscus tear. Postoperatively, he was examined in August 1997 at which time his incisions were well healed and he had full left knee extension and flexion to 120 degrees, with mild crepitus on motion. There was minimal knee tenderness but no pain on palpation of the patella. Left quadriceps strength was 5/5 and the knee was stable to varus and valgus stress but he had a slight positive anterior drawer's sign. He did not wish to have knee braces. On formal VA examination in September 1997, the report of which is in VBMS, both knees were stable and flexion of each was to 140 degrees. He was able to squat, but only gingerly, and he clearly favored the left knee. A February 1998 rating decision confirmed and continued the 10 percent right knee rating but, after assigning a temporary total convalescent rating, assigned a 20 percent rating for the left knee disability, each being rated under DC 5257. On VA examination in May 2003 it was noted that the Veteran worked for UPS as a driver. On examination his PO left knee scars were well healed. He had full flexion of each knee, but crepitus especially in the right knee. Lachman's and McMurray's tests were negative, bilaterally. On file are electronic versions of VA treatment records from 2005 to 2009 which were entered into VBMS on April 20, 2010, that showed occasional treatment for the Veteran's knees but much of the treatment was for nonservice-connected disorders which included sinusitis, a left 4th toe fracture, left hip pathology, low back strain, and psychiatric symptoms which included sleep disturbance. A May 2006 VAOPT record contained in VBMS shows that the Veteran worked out at Gold's gym about 3 times weekly. He lifted weights but did not do squats because he wanted to limit stress on his knees. He did aerobic activity, fast walking, and occasional biking about 15 to 20 minutes at a time. On VA examination in August 2006 the Veteran reported having had increased pain in both knees, but greater in the left than the right. He denied having any swelling or locking but reported having occasional buckling of the left knee once or twice monthly. He reported having stiffness in both knees on prolonged sitting. He took over-the-counter Motrin, with relief. He did not use any assistive device and was employed as a truck driver. It was reported that there were no occupational effects due to his knees but as to activities of daily living he had difficulty climbing stairs and had sleep disturbance due to pain. He had daily flare-ups of increased pain which last 8 to 10 hours. The examiner stated that an estimate of range of motion during flare-ups could not be made without speculation. On physical examination of both knees there was no deformity, erythema, effusion, instability or tenderness. McMurray's test and patellar grind test were negative. There was mild anterior crepitus, bilaterally. There was full extension of each knee to zero (0) degrees and flexion was to 135 degrees, bilaterally. There was no pain on motion of either knee and no additional loss of motion due to pain, weakness, fatigue, incoordination or lack of endurance following repetitive use. The impression was bilateral PFS. In the Veteran's VA Form 9, Appeal to the Board, dated in July 2007 he reported that his left knee was still numb following his recent left knee surgery. On VA examination in May 2008 of the Veteran's knees it was noted that a February 2007 left knee MRI revealed a very tiny ruptured Baker's cyst. There was no evidence of ligamentous injury but there was thinning of the ACL which suggested either a strain of that ligament or chronic repetitive injury without evidence of a tear. The remainder of the ligaments were intact. There was also partial truncation of the anterior horn of the medial meniscus consistent with past surgery, and the remainder of the mensci were intact. A September 2006 right knee X-ray was unremarkable but an April 2007 left knee X-ray revealed arthritic change in the medial compartment. The Veteran complained of daily intermittent right knee pain which he rated a 6 on a scale of 10, without any reports of flare-ups. He complained of constant left knee pain which he rated a 6 but increasing daily to 8 on a scale of 10 but during flare-ups, about 4 times weekly, he rated the pain as 10. He reported that during flare-ups he had greater limitation of motion and, so, avoided walking. The examiner was unable to assess any additional loss of motion during flare-ups without resorting to speculation. The Veteran reported having occasional buckling of the left knee, 7 to 8 times monthly, and which could occur when commencing to walk after sitting, with prolonged sitting causing bilateral knee stiffness. He reported that he used a left knee brace once in a while but no cane or crutches. He obtained a little relief from pain by resting, applying ice, and taking Advil about once weekly. It was noted that the Veteran had been employed in the past as a truck driver but now did maintenance work at the Post Office. He reported that he had given up working as a truck driver because he could not push a clutch. The effect on his current occupation and activities of daily living was stated to be none but he avoided squatting and transversing stairs and ladders. He also reported having sleep disturbance due to knee pain. On physical examination the Veteran had full right knee extension to zero (0) degrees and flexion to 130 degrees, all without pain. There was no additional loss of motion due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive use. Testing of right knee ligaments revealed that the knee was stable. There was no tenderness or weakness of the right knee. As to the left knee, he had full extension to zero (0) degrees and flexion to 130 degrees, with painful motion from 115 to 130 degrees of flexion. There was no additional loss of motion due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive use. Testing of left knee ligaments revealed that the knee was stable but McMurray's test was painful and produced a palpable click. There was no tenderness or weakness of the left knee. Surgical scarring of the left knee was nontender. It was noted that the Veteran reported having a limp due to his left knee. The diagnosis was bilateral PFS, left knee degenerative joint disease (DJD), and residual nontender scarring from prior left knee surgery. VAOPT records entered into VBMS on April 20, 2010, but dated in August 2008 noted that the Veteran complained of a mild feeling of pins and needles in both lower extremities from the knees down in a stocking distribution upon prolonged sitting but, after standing and walking around, it resolved. At the 2010 travel Board hearing the Veteran testified that as to his left knee he had difficulty walking and going down stairs, and when in a squatting position he had to grab something to help pull himself up. He also had numbness and tingling from the knee down to the foot. Page 6. He also had instability of the left knee because he sometimes lost his balance. He worked for the U.S. Post Office walking on a hard floor all night and often had to get down on his knees to fix machinery. He was having similar problems with his right knee but not of such severity as in the left knee. Page 8. In the past he had been told that he would be issued braces on each knee but he never received them. He had stopped taking pain relieving medication because he feared becoming addicted to it, and he now took Aleve. Page 9. He had instability of both knees but greater in the left knee. Page 10. He had fallen several times due to instability of the knees, particularly going down stairs. He had also had episodes of locking of the knees, and X-rays had documented arthritis in each knee. He had had knee surgery in the past. Page 11. During his surgery a cyst was removed from a knee. Page 12. On VA examination in June 2010 the Veteran's claim file and medical records were reviewed. On physical examination of the left knee there was giving-way pain, stiffness and decreased speed of the joint motion but there was no deformity, weakness, incoordination, or other symptoms. Motion of the left knee was affected. There was no locking and no episodes of dislocation or subluxation. There was crepitus and tenderness, including subpatellar tenderness. Left knee extension was full to zero (0) degrees and flexion was to 100 degrees. There was evidence of painful left knee motion. There was objective evidence of pain after repetitive motion but no additional limitation of motion after 3 repetitions of motion. On examination of the right knee there was pain, stiffness, and decreased speed of the joint motion but no deformity, giving way, instability, weakness, incoordination, or other symptoms. There was no locking and no episodes of dislocation or subluxation or symptoms of inflammation. Motion of the right knee was affected. There was tenderness, including subpatellar tenderness, but no crepitus. Right knee extension was full to zero (0) degrees and flexion was to 120 degrees. There was evidence of painful right knee motion. There was objective evidence of pain after repetitive motion but no additional limitation of motion after 3 repetitions of motion. The Veteran had no ankylosis or instability of either knee and no incapacitating episodes of arthritis. He could walk one mile and did not use an assistive device for ambulation. Also, his gait was normal and there was no evidence of abnormal weight-bearing. It was noted that the Veteran was currently employed full-time and had been for the last 2 to 5 years with no time lost from work in the last 12 months. His bilateral knee disabilities affected his occupational activities due to decreased mobility and problems with lifting and carrying, as well as pain. As a result, he had been assigned different work duties. Kneeling, squatting, and climbing were difficult. As to his activities of daily living there was a mild effect as to chores, recreation, and traveling. There was a moderate effect as to exercise and a severe effect as to sports. However, there was no effect as to shopping, feeding, bathing, dressing, toileting or grooming. A VA outpatient record in July 2010, after the June 2010 VA rating examination, shows that the Veteran complained of increasing knee pain, his medication was changed to Tramadol and he was to be considered for injections. In September 2010 he was given Synvisc injections. A September 2012 private left knee MRI revealed mild PO arthrofibrosis of the infrapatellar fat pad; nonspecific, linear, signal in the lateral meniscus which could be a PO residual but a tear could not be excluded; joint effusion with a small Baker's cyst; a ganglion cyst in the posterior and medial soft tissues along the medical aspect of the medial gastrocnemius muscle and anterior aspect of the semimembranosus muscle; distal semimembranosus tendinitis; and thickening of the distal quadriceps tendon which might be a PO residual or secondary to tendinitis without a tendon tear. On VA examination in December 2013 the Veteran's VA treatment records, including VA electronic (CAPRI) records in VBMS were reviewed. The Veteran reported having had intermittent pain and in 1997 he underwent reconstruction of the left anterior cruciate ligament (ACL) but continued to have progressive and constant bilateral knee pain. Typically, he had severe pain which lasted all day, until he was able to relax. He indicated that he was unable to measure range of motion and functional disability during these episodes. On physical examination the Veteran had active flexion of the right knee to 125 degrees, without limitation of motion or objective evidence of painful motion. Extension of the right knee was full to zero (0) degrees and without limitation of motion or objective evidence of painful motion. After three repetitions of motion his range of flexion and extension remained unchanged. Active flexion of the left knee to 120 degrees, without limitation of motion or objective evidence of painful motion. Extension of the left knee was full to zero (0) degrees and without limitation of motion or objective evidence of painful motion. After three repetitions of motion his range of flexion and extension remained unchanged. The examiner reported that the Veteran had functional loss or impairment of each knee due to limited motion and mild bilateral anterior crepitus. He had tenderness or pain on palpation of the joint line or soft tissue of the left but not the right knee. Strength in flexion and extension was 5/5 in each knee. He had no anterior, posterior, or anterior-lateral instability in either knee. There was no evidence of recurrent patellar subluxation or dislocation and had never had any tibial or fibular impairment. He had had a meniscectomy in the past for a left meniscus tear, as part of an ACL reconstruction in 1997. He had no residual signs or symptoms from the meniscectomy. His postoperative scarring was not painful or unstable. He did not use an assistive device for locomotion. X-rays had revealed arthritis in each knee but X-rays had not found evidence of patellar subluxation. The examiner stated, as to an impact on ability to work, that the Veteran sometimes had to have other employees help him up after performing a job requiring prolonged squatting. The Veteran reported having missed 17 days of work in the past year due to knee pain. He had worked from 1996 to 2006 as a tractor-trailer driver, and since 2006 as a maintenance machine mechanic. He had a high school education but had never attended college. He had had training as a tractor-trailer driver. It was opined that the Veteran was employable. It was stated that recent X-rays in December 2013 revealed no evidence of degenerative joint disease (DJD). It was commented that the Veteran's symptoms were not commensurate with X-ray or physical findings. It was stated that millions of people were capable of working with a complaint of knee pain or DJD. Also, when DJD became advanced in later years, people could still work in sedentary jobs and had the option of knee replacements. On VA examination in December 2014 the Veteran's VA electronic (CAPRI) records were reviewed. The Veteran reported having almost constant knee pain. He reported having had ACL reconstruction in1997, and also a left medial and lateral menisceal repair in August 2014. The Veteran did not report that flare-ups impacted function of his left knee. On physical examination left knee flexion was to 120 degrees and extension was to zero (0) degrees. He was able to perform repetitive motion testing and there was no additional function loss or limited motion after three repetitions. There was no pain noted during the examination and no pain upon weight-bearing. There was no evidence of tenderness or pain on palpation of the left knee joint or associated soft tissue. The examination neither supported nor contradicted the Veteran's statements of functional loss with repetitive use over time or during flare-ups. Without speculation, the examiner was unable to state whether pain, weakness, fatigability or incoordination significantly limited the Veteran's functional ability with repeated use over time or during flare-ups. Strength in flexion and extension was 5/5 in the left knee, and there was no muscle atrophy. There was no history of left knee recurrent subluxation, lateral instability or recurrent effusion. All tests of left knee stability were normal. He had no symptoms of any tibial or fibular impairment. His left knee PO scarring was not painful or unstable. He did not use an assistive device for locomotion. There was no objective evidence of crepitus. The examiner reported that whether pain, weakness, fatigability, lack of endurance or incoordination limited functional ability during flare-ups or on repetitive use over time was impossible to determine without speculation. Also, any additional limitation of motion due to pain on use or during flare-ups was impossible to measure or quantify without speculation. Rating Principles Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates such criteria. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. While a veteran's entire history is reviewed when making disability evaluations, in increased rating claims, it is the present level of disability that is of primary concern. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991); and Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased rating claim has been pending, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. For disabilities evaluated on the basis of limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment apply. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Range of motion ratings under 38 C.F.R. § 4.71a do not subsume 38 C.F.R. § 4.40, and that 38 C.F.R. § 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use including during flare-ups. DeLuca, 8 Vet. App. at 205-06. 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 of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent evaluation is assignable each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. 38 C.F.R. §§ 4.40 and 4.45 require that the disabling effect of painful motion be considered when rating joint disabilities. Deluca, 8 Vet. App. 202, 205-06 (1995). Pursuant to 38 C.F.R. § 4.40, "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." Further, functional loss "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 which becomes painful on use must be regarded as seriously disabled." Id. A separate rating for arthritis can be awarded on the basis of X-ray findings and painful motion under 38 C.F.R. § 4.59; VAOPGCPREC 9-98 (1998). The Veteran is competent to testify on factual matters of which he has first-hand knowledge, such as symptoms of pain, and is competent to describe symptoms and their effects on employment or daily activities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. The standard ranges of motion of the knee are zero degrees of extension and 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In addition, separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004. Limitation of motion of the knee is rated under Diagnostic Codes 5260 and 5261. Under DC 5260 flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to only 15 degrees warrants the maximum rating of 30 percent. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261 extension limited to 5 degrees or less warrants a noncompensable rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants the maximum rating of 50 percent. 38 C.F.R. § 4.71a, DC 5261. Separate ratings can be provided for a claimant who has compensable arthritis and instability of the knee. VAOPGCPREC 23-97. Diagnostic Code 5257 provides a 10 percent evaluation for lateral instability or recurrent subluxation of a knee that is slight, a 20 percent rating when those symptoms are moderate, and a 30 percent rating when severe. The terms "mild," "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. It should also be noted that use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Alternatively, dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, DC 5258. Impairment due to malunion of the tibia or fibula with slight knee disability warrants a 10 percent rating; when moderate a 20 percent rating is warranted; and when severe a 30 percent rating is warranted. With nonunion, with loose motion, requiring a brace, a maximum rating of 40 percent is warranted. 38 C.F.R. § 4.71a, DC 5262. Genu recurvatum, when acquired, traumatic, with weakness and insecurity in weight-bearing being objectively demonstrated 38 C.F.R. § 4.71a, DC 5263 provides for a single rating, of 10 percent. 38 C.F.R. § 4.71a, DC 5256 provides for rating criteria of a knee which is ankylosed. Analysis Initially the Board notes that the September 2006 rating decision evaluated the disorders at issue based on limitation of flexion under 38 C.F.R. § 4.71a, DC 5260. Rating decision prior thereto had evaluated each service-connected knee disorder under 38 C.F.R. § 4.71a, Diagnostic Code DC 5257 for recurrent subluxation, lateral instability or other impairment of the knee. However, a thorough review of the postservice evidence shows that prior to the September 2006 rating decision repeated examinations had found that the Veteran did not actually have clinically verifiable subluxation or instability of either knee. Specifically, VA general medical examination in November 1994 found no laxity of the knees; VA orthopedic examination in May 1995 revealed both knees were stable; and VA orthopedic examination in January 1996 found no ligamentous instability. Moreover, following VA left knee surgery in March, an examination in August 1997 found that the left knee was stable to varus and valgus stress but he had a slight positive anterior drawer's sign. Also, VA examination in September 1997 revealed that both knees were stable; VA examination in May 2003 found that Lachman's and McMurray's tests were negative, bilaterally; on VA examination in August 2006 there was no instability of either knee; on VA examination in May 2008 of the right knee was stable and while occasional buckling of the left knee was reported, testing of left knee ligaments revealed that the knee was stable, although McMurray's test was painful and produced a palpable click. Even more recently, and following the September 2006 rating decision which is appealed, while a VA examination in June 2010 noted the Veteran's complaint of giving-way pain in the left knee, there were no episodes of dislocation or subluxation, and in the right knee there was no instability, and December 2014 a VA examination noted there was no history of left knee recurrent subluxation or lateral instability. Although the Veteran has reported occasions when the left knee gave way, the objective clinical findings based on diagnostic testing outweigh the Veteran's lay assertions regarding instability. This is consistent with a recent VA examiner's finding that the Veteran's complaints were no commensurate with physical findings. Based on this, and even acknowledging that the Veteran had ACL surgery of the left knee, the Board finds that the Veteran has never actually had clinically identifiable recurrent subluxation or instability of either knee. Thus, these disabilities are best evaluated on the basis of limited motion inasmuch as this aspect of his knee disabilities is shown to cause his primary impairment of function of the knees. Thus, the evidence does not warrant a separate, compensable disability rating under Diagnostic Code 5257. As to this, DC 5257 indicates that "other impairment" of a knee is contemplated, but to the extent that such "other impairment" is actually limitation of motion, the assignment of separate ratings under both DC 5257 and under 5260 based on limitation of flexion would constitute pyramiding, i.e., double compensation, which is prohibited under 38 C.F.R. § 4.14. The evidence does not show that the Veteran has ever had any ankylosis or limitation of extension of either knee. Although he has had menisceal surgery of the left knee, the evidence does not confirm that the Veteran has had any actual episodes of locking of either knee or that during the appeal period he has had any dislocation of a semilunar, i.e., menisceal, cartilage. Further, he has not had genu recurvatum or ankylosis of either knee and the evidence affirmatively demonstrates that he has never had impairment of the tibia or the fibular of either lower extremity. Here, throughout the appeal period, the objective evidence of record does not reflect degrees of limited motion of flexion in either knee to warrant disability ratings greater than 20 percent for the left knee or 10 percent for the right knee either under Diagnostic Code 5260. In fact, the Veteran's range of motion in flexion has never been less than 100 degrees in the left knee and never less than 120 degrees in the right knee, which does not warrant, respectively, disability rating in excess of 20 percent and 10 percent for limited flexion. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Regarding any functional loss due to pain, fatigue, incoordination, or the like, the recent 2013 and 2014 examiners confirmed that repetitive testing did not result in additional limitation of motion. Even with consideration of functional loss expressed by the Veteran as pain and noted by examiners in regard to squatting and the Veteran's report of difficulty traversing stairs, the Veteran's knee disabilities do not demonstrate a degree of motion loss either in flexion or in extension greater than those contemplated by the current ratings assigned. Regarding flare-ups, the Veteran has reported frequent flare-ups but examiners have not been able to confirm the Veteran's report of greater limitation of motion during flare-ups. In other words, because any additional functional loss in the left knee is not severe enough to limit the appellant's flexion to 15 degrees or his extension to 20 degrees, it does not warrant a 30 percent disability rating. And, because any additional functional loss in the right knee is not severe enough to limit the appellant's flexion to 30 degrees or his extension to 15 degrees, it does not warrant a 20 percent disability rating. There also is no evidence or allegation that any other diagnostic code pertaining to the Veteran's disabilities of the knees is applicable in the present case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). The Board has considered the appellant's assertions and weighed them against the medical evidence of record. Although the appellant would disagree with the weight the Board assigns to his lay evidence, the evidence of record does not demonstrated that the Board's assignment of greater weight to the medical evidence is erroneous. See 38 U.S.C. § 7261(a)(4); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); Gilbert v. Derwinski, 1 Vet. App. 49, 52 (1990). For the foregoing reasons, increased disability evaluations for the Veteran's service-connected left PFS and right PFS are not warranted. Clinicians have evaluated the knee disabilities to determine the extent of the disability, and the findings do not show that the Veteran has sufficiently greater limitation of function in either knee as to warrant rating in excess of those currently assigned. In other words, the objective clinical findings consistently fail to show that the knee disabilities meet the criteria for increased ratings, and the Board concludes that those findings outweigh the Veteran's lay assertions regarding severity. ExtraSchedular Consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2014). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b)(1) (2014). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Other elements are marked interference with employment or frequent periods of hospitalization. If either (1) the claimant's disability picture is adequately contemplated by the rating schedule or (2) that there are no other "related factors," for example, frequent hospitalizations or marked interference with employment, then referral is not warranted and the other element need not be considered. The order in which these elements are addressed is irrelevant because they both have to be met before referral is warranted. See id.; Thun, 22 Vet. App. at 116; see also Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009). Addressing the adequacy of the scheduler rating criteria requires a comparison between the level of severity and symptomatology of the Veteran's service-connected disability(ies) with the criteria in the Rating Schedule. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Caution must be taken not to conflate the criteria in 38 C.F.R. § 3.321(b) with the criteria for a total disability rating based on individual unemployability (TDIU) in 38 C.F.R. § 4.16(b) (2010). The Court has recognized that "the effect of a service-connected disability appears to be measured differently for purposes of extra-schedular consideration under 38 C.F.R. § 3.321(b)(1) and for purposes of a TDIU claim under 38 C.F.R. § 4.16." Kellar v. Brown, 6 Vet. App. 157, 162 (1994). While the former requires marked interference with employment, the latter requires evidence of unemployability. Id.; see also Thun v. Peake, 22 Vet. App. at 117 (extra-schedular consideration under § 3.321 may be warranted for disability that present a loss of earning capacity that is less severe than total unemployability). The Board finds that the schedular evaluations assigned for the Veteran's service-connected left PFS and right PFS are adequate in this case. Examiners have not noted any occupational or functional impairment due to bilateral knee pain which is not already contemplated by the potentially applicable schedular criteria, including limitation of motion, of those joints. Specifically, the rating criteria adequately describe the severity and symptomatology of each of the Veteran's service-connected disabilities. Throughout the appeal the knee disabilities have been manifested primarily by pain, particularly when squatting, or when climbing stairs or ladders. By regulation, the ratings assigned for the service-connected knee disorders must encompass the factors enumerated at 38 C.F.R. §§ 4.40, 4.45, and 4.59 (as listed above). Specifically, a wide rating of signs and symptoms are contemplated in the applicable rating criteria, including pain, loss of motion, painful motion, muscle spasm, and findings as to strength. Therefore, even when considering each knee disorder individually, as well as the collective and cumulative impact of both knee disabilities together, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); see also Johnson v. McDonald, 762 F3d. 1362; 2014 WL 3844196 (C.A. Fed.); No. 2013-7104, slip op. (Fed. Cir. Aug. 6, 2014) overruling Johnson v. Shinseki, 26 Vet. App. 237, 248 (2013). TDIU A TDIU may be assigned where, without regard to advancing age, the schedular rating is less than total, and the veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2014). The impact of nonservice-connected disabilities and the effect of advancing age may not be considered. 38 C.F.R. §§ 3.341(a), 4.16(a). 38 C.F.R. § 4.16(b) provides that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Such cases should submit to the VA Director, Compensation and Pension Service, for extra-schedular consideration when a veteran is unemployable by reason of service-connected disabilities, but fails to meet the percentage standards of 38 C.F.R. § 4.16(a). Consideration must be given to all service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. While the Board does not have authority to grant an extraschedular TDIU rating in the first instance, the Board does have the authority to decide whether the claim should be referred to the VA Director of the Compensation and Pension Service for consideration of an extraschedular rating. 38 C.F.R. § 4.16(b). When adjudicating entitlement to TDIU, "VA is expected to give full consideration to 'the effect of combinations of disability.'" Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (quoting 38 C.F.R. § 4.15). However, as to extraschedular entitlement to a TDIU rating, the three-step analysis set forth in Thun v. Peake, 22 Vet. App. 111, 115-16 (2008) pertains to the extraschedular provisions of 38 C.F.R. § 3.321(b)(1) for increased rating claims, and is not relevant to a TDIU claim. See Thun, 22 Vet. App. at 117; and Geib, Id. The Veteran is service-connected for left PFS syndrome, rated 20 percent disabling, and right PFS, rated 10 percent disabling, with a combined disability rating of 30 percent. Thus, the Veteran does not meet the criteria of 38 C.F.R. § 4.16(a). With respect to consideration of an extraschedular TDIU rating under 38 C.F.R. § 4.16(b), it is clear that the Veteran has significant impairment from his service-connected disabilities of the knees. Nevertheless, he continues to be employed on a full-time basis. Equally significant, the Veteran's has maintained gainful employment for many years, despite his limited education and work experience. Moreover, he has 12 years of education and is thus capable of more than mere manual labor. Although he has reported that he had to quit his work as a truck driver because he could not push down on a clutch, there is nothing which suggests that he would not be able to operate a truck or other vehicle which has an automatic transmission that would not require pressing down on a clutch. Also, the recent VA examiner indicated that while the service-connected bilateral knee disabilities caused some occupational impairment, they did not cause any significant non-occupational impairment, i.e., in performing his activities of daily living. Here, the evidence does not establish that in light of the Veteran's past work experience, his even given his limited education, and remaining functional capacity he is incapable of obtaining or retaining substantially gainful employment. For these reasons, the Board concludes the record evidence establishes that the Veteran's service-connected disabilities alone do not prevent him from securing or following a substantially gainful occupation, and as such he does not meet the criteria for a TDIU rating and, additionally, there is no basis for referral of this case for extra-schedular consideration. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). In reaching the determinations in this case, the Board finds that the preponderance of the evidence is against the claims and, so, there is no doubt to be resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 52 (1990). ORDER Entitlement to an evaluation higher than 20 percent for left knee PFS is denied. Entitlement to an evaluation higher than 10 percent for right knee PFS is denied. Entitlement to a TDIU rating is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs