Citation Nr: 1513579 Decision Date: 03/30/15 Archive Date: 04/03/15 DOCKET NO. 09-01 887 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to an initial increased evaluation for a left knee disability, currently evaluated at 10 percent for degenerative arthritis with painful motion with a separate 10 percent evaluation for instability. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD A. Solomon, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1995 to February 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied the Veteran's claims for entitlement to service connection for hearing loss, left ear; seizures and residuals of a head injury; and granted service connection for degenerative disease of the left knee and assigned an initial rating of 10 percent for that disability. A hearing was held on March 8, 2013, by means of video conferencing equipment with the appellant in Atlanta, Georgia, before Kathleen K. Gallagher, a Veterans Law Judge, sitting in Washington, DC, who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2) and who is rendering the determination in this case. A transcript of the hearing testimony is in the claims file. In July 2013, the Board issued a decision granting a separate 10 percent rating for the left knee disability and remanding the remainder of the case for further development. In a January 2014 rating decision, the RO granted service connection for hearing loss in the left ear, and assigned a 10 percent rating, effective February 22, 2005. Since service connection was granted, the Veteran's appeal as to that issue has become moot. The Veteran has not disagreed with the assigned disability rating or the effective date. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). Therefore, this matter has been resolved and is not in appellate status. The Board subsequently remanded the issues of entitlement to service connection for residuals of TBI and an increased initial rating for left knee disability for further development in March 2014. In a December 2014 rating decision, the RO granted service connection for traumatic brain injury residuals, and assigned a 10 percent evaluation, effective February 22, 2005. Since service connection was granted, the Veteran's appeal as to that issue has become moot. The Veteran has not disagreed with the assigned disability rating or the effective date. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). Therefore, this matter has been resolved and is not in appellate status. The appeal of the remaining issue has been returned to the Board for appellate review. FINDINGS OF FACT 1. The Veteran's left knee disability has not manifested in flexion limited to 30 degrees or extension limited to 20 degrees, or functional impairment rising to a comparable level of severity. 2. The Veteran's left knee disability has not manifested in moderate recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for degenerative arthritis of the left knee with painful motion have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260 (2014). 2. The criteria for an initial disability rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must inform the Veteran about (1) the information and evidence not of record that is necessary to substantiate the claim; (2) the information and evidence that VA will seek to provide; and (3) the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In this case, the Veteran is challenging the initial disability rating assigned following the grant of service connection for degenerative disease of the left knee. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473, 490-91 (2006). Thus, VA's duty to notify has been satisfied. VA's duty to assist has also been satisfied in this case. The available relevant evidence pertinent to the issue on appeal is in the claims file, including the Veteran's VA treatment records. The Veteran and his spouse were also given the opportunity to provide testimony before the Board. Finally, pursuant to the Board's March 2014 remand instructions, the Veteran was provided with a VA examination in June 2014 to assess the current severity of his left knee disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the June 2014 examination is adequate, as the examiner noted review of the Veteran's claims file, personally interviewed and examined the Veteran, and included sufficient information regarding limitation of motion including after repetitive-use testing, instability, flare-ups, and functional limitation for evaluation under the relevant diagnostic codes. Additionally, there is no evidence indicating that there has been a material change in the severity of the Veteran's left knee symptoms since the Veteran was last examined. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Accordingly, 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). As this is in substantial compliance with the Board's remand directives, further remand on this basis is not necessary. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). The available records and medical evidence have been obtained in order to make adequate determinations as to the claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. at 183. II. Increased Initial Evaluation for Service-Connected Left Knee Degenerative Arthritis with Painful Motion and Instability a. Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to active service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2014). VA should 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 elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2014). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection is most probative of the degree of disability existing at the time that the initial rating was assigned, and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The Veteran seeks an increased initial evaluation for his service-connected left knee disability. The Veteran's left knee disability is currently rated 10 percent for degenerative arthritis with painful motion with a separate 10 percent evaluation for instability. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. See Butts v. Brown, 5 Vet. App. 532 (1993). Diagnostic Code 5010 states that arthritis, due to trauma, substantiated by X-ray findings, is to be rated as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected, which in this case would be Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a , Diagnostic Code 5003 (2014). Under Diagnostic Code 5257, a 10 percent disability evaluation is contemplated when other impairment of the knee, recurrent subluxation or lateral instability, is mild. A 20 percent disability evaluation is contemplated when such impairment is moderate. A 30 percent disability evaluation is assigned when such impairment is severe. 38 C.F.R. § 4.71a , Diagnostic Code 5257 (2014). The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. 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). It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not necessarily 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 (2014). Under Diagnostic Code 5260, a 10 percent disability evaluation is warranted when flexion of the leg is limited to 45 degrees. A 20 percent disability evaluation is warranted when flexion is limited to 30 degrees. A 30 percent disability evaluation is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a , Diagnostic Code 5260 (2014). Under Diagnostic Code 5261, a 10 percent disability evaluation is warranted when extension is limited to 10 degrees. A 20 percent disability evaluation is warranted when extension is limited to 15 degrees. A 30 percent disability evaluation is warranted when extension is limited to 20 degrees. 38 C.F.R. § 4.71a , Diagnostic Code 5261 (2014). Standard range of knee motion is from 0 degrees (extension) to 140 degrees (flexion). 38 C.F.R. § 4.71, Plate II (2014). VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or 5261 in order to obtain a separate rating for arthritis. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, the VA General Counsel also held that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, and 4.59 must be considered. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent X-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. Painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. 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. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. See 38 C.F.R. § 4.45. Determination of whether the application of sections 4.40 and 4.45 entitles the Veteran to an increased rating for his left knee disability requires factual findings as to the extent to which the Veteran's symptoms such as pain, weakness, and fatigability cause additional disability beyond that reflected in the measured limitation of motion. DeLuca 8 Vet. App. 202. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; see also Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2014); see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 is not limited to arthritis). b. Factual Background Shortly after his discharge from service in February 2005, the Veteran applied for service connection for a left knee disability. In August 2005, he underwent a VA QTC examination during which he reported a left knee condition due to injury which occurred in January 1998 when his parachute collapsed. He reported that symptoms of the condition were constant pain and swelling but not incapacitation. The treatment at that time was a knee brace. He described functional impairment as trouble walking, standing and running. On examination, the general appearance of the left knee was within normal limits. There was crepitus. The range motion was from 0 degrees extension to 140 degrees of flexion. The degree at which pain set in on range of motion testing was 140 degrees. Joint function on the left was limited by pain after repetitive use but not by fatigue, weakness, lack of endurance or incoordination. McMurray's test was abnormal with slight instability. The diagnosis was chronic left knee strain. The Veteran sought VA treatment in April 2010 and presented with left knee pain. He stated that he had left knee pain of a nine year duration of a 6/10 severity which was worse during the winter. The Veteran also reported that the knee gives way if he does not use his knee brace. He was diagnosed with left knee arthritis. The Veteran and his wife both presented testimony before the Board in March 2013. The Veteran testified that he experiences knee pain and currently uses a cane for ambulation. The Veteran's wife testified that there are some days when the pain is so bad that the Veteran can hardly move, he has fallen, and his young son must help him walk from room to room. She also described that when the Veteran tries to bend and get on the floor, it takes almost ten minutes for him to get back up. She also stated that he uses a knee brace and does not play outside or on the floor with his son because he cannot move his knee as much. Pursuant to the March 2014 Board remand, the Veteran was provided with a VA examination in June 2014. The examiner reviewed the Veteran's claims file and noted a prior diagnosis of knee strain. The Veteran reported that his left knee gives way, it swells, makes popping noise, and he has fallen due to his left knee giving away. He described a dull, throbbing ache, with pain of 6-7/10 severity which is worse with overuse and is aggravated by cold weather, rain, standing for long periods, occasional stair climbing, but not by bending or sitting. The Veteran stated that he used Tylenol or Motrin with relief, and has a brace and cane. The Veteran further described flare-ups, but was unable to describe the functional impact of his flare-ups. On physical examination, range of motion testing demonstrated flexion to 140 or greater degrees and extension to zero degrees, both without objective evidence of painful motion. Following repetitive-use testing, there was no additional limitation of range of motion or functional loss. The examiner wrote that there is no functional loss or impairment of the knee and lower leg. There was no tenderness or pain to palpation for the joint line or soft tissues of either knee. Muscle strength testing was normal for both flexion and extension of the left knee. There were normal anterior instability, posterior instability, and medial-lateral instability tests. There was also no evidence of recurrent patellar subluxation or dislocation. The examination report specifies that there were no meniscal conditions, no shin splints, and no knee surgery. The Veteran was noted to use assistive devices including a brace occasionally and a cane regularly. Diagnostic testing showed degenerative or traumatic arthritis, with no X-ray evidence of patellar subluxation. The examiner stated that the Veteran's left knee disability impacts his ability to work, specifying that continuous walking and stair climbing may cause the knee to become stiff. The examiner noted that the Veteran's gait was steady and non-antalgic, despite using a cane at the examination. He opined that the severity level of the Veteran's left knee disability was minimal at the current time, and the left knee does not preclude ambulation, completing daily chores, activities of daily living, nor retaining gainful employment. c. Analysis In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran's service-connected left knee disability does not warrant an initial rating in excess of 10 percent for degenerative arthritis of the left knee with painful motion or in excess of 10 percent for instability. The Veteran's degenerative arthritis of the left knee is currently evaluated at 10 percent for arthritis of 1 major joint with painful motion pursuant to diagnostic code 5003 and 38 C.F.R. § 4.59. In order to warrant a 20 percent evaluation under this diagnostic code, there would need to be X-ray evidence of involvement of 2 or more major joints, or 2 or more minor joint groups, with occasional incapacitating exacerbations. The Veteran's left knee represents one major joint with arthritis, therefore, a 20 percent evaluation is not warranted under this diagnostic code. A higher evaluation would also be warranted if the Veteran's left knee disability resulted in either flexion limited to 30 degrees, or extension limited to 15 degrees. At the June 2014 VA examination, the Veteran demonstrated full range of motion of the knee, without objective evidence of painful motion. Therefore, a higher evaluation based on limitation of flexion or extension is not warranted. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca v. Brown. However, an increased disability rating for the Veteran's service-connected degenerative arthritis of the left knee is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are supported by pathology consistent with the currently assigned 10 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of left knee pain and stiffness. However, the effect of the pain is contemplated in the currently assigned rating under 38 C.F.R. § 4.59. The Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant a 20 percent rating. Additional limitation due to pain, weakness, fatigue, or repetitive use was not found by the June 2014 VA examiner. Further, the VA examiner noted no pain throughout the range of motion testing of the left knee. Additionally, although he described flare-ups of pain, he was not able to describe any additional functional impairment during such flare-ups. During the VA examination, repetitive use-testing did not elicit any additional loss of range of motion or function. The VA examiner also noted that there is no functional loss or impairment of the knee and lower leg. Therefore, a preponderance of the evidence indicates that Veteran's disability picture does not rise to a level of severity comparable to that contemplated by a 20 percent evaluation for limitation of flexion or extension. A preponderance of the evidence is also against a finding that the Veteran's left knee instability warrants a rating in excess of 10 percent under Diagnostic Code 5257. The VA examination of the Veteran found no objective evidence of recurrent subluxation or lateral instability. The June 2014 examination report noted that all joint instability tests were normal and there was no X-ray evidence of patellar subluxation. The Veteran's current evaluation for left knee instability is for slight recurrent subluxation or lateral instability. Although the Veteran uses a cane and brace as assistive devices, and his wife testified at the hearing that he has fallen due to his knee giving away, the Board finds more probative the objective medical evidence of record, which does not demonstrate instability of a moderate or severe degree. In coming to the aforementioned conclusions, the Board has considered the Veteran and his wife's descriptions of his left knee impairment, including at the March 2013 Board hearing. Their descriptions of left knee pain limiting movement and sometimes causing falls are considered to be competent evidence. See Jandreau v. Nicholson, 492 F.3d 1371 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran and his spouse are also found to be credible in these assertions. See Caluza v. Brown, 7 Vet. App. 498 (1995). In this regard, while the Veteran and his wife are competent to report such manifestations, the Board finds the medical evidence of record should be afforded greater probative weight, as the VA examiner considered the Veteran's lay statements and recorded measurements of the left knee's limitation of motion, which are necessary for evaluation under diagnostic codes 5260 and 5261. The Board has also considered whether an increased evaluation is warranted under any other relevant diagnostic code. However, the evidence of record does not demonstrate that the Veteran's left knee disability has manifest in ankylosis of the knee (DC 5256), cartilage, semilunar, dislocated (DC 5258), nonunion or malunion of the tibia and fibula (DC 5262), or genu recurvatum (5263). In conclusion, the Board finds that the Veteran's service-connected degenerative arthritis of the left knee with painful motion does not result in manifestations that approximate the criteria for an evaluation in excess of 10 percent for degenerative arthritis of the left knee with painful motion or in excess of 10 percent for instability. As the Board finds that the preponderance of the evidence is against the Veteran's claim for an increased initial evaluation, there is no reasonable doubt to be resolved, and therefore the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3. In reaching these conclusions, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the left knee disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (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 that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the left knee are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The evidence demonstrates that the Veteran has had left knee pain and stiffness which makes such activities as getting up off the floor difficult, with instability which has caused falls. Although the Veteran described flares of left knee pain, he was not able to provide a description of additional functional impairment resulting from such flare-ups. Regardless, the Veteran's functional limitations have been considered under the holding in DeLuca. The Board finds that these symptoms and outcomes are neither exceptional nor unusual for degenerative arthritis of the knee and finds that the Veteran's impairments are sufficiently contemplated by the rating criteria for arthritis with painful motion and mild instability. As discussed above, there are higher ratings available under the applicable diagnostic codes, but the disabilities are not productive of such manifestations. As such, it cannot be said that the available schedular evaluations for the Veteran's left knee disability are inadequate. The Board also notes that the Veteran has been granted service connection for left ear hearing loss and residuals of traumatic brain injury. Under Johnson v. McDonald, 2013-7104, 2014 WL 3844196 (Fed. Cir. Aug. 6, 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, the evidence does not demonstrate, and the Veteran has not asserted, that there are additional symptoms or disability associated with his service-connected conditions that have not been adequately covered by the rating criteria for each individual condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Based on the foregoing, the Board finds that the requirements for extraschedular evaluation for the Veteran's service-connected lumbar spine, herniated disc at L4-L5 & L5-S1, with lower extremity radiculopathy, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that his service-connected left knee disability renders him totally unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised in connection with his claim for entitlement to an increased initial evaluation for degenerative arthritis of the left knee. ORDER An initial evaluation in excess of 10 percent for degenerative arthritis of the left knee with painful motion is denied. An initial evaluation in excess of 10 percent for left knee instability is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs