Citation Nr: 1540539 Decision Date: 09/21/15 Archive Date: 10/02/15 DOCKET NO. 08-26 444 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado THE ISSUES 1. Entitlement to a higher initial rating for a service-connected left knee disability, rated as noncompensable prior to June 26, 2008, and as 10 percent prior to August 21, 2012. 2. Entitlement to a higher rating for a total left knee replacement, rated as 30 percent disabling from October 1, 2013. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from January 2003 to September 2007 with additional reserve service. This case has a lengthy procedural history and comes to the Board of Veterans' Appeals (Board) on appeal from a March 2008 decision by the RO in Denver, Colorado, that in pertinent part, granted service connection and a noncompensable rating for left knee degenerative joint disease, retroactively effective from September 20, 2007. The Veteran appealed for a higher initial rating. A personal hearing was held at the RO before the undersigned Veterans Law Judge (VLJ) of the Board in June 2011. A transcript of this hearing is of record. During the course of the appeal, in a February 2010 decision, the RO granted a higher 10 percent rating for the service-connected left knee disability, effective June 26, 2008. In a February 2013 rating decision, the RO granted a temporary 100 percent post-surgical rating for the left knee disability (now characterized as total left knee replacement) effective August 21, 2012, and a 30 percent rating effective October 1, 2013. Thus, the RO has assigned "staged" ratings for the left knee disability. See Fenderson v. West, 12 Vet. App. 119 (1999). Although higher staged ratings have been awarded, as the highest possible rating was not assigned for the left knee disability throughout the rating period on appeal, the issue of entitlement to a higher rating for the left knee disability remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993) (a Veteran is presumed to be seeking the highest possible rating unless he expressly indicates otherwise). In September 2011 and January 2014, the Board remanded this case to the Agency of Original Jurisdiction (AOJ) for additional development, and the case was subsequently returned to the Board. The Board notes that the Veteran is currently in receipt of a combined 100 percent service-connected disability rating. The record before the Board consists of the Veteran's paper claims file, and electronic Virtual VA and VBMS claims files. FINDINGS OF FACT 1. Prior to June 26, 2008, the Veteran's service-connected degenerative joint disease of the left knee was manifested by full range of motion, painful motion, and X-ray evidence of arthritis, but with no recurrent subluxation or lateral instability, and no evidence of dislocated or absent semilunar cartilage. 2. From June 26, 2008 to November 17, 2011, degenerative joint disease of the left knee was manifested by X-ray evidence of arthritis, pain and limitation of motion no worse than 5 degrees of extension to 80 degrees of flexion, even with consideration of pain. The residual surgical scars are linear and superficial, are not tender or painful, and do not limit the function of the left knee. 3. From June 26, 2008 to August 21, 2012 (the date of a TKA), the Veteran's service-connected left knee disability included a torn medial meniscus, manifested by frequent episodes of locking, pain, and effusion into the joint. 4. From June 26, 2008 to August 21, 2012, the left knee disability included knee impairment with slight recurrent subluxation of the patella. 5. From November 17, 2011 to August 21, 2012, degenerative joint disease of the left knee was manifested by pain, X-ray evidence of arthritis, and limitation of extension to no worse than 15 degrees, with consideration of pain, and limitation of flexion to no worse than 120 degrees. 6. From October 1, 2013, the Veteran's right knee disability is not manifested by severe painful motion or weakness; there is no recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. Prior to June 26, 2008, the criteria for a higher 10 percent rating, and no higher, for degenerative joint disease of the left knee have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5258, 5259, 5260, 5261 (2015). 2. From June 26, 2008 to November 17, 2011, the criteria for a rating in excess of 10 percent rating for degenerative joint disease of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2015). 3. From June 26, 2008 to August 21, 2012, the criteria for a separate 20 percent rating for a torn medial meniscus have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258 (2015). 4. From June 26, 2008 to August 21, 2012, the criteria for a separate 10 percent rating for recurrent subluxation have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2015); VAOPGCPREC 23-97. 5. From November 17, 2011 to August 21, 2012, a higher 20 percent rating for degenerative joint disease of the left knee is warranted. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5261; DeLuca v. Brown, 8 Vet. App. 202 (1995). 6. For the period from October 1, 2013, the criteria for a disability rating in excess of 30 percent for status post total left knee replacement, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1-4.7, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5055, 5261, 5257, 5262 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice as to her original service connection claim by a letter dated in April 2007. In cases such as this, where service connection has been granted and an initial disability rating and effective date has been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, supra; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA also fulfilled its duty to assist the Veteran with this claim by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing her. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). VA has obtained service treatment records and VA medical records, assisted the appellant in obtaining evidence, and afforded the appellant VA compensation examinations in October 2007, November 2011, and May 2014. A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds that the VA examinations are adequate as they provide the information needed to properly rate her service-connected left knee disability. 38 C.F.R. §§ 3.327(a), 4.2. Only if the record is inadequate or there is suggestion the current rating may be incorrect is there then a need for a more contemporaneous examination. 38 C.F.R. § 3.327(a) (2015). Here, the most recent VA compensation examination for this condition was conducted in May 2014. The mere passage of time since does not, in and of itself, necessitate another examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The Board also notes that the actions requested in the prior September 2011 and January 2014 remands have been completed. Additional VA medical records were obtained, VA compensation examinations of the left knee disability were conducted, the claim was readjudicated by the AOJ, and the Veteran and her representative were furnished with a supplemental statement of the case. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Board finds that this was done at the June 2011 Board hearing. Moreover, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. Neither the appellant nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the June 2011 Board hearing. Law and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting 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; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. When the requirements for a compensable rating are not met, a 0 percent rating is assigned. 38 C.F.R. § 4.31. Governing law provides that the evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14 (2014). In Esteban, the United States Court of Appeals for Veterans Claims (Court) found that when a Veteran has separate and distinct manifestations from the same injury he should be compensated under different Diagnostic Codes. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). In general, the degree of impairment resulting from a disability is a factual determination and the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any initial rating/increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. 38 C.F.R. § 4.40. However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. 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. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Board accordingly will consider whether another rating code is more appropriate than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Under Diagnostic Code 5010, arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5003, 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 (Diagnostic Code 5200 etc.). 38 C.F.R. § 4.71a, Diagnostic Code 5003. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for 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. In the absence of limitation of motion, a 10 percent rating is assigned for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and a 20 percent rating is assigned for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, pertaining to limitation of leg flexion, a noncompensable evaluation is assigned where flexion is limited to 60 degrees. A 10 percent rating is warranted where flexion is limited to 45 degrees. A 20 percent evaluation is for application where flexion is limited to 30 degrees. Finally, a 30 percent rating applies where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2015). Under Diagnostic Code 5261, pertaining to limitation of leg extension, a noncompensable evaluation is assigned where extension is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent evaluation is for application where extension is limited to 15 degrees. A 30 percent rating applies where extension is limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. Finally, a 50 percent evaluation is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2015). Knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2015). Symptomatic removal of the semilunar cartilage is assigned a maximum 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2015). Disabilities involving cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint are assigned a maximum 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2015). Diagnostic Code 5020 provides that synovitis is rated based on limitation of motion of the affected parts, as arthritis, degenerative. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (July 1, 1997; revised July 24, 1997). The General Counsel subsequently clarified in VAOPGCPREC 9-98 (August 14, 1998) that for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. VA's General Counsel further explained that, if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. This is because, read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). VA's General Counsel has additionally held that separate ratings may also be assigned for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59, 990 (2004). Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same knee, the limitations must be rated separately to adequately compensate him for functional loss associated with injury to his leg and knee. Id. The Veteran's lay statements and testimony are considered competent evidence when describing her symptoms of disease or disability that are non-medical in nature. Barr v. Nicholson, 21 Vet. App. 303 (2007), Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); and Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Her lay statements and testimony regarding the severity of her symptoms must be viewed in conjunction with the objective medical evidence of record and the pertinent rating criteria. And the ultimate probative value of her lay testimony and statements is determined not just by her competency, but also her credibility to the extent her statements and testimony concerning this is consistent with this other evidence. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). See also 38 C.F.R. § 3.159(a)(1) and (a)(2). Analysis The Veteran contends that her left knee disability is more disabling than currently evaluated. In the March 2008 rating decision on appeal, service connection was established for degenerative joint disease of the left knee, rated as 0 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5010, effective September 20, 2007. The RO has rated the left knee disability as 10 percent disabling from June 26, 2008 to August 21, 2012 (the date of a left total knee replacement). Since August 21, 2012, the AOJ has recharacterized the left knee disability as left total knee replacement, rated 100 percent disabling from that date, and as 30 percent disabling from October 1, 2013, under Diagnostic Code 5055. Rating Period Prior to June 26, 2008 Service treatment records reflect that a December 2006 bone scan showed degenerative changes in the left knee. On separation medical examination during service in April 2007, range of motion of the left knee and right knee was from 0 to 120 degrees bilaterally. The diagnosis was bilateral knee decreased range of motion. A concurrent report of medical history reflects that the Veteran reported bilateral knee pain. On VA examination in October 2007, less than a month after separation from service, the Veteran complained of daily bilateral knee pain, bilateral swelling, left worse than right, and daily stiffness. She said her knees did not give out, but she did have a locking sensation. She said that using stairs was very painful, and she could stand for a half-hour, and walk approximately one mile before having increased pain. She did not run. She stated that she wore braces on her knees before her daily walks, and walked twice a day in half-mile increments. On examination, there was no crepitus, no bilateral joint line, or medial or lateral aspect joint line tenderness of the bilateral patellae. Left knee range of motion was from 0 degrees of extension to 145 degrees of flexion. She was able to do three repetitions, with decreased range of motion on the third repetition, which was not due to knee pain, but rather was due to back pain. Extension was full, with a minimal pulling sensation. There was no ligament laxity, and anterior and posterior drawer signs were negative. An X-ray study of the left knee showed mild degenerative joint disease. The diagnosis was bilateral knee degenerative joint disease with residual chronic pain, stiffness, and radiographic evidence of degenerative joint disease. The clinical reports during the period prior to June 26, 2008 do not document that the Veteran's left knee degenerative joint disease was productive of functional impairment consistent with limitation of extension to 10 degrees or more or limitation of flexion to 45 degrees or more as required under Diagnostic Codes 5261 and 5260 for a rating in excess of 0 percent at any time during the appeal period prior to June 26, 2008. In fact, range of motion of the left knee was full on VA examination in October 2007. See 38 C.F.R. § 4.71, Plate II. Even considering the effects of pain on motion, there is no probative evidence that pain reduced motion during this period to the extent required for a higher rating under the limitation of motion codes. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In essence, the medical reports on file do not demonstrate the level of loss of motion (in either flexion or extension) necessary for either a higher rating or separate ratings based on limitation of flexion or extension at any time during this portion of the appeal period. However, based on the Veteran's competent and credible lay statements of left knee pain, and the clinical and X-ray evidence of record, including the examiner's finding of stiffness, although there was no demonstrated limitation of motion of the left knee during this period, the Board finds that a higher initial 10 percent rating is warranted for the left knee disability based on X-ray evidence of arthritis with painful motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5010; Lichtenfels, supra; VAOPGCPREC 9-98. After a review of all of the evidence of record during this period, the Board finds that the weight of the probative evidence does not show that the Veteran had a compensable degree of recurrent subluxation or instability in the left knee such as to warrant assignment of a separate compensable rating under Diagnostic Code 5257. In fact, the October 2007 VA examiner indicated that there was no laxity of left knee ligaments. See VAOPGCPREC 23-97; VAOPGCPREC 9-98. Moreover, a higher rating is not warranted under any applicable rating criteria prior to June 26, 2008. Because there continued to be full range of motion of this knee, even considering the arthritic pain, ankylosis of the left knee is not shown. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."). Thus, Diagnostic Code 5256 does not apply. Prior to June 26, 2008, as the evidence fails to demonstrate nonunion or malunion of the tibia or fibula, a higher rating is not possible under Diagnostic Code 5262. Additionally, as there is no showing of genu recurvatum, Diagnostic Code 5263 is inapplicable. Moreover, as the evidence fails to demonstrate a dislocated semilunar cartilage, or removal of such, Diagnostic Codes 5258 and 5259 are inapplicable. There are no other relevant codes for consideration. The Board finds that a 10 percent disability rating adequately reflects the disability picture presented during this period. In sum, throughout the rating period prior to June 26, 2008, a higher initial 10 percent rating, but no higher, is warranted for the left knee disability. Rating Period from June 26, 2008 to August 21, 2012 The AOJ has rated the left knee disability as 10 percent disabling from June 26, 2008 to August 21, 2012, under Diagnostic Codes 5010-5257. VA outpatient treatment records during this period reflect regular ongoing treatment for persistent left knee pain. A June 26, 2008 magnetic resonance imaging (MRI) scan of the left knee showed a medial meniscal tear and high grade chondromalacia in the medial joint compartment with some areas down to bone with bone marrow edema in the distal femoral condyle, chondromalacia patella of the femoral joint, and synovitis of the infrapatellar bursa. The lateral joint compartment was unremarkable for tears or malacia, and the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were intact. The medial and lateral collateral support structures were intact. The extensor mechanism was intact, and the patella was mildly laterally subluxed and tilted. There was high grade chondromalacia in the medial patellar facet and involving the medial trochlear groove, and underlying bone marrow edema. A July 2008 VA physical therapy note reflects that the Veteran complained of knee pain, and said that her knees hurt when moving around, including standing up and sitting down, and while biking. She said she had to side-step when climbing stairs because of knee pain, housework was painful, and she was unable to get down on her hands and knees. She said she had been falling a lot due to both knees giving out, and her ankle giving out. On examination, on ligament testing, there was pain in the ACL posteriorly, pain in the medial collateral ligament (MCL), and no pain in the lateral collateral ligament (LCL). There was tenderness to palpation over the left medial meniscus and left MCL. The diagnostic assessment was left knee pain, with a left medial meniscal tear. A July 2008 VA orthopedic surgery note reflects that the Veteran complained of chronic left knee pain, worse with rotation, standing, and ascending or descending stairs. She denied locking or giving way. On examination, there was tenderness to the left knee over the medial joint line, and full active range of motion with crepitus. Instability tests were negative. An X-ray study was equivocal for tiny suprapatellar effusion, and there was minimal spurring of the tibial spines, medial tibial plateau, and inferior pole of the patella. There was no acute fracture, subluxation or dislocation. Joint spaces appeared relatively maintained. The clinical diagnosis was left knee mild osteoarthritis, medial meniscal tear, and grade III-IV chondromalacia of the medial compartment. An August 2008 orthopedic surgery note reflects that the Veteran was seen for complaints referable to a left knee medial meniscus tear. On August 21, 2008, the Veteran underwent left knee arthroscopy with medial femoral condyle microfracture, medial plica resection, and medial femoral condyle chondroplasty. The preoperative diagnosis was medial meniscus tear, and the postoperative diagnosis was grade 2 chondromalacia patella, grade 4 chondromalacia medial femoral condyle, grade 2 chondromalacia medial tibial plateau, grade 2 chondromalacia lateral compartment (femur/tibia), and medial plica. The surgeon noted that the ACL and PCL were intact. Postoperatively, she was to be weightbearing as tolerated on the affected extremity, and would be seen in two weeks for suture removal and routine postoperative care. She was given crutches, and a medial unloader knee brace was prescribed. A September 3, 2008 orthopedic surgery postoperative note reflects that her stitches were removed, and post-surgery range of motion was negative 5 degrees extension to 80 degrees flexion. She was advised to actively work on her range of motion. The Veteran was weight-bearing and using a cane in her right hand. She could walk for three blocks before being limited by pain. Her pain was moderately well controlled on Percocet used mainly at night, and she also took Tramadol for osteoarthritis. In her September 2008 substantive appeal (VA Form 9), the Veteran stated that she had subluxation of the left knee. An October 17, 2008 noncontrast MRI of the left knee showed a large joint effusion, at least one loose intra-articular body, and low signal intensity suggesting small meniscal fragment. There was mildly increased fluid in the medial femoral condyles, prominently anterior, minimal increased fluid in the opposing anterior medial tibial plateau, and high-grade chondromalacia in the medial patellar facet. The ACL, PCL, MCL, and LCL were grossly unremarkable. There was a horizontal tear of the posterior horn of the medial meniscus, and nonvisualization of the anteromedial portion of the anterior horn of the medial meniscus, which may represent a complete radial tear, with partial anterolateral displacement of remainder of the anterior horn. There was a possibility of a flipped meniscus or loose intraarticular meniscal fragment, and mild synovitis along the infrapatellar plica. An X-ray study of the left knee dated in late October 2008 demonstrated mild to moderate osteoarthritis in the medial compartment of the left knee joint. An October 27, 2008 orthopedic surgery note reflects that the Veteran was seen for pre-operative consultation regarding her left knee. The Veteran reported that she had left knee pain since her arthroscopy in August 2008, and could not bend her knee all the way back or fully extend. She also reported swelling and tingling, but denied numbness, locking, catching, and buckling. On examination, there was mild swelling of the left knee, and well-healed incisions. Active range of motion of the left knee was from -5 to 95 degrees, and passive range of motion was from 0 to 110 degrees. The knee was stable to valgus, varus, and anterior stress. There was tenderness to palpation of the medial-lateral joint line. McMurray's test was negative. The diagnostic assessment was left knee pain, osteoarthritis, and past history of medial meniscus tear, with no pain relief since the last arthroscope in August 2008. On November 6, 2008, the Veteran underwent a diagnostic arthroscopy of the left knee. It was noted that she continued to have knee pain and catching since a prior arthroscopy four months ago. The surgeon performed a partial medial meniscectomy for a small tear in the meniscus, and abrasion chondroplasty of the patella. The postoperative diagnosis was left knee osteoarthritis, grade 4 patella, grade 2 trochlea, grade 4 medial femoral condyle, and small medial meniscal tear. Postoperatively, she was to be weightbearing as tolerated on this lower extremity. A November 19, 2008 orthopedic surgery note reflects that since her surgery, she was healing well, with sutures in place. There was mild postoperative joint effusion, but no drainage, erythema or signs of infection. Range of motion was from 0 to 90 degrees, and the knee was stable. The diagnostic assessment was osteoarthritis knee status post debridement. Synvisc injections were recommended. A December 2008 internal medicine note reflects that the Veteran reported that her left knee was worse after her two surgeries, and she had sharp shooting pains in her knee. A January 2009 VA orthopedic note reflects that she was eight weeks status post left knee scope debridement that showed grade 4 chondromalacia throughout three compartments. She continued to have pain, but function remained high, with walking, use of an elliptical, and weights. On examination, her incisions were healed, there was tenderness around the incisions, the medial joint line and patellofemoral joint were painful, and there was full range of motion. The diagnostic assessment was stable post left knee arthroscopic debridement. A knee sleeve and Synvisc injections were recommended. In February 2009, she received her first and second Synvisc injections of the left knee, at which time she denied swelling, warmth, fevers/chills, redness, tingling, numbness, catching, bucking, and locking. The diagnostic assessment was left knee osteoarthritis, grade 3. She received a third injection in March 2009; knee effusion was noted after the injection. In May 2009, the Veteran complained of left knee pain, instability and swelling. On examination, she was ambulatory with a limp and use of a cane. Her knees were in normal alignment, and small surgical scars and swelling were noted in the left knee. There was no left knee crepitus. The left knee was mildly tender to palpation along the joint line, nontender along the collaterals, and on the patella. There was 2+ effusion of the left knee. Range of motion was from 0 to 95 degrees, and the left knee was stable medially and laterally. Lachman test was negative, and extensor strength was intact. The diagnostic assessment was left knee osteoarthritis. She was given a left knee brace in June 2009. A July 2009 orthopedic note reflects that the Veteran complained of persistent left knee pain, and swelling, and said her brace helped a bit. She reported buckling with pivoting, and locking after having her knee in a bent position. The Veteran reported that she walked one mile every day, but was unable to run. She said she walked with a cane ever since her back surgery in 2007. On examination, there was crepitus in the knee. Range of motion was from 0 to 110 degrees in the brace. A January 29, 2010 VA orthopedic surgery note reflects that the Veteran complained of diffuse left knee pain, with some good days and some bad, usually worse with walking, and intermittent swelling. She had two knee arthroscopies in 2008, the first one did not help, and the second one helped for a short time. She used a Bellacure brace. She tried three injections/ series of Synvisc; the third increased swelling, but it quickly resolved. An X-ray study showed osteoarthritis with apparent progression in the medial compartment when compared with the prior study. A MRI showed diffuse osteoarthritic tricompartmental changes, debrided menisci, bone edema, and swelling. The diagnostic assessment was left knee tricompartmental osteoarthritic changes, no recommendation for further arthroscopic surgery. The treatment provider indicated that the next recommended surgery would be a total knee arthroplasty (TKA), and the Veteran preferred to wait as long as possible before such surgery. An August 2010 internal medicine note reflects that the Veteran complained of problems with her left knee degenerative joint disease, and said the new brace was sometimes helpful. She had Synvisc injections that were initially helpful, as were cortisone injections. The third Synvisc injection resulted in a lot of swelling. The orthopedics department had reviewed her case and felt the next step would be a total knee replacement (TKR), but the Veteran wanted to wait. A March 2011 VA outpatient treatment record reflects that the Veteran reported that she walked twice a day for thirty minutes, but was limited by knee pain. During the Veteran's June 2011 testimony before the Board, she stated that in 2008, her left knee was very painful, including when walking, or climbing or descending stairs. She said that her left knee was "scoped" in August 2008, but the surgery only made the disability a little bit better. She was then given a knee sleeve to wear, and later received Synvisc injections to her knee in February and March 2009. Her knee swelled up after the last injection. She subsequently had a cortisone injection, which was briefly effective, and was given another knee brace, and eventually was told she needed a knee replacement. She testified that her left knee disability had progressively worsened since 2008. Currently, the left knee was starting to bow out, and when she got up in the morning, it sometimes did not support her. She said her knee pain woke her up at night. She was currently wearing a hard knee brace, and the knee was weak and unstable without the brace. She stated that her knee gave way once or twice a week. She said she could walk for about a block before having to sit down. She took Tramadol, Naproxen, and occasionally Vicodin for her knee. She stated that her knee operations made her knee worse, and she currently had knee pain and instability, and her knee hurt even when she was lying down or sitting. She reported limitations in her activities of daily living due to her knee disability. She wore the brace whenever she left the house, and sometimes at home. She said she was not working, and was retired. She also testified that her left ankle disability sometimes gave out, and caused her to fall. She said that because of her knee and ankle disabilities she had lost the ability to do a lot of different exercises, such as riding a bicycle, or other outdoor activities. On November 17, 2011 VA compensation examination of the left knee, the examiner indicated that the claims file was reviewed. The Veteran reported that she had retired from her civilian job in December 2007. She volunteered at a VA Medical Center once per week. She said she could perform her daily activities without assistance, but sometimes needed assistance putting on her socks due to left knee pain. She said driving, sitting, standing, walking and stairs were limited due to low back and left knee pain. She said she could walk a block before needing to rest due to left knee pain. She wore a hinged left knee brace four times per week for prolonged walking. She complained of constant daily left knee pain, at a level of 5/10. She reported stiffness, swelling, and instability, but denied locking. On examination, range of motion of the left knee was as follows: extension to 5 degrees, with objective evidence of painful motion beginning at 10 degrees, and extension to 130 degrees, with objective evidence of painful motion beginning at 100 degrees. After repetitive motion testing times three, range of motion of the left knee was from 15 to 120 degrees. The examiner indicated that the Veteran had additional limitation of motion of the left knee following repetitive use testing, and had functional impairment of the left knee after repetitive use including reduced and weakened movement, excess fatigability, incoordination, pain on motion, swelling, atrophy of disuse, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The examiner stated that there was significant change in active range of motion following repeat testing times three against resistance, and so an additional loss of 10 degrees for flexion and extension was recommended for the left knee joint due to painful motion, weakness, impaired endurance, incoordination, and instability. There was pain to palpation of the knee, and muscle strength was 4/5 in flexion and extension. There was no anterior instability, posterior instability, or medial-lateral instability. There was evidence of slight recurrent patellar subluxation/dislocation. The examiner stated that the Veteran had evidence of a left knee meniscus (semilunar) cartilage condition, specifically a meniscal tear, and frequent episodes of joint pain and effusion. She had residual pain, swelling, and instability due to her 2008 meniscectomy. She had post-surgical scars that were not painful or unstable, or greater than 39 square centimeters. She used a hinged brace. The examiner opined that her left knee functioning was not so diminished that amputation with a prosthesis would equally serve the Veteran. A November 2011 X-ray study of the left knee showed worsened overall moderate three-compartment osteoarthritis, with similar nonspecific large knee joint effusion, and possible discrete corticated body at the medial knee joint margin. A left knee MRI showed advanced osteoarthritis of the medial compartment, with a complex tear of the body and anterior horn of the medial meniscus, joint effusion, and significant chondromalacia patella. The diagnoses were severe left knee degenerative joint disease status post arthroscopic surgery, torn medial meniscus status post partial meniscectomy, and chondromalacia patella with subluxation. The VA examiner opined that the Veteran would be limited to a sedentary type job due to severe left knee pain with prolonged standing or walking. A March 2012 weightbearing X-ray study of the left knee showed severe osteoarthritis, with normal alignment, with no subluxation of the patella. After a review of all of the evidence of record during the period from June 26, 2008 to August 21, 2012, the Board finds that the left knee disability was manifested by separate and distinct manifestations during this period, and separate ratings will therefore be assigned under different Diagnostic Codes during this period. Moreover, as discussed below, the Board finds that the evidence demonstrates decreased range of motion from November 17, 2011. The Board finds that a separate 20 percent rating is warranted for a torn medial meniscus that was first demonstrated on a June 26, 2008 MRI of the left knee. The evidence during this period shows frequent episodes of locking, pain, and effusion into the joint. Rating this disability as a dislocated semilunar cartilage (meniscus), the Board finds that a separate 20 percent rating under Code 5258 is warranted throughout the portion of the rating period on appeal from June 26, 2008 to August 21, 2012. 38 C.F.R. § 4.71a, Diagnostic Code 5258. This is the maximum rating available under this code. Considering the knee impairment under the Diagnostic Codes pertaining to arthritis and limitation of motion, the clinical reports during the period from June 26, 2008 to November 17, 2011 do not document that the Veteran's left knee degenerative joint disease was productive of functional impairment consistent with limitation of extension to 15 degrees or more or limitation of flexion to 30 degrees or more as required under Diagnostic Codes 5261 and 5260 for a rating in excess of 10 percent at any time during this portion of the appeal period. Range of motion during this period was no worse than 5 to 80 degrees, and this measurement was taken in September 2008, within two weeks of arthroscopic knee surgery. Range of motion was generally better than this throughout this portion of the rating period. For example, in October 2008, active range of motion of the left knee was from -5 to 95 degrees, and passive range of motion was from 0 to 110 degrees. In November 2008, range of motion was from 0 to 90 degrees. A January 2009 VA orthopedic note reflects that although the Veteran had left knee pain, left knee function remained high. Range of motion was from 0 to 95 in May 2009, and 0 to 110 degrees in July 2009. Thus, even considering the effects of pain on motion, there is no probative evidence that pain reduced motion during this period to the extent required for a higher rating for degenerative joint disease of the left knee in excess of 10 percent under the limitation of motion codes. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). During the period from June 26, 2008 until November 17, 2011, the medical reports on file do not demonstrate the level of loss of motion (in either flexion or extension) necessary for either a higher rating in excess of 10 percent or separate ratings based on limitation of flexion or extension at any time during this portion of the appeal period. However, the Board finds that as of November 17, 2011, a higher 20 percent rating is warranted for degenerative joint disease of the left knee under Diagnostic Code 5261, based on limitation of extension to 15 degrees, with consideration of pain. 38 C.F.R. § 4.71a, Diagnostic Code 5261; DeLuca, supra. At the VA examination of that date, range of motion was from 5 to 130 degrees, and after repetitive motion testing, was from 15 to 120 degrees. A separate rating is not warranted for limitation of flexion of the left knee under Diagnostic Code 5260 during this period, as a compensable degree of limitation of flexion has not been demonstrated. VAOPGCPREC 9-2004. A rating in excess of 20 percent is not warranted for degenerative joint disease of the left knee during this period, as the evidence does not show flexion limited to 15 degrees or extension limited to 20 degrees or more. Thus, a 20 percent rating (and no higher) is assigned for degenerative joint disease of the left knee during the period from November 17, 2011 to August 21, 2012. 38 C.F.R. § 4.71a, Diagnostic Code 5261. During the period from June 26, 2008 to August 21, 2012, the Board finds that the evidence, including a June 26, 2008 MRI, shows that the patella was mildly laterally subluxed and tilted, and such warrants a separate 10 percent rating based on knee impairment with slight recurrent subluxation of the patella. 38 C.F.R. § 4.71a, Diagnostic Code 5257. A separate rating is warranted because the Veteran's degenerative joint disease of the left knee was manifested by at least a noncompensable degree of limitation of motion during this period. VAOPGCPREC 23-97; VAOPGCPREC 9-98. The Board is mindful of the Veteran's lay assertions regarding the severity of her left knee disability and her contention that her knee has occasionally caused her to fall. Her statements are competent in regard to reports of symptoms and credible to the extent of the Veteran's sincere belief that her symptoms are more severe than the current rating with regard to instability or subluxation. The Board nevertheless must consider these lay assertions along with the other relevant evidence in the file, including the medical evidence as reflected in the results of his objective medical examination. As to the presence and degree of any instability, the competent and credible lay evidence is outweighed by the competent and credible objective medical opinions of the VA examiner as they have expertise in evaluating the severity of her knee disability. The November 2011 examiner opined that there was slight recurrent patellar subluxation/ dislocation. An even higher rating is not warranted under Diagnostic Code 5257, as moderate instability of the left knee has not been objectively noted by a medical professional during evaluation or treatment, and the ligaments have repeatedly been shown to be intact on diagnostic studies. Moreover, no subluxation of the patella was seen on X-ray study in March 2012. Although she wore a left knee brace during this period, the evidence does not suggest that she has moderate or severe difficulty with instability or subluxation such that a rating in excess of 10 percent rating is warranted under Diagnostic Code 5257. The Board finds that during this period, the evidence does not show more than slight recurrent subluxation or lateral instability as required for a rating in excess of 10 percent under Diagnostic Code 5257. Throughout the rating period from June 26, 2008 to August 21, 2012, higher ratings are not warranted for the left knee disability under any other applicable codes. There is no evidence of ankylosis of the left knee (Diagnostic Code 5256), nonunion or malunion of the tibia or fibula (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263). Although synovitis has been shown on MRI, a higher rating cannot be assigned under Diagnostic Code 5020, as this disability is rated on limitation of motion of the knee, as arthritis. And a separate rating cannot be assigned under this code as that would be impermissible pyramiding. 38 C.F.R. § 4.14. The Board finds that the ratings assigned above adequately reflect the disability picture presented during this period. From October 1, 2013 The Veteran underwent a left total knee replacement (TKR) on August 21, 2012. Since August 21, 2012, the left knee disability has been rated under Diagnostic Code 5055, with a 100 percent post-surgical rating until October 1, 2013, after which the disability has been rated 30 percent disabling. Under Diagnostic Code 5055, a 100 percent rating is assigned for prosthetic replacement of the knee joint for one year following implantation of prosthesis. Subsequently, a 60 percent evaluation may be assigned for knee replacement (prosthesis) with chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the knee disability is rated by analogy to diagnostic codes 5256, 5261, or 5262. The minimum rating is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. On VA examination in May 2014, the examiner stated that the claims file was reviewed. The diagnosis was severe knee osteoarthritis, status post TKA with residual limited range of motion. The claims file was reviewed. After her VA examination in November 2011, she was first seen regarding her left knee in March 2012, when she was prescribed a medial off-loader brace and referred for surgery. Veteran underwent TKR on August 21, 2012. The surgery was uncomplicated and she did well afterward. One day after surgery, range of motion was 10-45 degrees. After discharge, she received physical therapy. Range of motion was from 0 to 95 degrees in September 2012. According to the Veteran she never got past 100 degrees. Although the medical records were documented as having a range to 120 degrees in October and November 2012, the Veteran stated that on these visits her knee was not measured. She also had a post-operative stitch abscess in October 2012, which completely resolved by early November 2012. One year later, in August 2013, she was doing well, except for significant limited range of motion at 95 degrees flexion and 0 degrees extension along with pain in left knee. She complained of tenderness in the lateral knee over the IT band insertion and discomfort with prolonged standing and walking. The Veteran did not report that flare-ups impacted the function of the knee and/or lower leg. On examination, range of motion of the left knee was as follows: flexion to 100 degrees, with objective evidence of painful motion at 100 degrees, and extension to 5 degrees, with no objective evidence of painful motion. After repetitive motion testing, left knee range of motion was unchanged. The examiner indicated that the Veteran did not have additional limitation in range of motion of the knee and lower leg following repetitive-use testing, but did have functional loss after repetitive motion testing, specifically less movement than normal, pain on movement, swelling, deformity, interference with sitting, standing and weight-bearing, and disturbance of bending knee, and doing stairs. There was pain to palpation of the left knee. Muscle strength was full in the left knee in both extension and flexion. There was no instability in the left knee. Stability was described as normal. The examiner indicated that the Veteran previously had a meniscectomy in 2008, and that meniscal symptoms were resolved. The Veteran had a left TKR on August 21, 2012, and had residual severe limitation of motion which was limiting in daily life. The Veteran had surgical scars but they were not painful or unstable, nor was the total area of all scars greater than 39 square centimeters. The Veteran did not use any assistive devices. A May 2014 X-ray study showed status post left knee arthroplasty, and anatomic alignment of the prosthetic components without evidence of loosening. The VA examiner opined that the Veteran's knee and/or lower leg conditions impacted her ability to work in that the Veteran was limited to sedentary position due to discomfort with prolonged walking of 10 minutes or standing for 15 minutes and inability to do stairs. He stated that there is no anticipated change over time in range of motion from flares, pain or repetitive motion. Her prior meniscus abnormality, patellar subluxation, ligamental laxity including lateral instability, weakness and mild atrophy of disuse conditions all resolved with TKA. The severe limitation of flexion was result of the TKA. The Board finds that a disability rating in excess of 30 percent is not warranted for the rating period from October 1, 2013. A higher rating under Diagnostic Code 5055 is not assignable based upon intermediate degrees of residual weakness, pain, limitation of motion. There are no findings of ankylosis; therefore, a rating in excess of 30 percent under Diagnostic Code 5256 is not warranted. Under Diagnostic Code 5261, a rating in excess of 30 percent requires limitation to 30 degrees of extension. In the instant case, the Veteran has extension of the right knee to 5 degrees. Although the 2014 VA examiner described the residuals of the Veteran's knee replacement as residual severe limitation of motion which was limiting in daily life, the reported findings do not approximate extension limited to 30 degrees. Accordingly, a rating in excess of 30 percent is not assignable for limitation of extension based upon functional limitation. The evidence does not show findings of impairment of the tibia and fibula; accordingly, a rating in excess of 30 percent is not assignable under Diagnostic Code 5262. The evidence does not show that the Veteran's right knee replacement is manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity. Accordingly, the criteria for a 60 percent rating under Diagnostic Code 5055 are not met. In conclusion, the Board finds that a higher rating in excess of 30 percent for service-connected status post left total knee replacement is not warranted during the period from October 1, 2013. The preponderance of the evidence is against the Veteran's claim for a higher rating during this period. Consequently, the benefit-of-the-doubt rule does not apply. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Extraschedular Consideration 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 ratings for that service-connected disability are inadequate. Second, if the schedular rating 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. 38 C.F.R. § 3.321(b) (2014); Thun v. Peake, 22 Vet App. 111 (2008). The Board finds that the evidence in this case does not show such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. The rating criteria reasonably describe the Veteran's disability level and symptomatology due to her service-connected left knee disability. The Veteran has not exhibited symptoms of the service-connected disability that are not contemplated in the relevant rating criteria or that are shown to be exceptional or unusual. Therefore, the Board finds that referral for consideration of the assignment of extraschedular ratings is not warranted. ORDER Throughout the rating period prior to June 26, 2008, a higher 10 percent rating for left knee degenerative joint disease is granted. From June 26, 2008 to August 21, 2012, a separate 20 percent rating for a torn medial meniscus is granted. From June 26, 2008 to August 21, 2012, a separate 10 percent rating for knee impairment with recurrent subluxation is granted. From November 17, 2011 to August 21, 2012, a higher 20 percent rating for degenerative joint disease of the left knee is granted. From October 1, 2013, a rating in excess of 30 percent for total left knee replacement is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs