Citation Nr: 1607173 Decision Date: 02/24/16 Archive Date: 03/01/16 DOCKET NO. 07-00 336 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased rating for retropatellar pain syndrome of the right knee, currently rated as 10 percent disabling. 2. Entitlement to an increased rating for retropatellar pain syndrome of the left knee, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from July 2002 to November 2003. This case comes to the Board of Veterans' Appeals (Board) on appeal of an April 2005 rating decision of the Houston, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In May 2009, a travel board hearing was held before the undersigned in San Antonio, Texas. A transcript of the hearing is associated with the Veteran's claims file. The case was remanded by the Board in October 2009 so that the Veteran could be afforded a VA examination. The examination was accomplished in May 2010 and, in a February 2011 decision, the Board denied the issues on appeal. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court), and the Board's decision was vacated pursuant to a September 2012 memorandum decision of the Court. The Court indicated that the most recent VA examination that had been conducted was inadequate for rating purposes in that it failed to reflect an evaluation of the Veteran's pain during flare-ups. The Court then remanded the case to the Board. Following the Court remand, the case was remanded so that an additional examination could be conducted. The examination was accomplished in January 2014 and, in a May 2014 decision the Board again denied the issues on appeal. The Veteran again appealed to the Court and the Board's May 2014 decision was vacated pursuant to a March 2015 order following Joint Motion for Remand (JMR). The JMR pointed out the Board's instructions in the August 2013 remand requiring that "[i]f possible, the examination should be arranged to coincide with one of the frequent episodes of flare-ups that [Appellant] has testified to." The JMR noted the Board did not mention whether the January 2014 VA examination occurred during a flare-up or why it was not possible to have it conducted during a flare-up. This was found to be inadequate. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). An additional examination was conducted in September 2015. The case has been returned to the Board for further appellate consideration. FINDINGS OF FACT 1. Throughout the appeal, the retropatellar pain syndrome of the right knee has been manifested by pain and range of motion from 0 degrees extension to 125 degrees of flexion, at worse, without recurrent subluxation, lateral instability or other impairment and no current reports of flare-ups. 2. Throughout the appeal, the retropatellar pain syndrome of the left knee has been manifested by pain and range of motion from 0 degrees extension to 125 degrees of flexion, at worse, without recurrent subluxation, lateral instability or other impairment and no current complaints of flare-ups. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 10 percent for retropatellar pain syndrome of the right knee have not been met for any period. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Code (Code) 5260 (2015). 2. The criteria for an increased rating in excess of 10 percent for retropatellar pain syndrome of the left knee have not been met for any period. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Code 5260 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of the claims. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). A December 2004 letter explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. The Veteran has had ample opportunity to respond or supplement the record. With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded VA medical examinations, most recently in January 2014. The Board finds that the opinions obtained are adequate. The opinions were provided by a qualified medical professional and were predicated on a full reading of all available records. The examiner also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2015). Increased Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2015). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2015). The Court has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Bilateral Knee Disability Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings 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. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent 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. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Code 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When x-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling; unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling; extremely unfavourable ankylosis, in flexion at an angle of 45 degrees or more, is to be rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Malunion of the tibia and fibula with slight knee or ankle disability is rated 10 percent disabling; malunion of the tibia and fibula with moderate knee or ankle disability is rated 20 percent disabling; and malunion of the tibia and fibula with marked knee or ankle disability is rated 30 percent disabling. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated 40 percent disabling. 38 C.F.R. § 4.71a. More generally, 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. 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 addition, 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. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. Thus, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The Court has also held that VA's regulations pertaining to whether a compensable rating is warranted for pain (as shown by adequate pathology and evidenced by the visible behavior in undertaking motion), 38 C.F.R. §§ 4.40 and 4.59, apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). An examination was conducted by VA in February 2005. At that time, the Veteran complained of constant pain, graded at 5/10, which increased with sitting more than ten minutes; running, squatting, kneeling, or standing more than 20 minutes; ascending more than descending stairs. He denied episodes of locking, giving way, or swelling of either knee. He reported no treatment since leaving service, and self-treated his knee with over the counter medication and braces. He stated that he had lost no days of work due to knee complaints. On examination the knees showed no deformity or swelling. There was slight tenderness to palpation on the left knee, more so than on the right. Range of motion testing showed that both the left and right knees moved from 0 to 135 degrees and to 140 degrees on passive range of motion. He experienced discomfort to both knees with repetition and full flexion. He had no crepitus or grating, and there was no evidence of instability on varus and valgus stress testing. The Lachman's and drawer tests were negative bilaterally. X-ray studies showed no significant abnormality of the knee joints. The examiner found no objective clinical evidence that the Veteran's function was additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance, and indicated that the Veteran's subjective pain appeared to have the greatest functional impact. An examination was conducted by VA in April 2007. At that time, the Veteran reported that his knees hurt all the time. He said that he avoided activities that caused pain in the knees. He reported that his knees would buckle and give out on him and cause him to fall. He reported his knees became weak with repetitive use. The primary methods for relieving his knee pain were to rest and take medication. He reported that the knee pain was brought on by prolonged sitting, standing, or walking. His knees felt stiff after prolonged sitting, squatting down, or kneeling down. He denied disabling flare-ups. He claimed he had been given knee braces, but only occasionally wore them if he was going to be up walking for a prolonged period. He claimed his activities of daily living were impacted by his knee pain, and he had to hold onto railings and countertops to avoid knee buckling and falling. He reported he worked on a ranch and had modified his activities, but had not missed days because of his knee. He used a golf cart or truck, rather than to walk distances or carry heavy items. He reported that his recreational activities had been curtailed, and he could not do mountain climbing, running, water-skiing, or play paint ball due to his knees. He claimed that twice a week one of his knees buckled and gave out on him, causing him to fall. On examination he had pain and tenderness of both knees on palpation. On range of motion testing, the right knee had active flexion to 125 degrees and passive flexion to 140 degrees, and the left knee had active flexion to 130 degrees and passive flexion to 135 degrees. Extension of both knees was to 5 degrees. Muscle strength was 5/5 bilaterally, and his right quadriceps measured 1 centimeter smaller than the left. An anterior drawer test was negative on the right and revealed 1+ laxity on the left knee. He was asked to step up on a step five times with each knee, and he was able to accomplish this slowly with no complaints. After these repetitions, examination of the knees for power, sensation, and palpation was unchanged. X-ray studies of the knees were unremarkable. The examiner specifically found no objective clinical evidence that function was additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance. In May 2009, the Veteran testified that his right and left knees had worsened since his last VA examination (in April 2007), and that knee disabilities affected his employment and other daily activities. He testified he worked on a farm, and also worked on a job site through school, where he was pursuing a degree in project management or superintendent. At that time, he stated that he had difficulties climbing on and off a tractor, as well as with climbing stairs and ladders. An examination was conducted by VA in May 2010. At that time, the Veteran complained of pain and stiffness in both knees every day, as well as difficulty climbing stairs and exercising. His knee condition improved when he rested and did not engage in activity. He also had a good response to taking ibuprofen. It was noted that he had giving away of the knees, but no instability. There were no episodes of dislocation or subluxation or locking. There was swelling and tenderness in the knees, but no effusions. He reported weekly mild flare-ups of joint disease that lasted for hours, and were precipitated by carrying heavy objects and climbing stairs, and alleviated by ice and ibuprofen. He reported mild functional impairment due to flare-ups. He reported he was unable to stand for more than a few minutes, and was able to walk more than 1/4 mile, but less than 1 mile. His gait was normal, and he had crepitus in both knees. Range of motion testing showed no objective evidence of pain in either knee on active motion. In both knees, range of motion was from 0 to 125 degrees. There was no objective evidence of pain in either knee following repetitive motion, and no additional limitations after three repetitions of range of motion. X-ray studies showed no radiographic abnormalities. It was also noted that the Veteran was employed full time, for less than a year, and had lost less than a week from work during the last year. The diagnoses included right and left knee strain, which the examiner indicated had significant effects on the Veteran's occupation, due to pain, and had at most mild effects on the Veteran's usual daily activities. An examination was conducted by VA in January 2014. At that time, the diagnosis was retropatellar pain syndrome. The Veteran reported having had a long history of dull to sharp bilateral anterior knee pain that is constant in nature and increases with squatting, walking up and down stairs along with climbing ladders at his previous job as a construction worker for which took Tylenol and Whiskey. He stated that it felt like his knees locked up at times and they felt weak at times, especially after being on his feet for long periods. He denied any history of trauma, numbness or tingling. He stated that he had been working as a roughneck since March 2013 performing maintenance on oil field machinery where he worked 14 days straight of 12 hours shifts followed by 14 days off. He had not missed any days off from work. When asked if his knee stopped him from working he replied that he had knee pain but it does not stop him from working. The Veteran reported having flare-ups of increased knee pain with climbing ladders when he worked construction, but that he now worked as a roughneck. Range of motion of the knees was from 0 degrees extension to 135 degrees flexion, bilaterally. The Veteran was able to perform repetitive movements, without additional limitations of range of motion. There was additional functional loss after repetition in the form of less movement than normal and additional pain. There was tenderness and pain to palpation of the joints or soft tissues of each knee. Strength was normal in each knee and there was no anterior, posterior, or medial-lateral instability. There was no patellar subluxation or dislocation. X-ray studies showed no degenerative changes of the knees. The Veteran's knee disability did not impact his ability to work and pain, weakness, fatigability, or incoordination did not significantly limit functional ability during flare-ups, or when the joint was used repeatedly over a period of time. The examiner concluded that, based on the fact that the Veteran was currently working at a very physically demanding job as a roughneck and had not missed any days of work due to knee pain, the fact that he states his knees did not prevent him from working, the fact that he had stable knees, and that retropatellar pain syndrome did not cause weakness or instability of the knees, it was less likely than not that the service-connected disabilities of bilateral retropatellar pain syndrome affected the Veteran's ordinary activities or his ability to procure and maintain employment. An examination was conducted by VA in September 2015. At that time, the diagnosis was retropatellar pain syndrome of each knee. The Veteran complained of constant bilateral knee pain and that his knees gave up at times. He used non-steroidal anti-inflammatory drugs and Tylenol to treat his pain. He reported that he did not have flare-ups of his knee disabilities. He reported weakness and pain with standing, lifting, or climbing. Range of motion was recorded as normal, from 0 degrees extension to 140 degrees flexion, bilaterally. He reported pain on weight bearing. There was objective evidence of crepitus and of mild erythema and tenderness on each anterior knee. Pain causing functional loss was noted on examination of the right knee, but not the left. The Veteran was able to perform repetitive use testing without additional loss of function or additional limitation of range of motion. Muscle strength testing showed reduced muscle strength, rated as 4/5 by the examiner, in each knee. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing showed no instability. The Veteran did not report the use of any assistive devices. X-ray studies reportedly showed no degenerative or traumatic arthritis. The Veteran reported one to two weeks per year of time lost from work, with severe pain with long standing or climbing of stairs. The Veteran's patellofemoral pain syndrome has been rated as 10 percent for each knee on the basis of limitation of flexion of each knee. Review of the VA examination reports and the Veteran's testimony shows that during the appeal period he had nearly full range of motion of both knees, with no restriction on extension and flexion limited to, at most, 125 degrees for each knee. It is important to note that the most recent examination showed the range of motion of each knee to be normal. Thus, there is no competent medical evidence of limitation of right or left knee motion that would reach a compensable level under either Code 5260 or 5261. The Board concludes, therefore, that these diagnostic codes do not provide a basis for a rating in excess of 10 percent for limitation of motion of either the right or left knee. As there has been no evidence of limitation of extension, separate evaluations for limited flexion and extension of either knee under the codes for limitation of motion are not warranted. The Board has also considered whether any alternative diagnostic codes would allow for a rating in excess of 10 percent for either the service-connected right or left knee disabilities. The Veteran has never been diagnosed with ankylosis of the knee, nor has he complained of an inability to move his knees. On recent examination, X-ray studies reportedly showed no arthritis. Therefore, Diagnostic Code 5256 is not for application. Likewise, the Veteran has never been diagnosed with nonunion or malunion of the tibia and fibula, so Diagnostic Code 5262 does not apply and there have been no finding of dislocated semilunar cartilage or episodes of locking or findings of effusions of the knees. Therefore, Diagnostic Code 5258 does not apply. With regard to Diagnostic Code 5257, the Board concludes that the competent evidence of record does not support a separate compensable rating for either knee under Diagnostic Code 5257, which would require slight recurrent subluxation or lateral instability. In that regard, the Board notes that on VA examination in 2005, the Veteran denied episodes of locking or giving way of either knee. There was no evidence of instability on varus and valgus stress testing. In 2007, he reported that his knees would buckle and give out and cause him to fall, but anterior drawer testing was negative on the right and revealed 1+ laxity on the left knee. On VA examination in May 2010, he again reported that he had giving way of the knees, but no instability, and no episodes of dislocation, subluxation, or locking were demonstrated. In 2014 it was noted that there was no anterior, posterior, or medial-lateral instability and no patellar subluxation or dislocation. In 2015, there was no evidence of dislocation, subluxation, locking or instability noted. Thus, although the Veteran has reported having buckling and giving way of the knees, objective examination, including the most recent examination, has, for the most part, shown that the knees are stable. Thus, the Board concludes that the competent evidence of record does not approximate a finding of slight recurrent subluxation or slight instability, as required for the assignment of a separate 10 percent evaluation under Diagnostic Code 5257, for either the right or left knee. The Board has also considered whether an increased rating is warranted due to functional loss or flare-ups. In this case, the record reflects that the Veteran has reported ongoing bilateral knee pain, but that objective examinations have not shown additional limitation as a result of pain or repetitive motion. Muscle strength has been observed to be basically intact and VA examinations show no objective clinical evidence that the Veteran's function was additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance. On examination in 2005, the Veteran complained of constant pain that increased with sitting more than ten minutes; running, squatting, kneeling, or standing more than 20 minutes; or ascending stairs. At that time; however, he denied episodes of locking, giving way, or swelling of either knee. The examiner found no objective clinical evidence that the Veteran's function was additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance, and indicated that the Veteran's subjective pain appeared to have the greatest functional impact. In April 2007, he specifically denied disabling flare-ups and, when asked to step up on a step five times in repetition, there was no objective clinical evidence that function was additionally limited by pain. In May 2010, he reported flare-ups that were characterized as mild in nature and lasting only a matter of hours. Again, there was no objective evidence of pain in either knee following repetitive movements. In January 2014 he stated that he had been working as a roughneck on oil field machinery, which activity he was able to perform without flare-ups. At that time, he specifically stated that he did not have flare-ups now that he had obtained this type of employment and that these no longer occurred now that he was not required to walk up and down ladders as he had in his former employment, which was in construction. On examination in September 2015, the Veteran specifically denied having flare-ups of his knee disabilities. In this case, the Veteran has been afforded numerous examinations in an attempt to provide him with an evaluation during a period of exacerbation of his bilateral knee disorder. "[W]hen a claimant's medical history indicates that his condition undergoes periods of remission and recurrence, VA is required to provide a medical examination during the period of recurrence in order to provide a proper disability rating." Voerth v. West, 13 Vet. App. 117 (1999) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994) which cites Bowers v. Derwinski, 2 Vet. App. 675, 676 (1992) in interpreting 38 C.F.R. § 4.1 as requiring that the "frequency and duration of outbreaks and the appearance and virulence of them during the outbreaks that must be addressed"). This case, however, goes on to note that examination during recurrence, was infeasible when the recurrence only lasted a day or two, (whereas in Ardison, supra, the recurrences lasted weeks or months). Here, the Veteran denied flare-ups on several examinations and stated that when they did occur they were mild and lasted for only hours, as opposed to weeks or months. As such, there is no evidence in the record that the Veteran has flare-ups that result in quantifiable additional functional limitation such as to provide a basis for a higher schedular rating for either knee. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, supra. In summary, the Board finds that, based on the preponderance of the evidence, the criteria for a 20 percent or higher rating or a separate rating for retropatellar pain syndrome of the right knee or the left knee have not been met at any time during the appeal period. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claims for ratings in excess of 10 percent for retropatellar pain syndrome of the right knee and the left knee must be denied. 38 U.S.C.A. § 5107(b) ; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board also has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. In this case, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's knee limitation of flexion directly corresponds to the schedular criteria for the 10 percent evaluation for each knee, which also incorporates various orthopedic factors that limit motion or function of the knee. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. As noted slight knee impairment due to recurrent subluxation or lateral instability has not been demonstrated. On examination by VA in January 2014, the examiner stated that it was less likely than not that the service-connected disabilities of bilateral retropatellar pain syndrome affected the Veteran's ordinary activities or his ability to procure and maintain employment. He also noted retropatellar syndrome does not cause knee instability. On examination in September 2015, the Veteran reported loss of only one to two weeks of work per year due to knee pain, which the Board does not find represents marked interference with employment. For these reasons, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's knee disabilities, and no referral for an extraschedular rating is required. ORDER An increased rating in excess of 10 percent for retropatellar pain syndrome of the right knee is denied. An increased rating in excess of 10 percent for retropatellar pain syndrome of the left knee is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs