Citation Nr: 1611388 Decision Date: 03/21/16 Archive Date: 03/29/16 DOCKET NO. 08-05 849 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to an evaluation in excess of 10 percent for left knee lateral collateral laxity (left knee instability). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD H.M. Walker, Counsel INTRODUCTION The Veteran served on active duty from September 1999 to September 2004. This case initially came before the Board of Veterans' Appeals (Board) on appeal from February 2008 and October 2014 decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In April 2009, the Veteran appeared at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). In June 2009, the Board remanded these matters for further development. In January 2012, the Board denied entitlement to an evaluation in excess of 10 percent for left knee lateral collateral laxity and remanded claims of entitlement to an evaluation in excess of 10 percent for musculoligamentous strain of the left knee, status post arthroscopy for lateral medial meniscus tear, and entitlement to service connection for a leg length discrepancy for additional development. Per the January 2012 remand, in June 2012 the Appeals Management Center (AMC) issued a statement of the case pertaining to the issue of entitlement to an evaluation in excess of 10 percent for musculoligamentous strain of the left knee, status post arthroscopy for lateral medial meniscus tear; however, the Veteran did not perfect an appeal as to this issue. Thus, the claim for increase for musculoligamentous strain of the left knee, status post arthroscopy for lateral medial meniscus tear, is no longer before the Board for appellate consideration. Additionally, in the June 2015 Board decision, it denied entitlement to service connection for leg length discrepancy. As such, the only issue remaining on appeal is noted on the cover page of this decision. In September 2013, pursuant to a settlement agreement in the case of National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs, 725 F.3d 1312 (Fed. Cir. 2013), the Board sent the Veteran a letter notifying him of an opportunity to receive a new decision from the Board that would correct any potential due process error relating to the duties of the VLJ that conducted the April 2009 hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). In September 2013, the Veteran responded that he wished to have the prior decision vacated and a new one issued in its place after a new hearing has been conducted. In June 2014, the Board vacated the portion of the January 2012 Board decision that denied entitlement to an evaluation in excess of 10 percent for left knee lateral collateral laxity. In January 2015, the Veteran again testified before the undersigned VLJ during a Board hearing held via videoconference capabilities from the RO. A copy of the hearing transcript has been associated with the claims folder. The claim was most recently remanded in June 2015, and has since been returned to the Board for adjudication. FINDING OF FACT Throughout the entire appeal period, the Veteran's left knee lateral collateral laxity has been manifested by complaints of pain and no more than mild instability. CONCLUSION OF LAW The criteria for an evaluation in excess of 10 percent for left knee lateral collateral laxity have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257(2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (finding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, the VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim has been eliminated by the Secretary. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. A VCAA letter dated in November 2007 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b)(1) (2015); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As noted above, the Veteran also was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which he presented oral argument in support of his service connection claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ/DRO who chairs 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. Here, the VLJ explained the issues on appeal during the hearing and generally discussed the basis of the prior determination. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) (stating that "no error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced national service organization in this matter who has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of an increased rating. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (indicating that remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records (STRs) and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt was relevant to the claim. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2015). The RO provided the Veteran appropriate VA examinations-most recently in August 2015. The VA examination reports are thorough and supported by the other treatment evidence of record. The examination reports discussed the clinical findings and the Veteran's reported history as necessary to rate the disability under the applicable rating criteria. The examination report also discussed the impact of the disability on the Veteran's daily living. Based on the examination, the absence of evidence of worsening symptomatology since the examination, and the fact there is no rule as to how current an examination must be, the Board concludes the August 2015 examination report in this case is adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Given the August 2015 VA examination and report; the association of outstanding treatment records; and the subsequent readjudication of the claim; the Board finds that there has been substantial compliance with its June 2015 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (finding that a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Legal Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2015). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). Factual Background and Analysis The Veteran contends that his left knee laxity warrants a rating in excess of 10 percent. By way of background, the RO separately awarded service connection for left knee laxity in the February 2008 rating decision. It assigned a 10 percent rating, effective May 31, 2006. The Veteran's left knee laxity has been evaluated under Diagnostic Code 5257. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, the following evaluations are assignable for other impairment of the knee, to include recurrent subluxation or lateral instability: 30 percent for severe, 20 percent for moderate, and 10 percent for slight. The Veteran has been noted to have a bipartite patella which has been found to be congenital and not related to his service-connected left knee disability. However, as the evidence does not distinguish between the symptoms attributed to the service-connected left knee disabilities and any nonservice connected bipartite patella, the Board will consider all symptomatology in the knee to be associated with the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In this case, the Veteran's increased rating claim for left knee disability was received in October 2007. The evidence relevant to the severity of his left knee laxity includes VA treatment notes that primarily show complaints of left knee pain. On VA examination in August 2006, the examiner noted the Veteran's complaints of constant pain with stiffness, swelling, weakness, and occasionally feeling as if the knee were to buckle or give way. The Veteran indicated that the knee popped and cracked; he had flare-ups occurring at least weekly lasting one to two days and they were of a moderate to severe degree. He took medication for the discomfort. Precipitating factors for flare-ups included increase in activity and weight-bearing activities. Kneeling, squatting, and high impact activities, in particular, caused difficulty and pain. He used a knee brace in the past with little relief. On evaluation, the examiner noted that left knee active range of motion was 0 to 135 degrees with pain beginning at 10 (extension) and 135 degrees (flexion); there was no additional loss of motion on repetitive use. Internal rotation was 0 to 90 degrees without additional limitation of motion on repetitive use. There was no ankylosis, bumps consistent with Osgood-Schlatters disease, or mass behind the knees, but there was crepitation, clicks/snaps, grinding, and mild medial/lateral instability. Anterior/posterior cruciate ligament stability in 30 degrees of flexion was normal, as was medial/lateral collateral ligament stability in 90 degrees of flexion. However, medial/lateral collateral ligament stability (varus/valgus) in neutral position and in 30 degrees of flexion was abnormal; 1-2+ lateral collateral ligament and laxity of the left knee. There was also patellar abnormality consisting of mild dislocation/subluxation, abnormal tracking, and subpatellar tenderness. Additionally, there was meniscus abnormality, meniscus was not surgically absent, and there was no effusion, dislocation, or locking. McMurray's test was positive. X-rays of the left knee were normal. During his December 2007 VA examination, the Veteran's reported persistent knee pain which was sharp with weakness, stiffness, grinding, popping with range of motion, and episodes of buckling and giving way. He took medication which provided some benefit. The Veteran also described flare-ups as often as weekly, depending on his activity level. These flare-ups were moderate and lasted from hours up to one day. They were precipitated by cold weather and overall increase in weight-bearing activities, and the alleviating factors included rest, medication, and sometimes ice/heat. He recalled injections to the knee in the past, but denied wearing any type of brace, wrap, or assistive device. He was able to tolerate 20 to 30 minutes of weight-bearing activities. On evaluation, the left knee demonstrated flexion from 0 to 130 degrees with tenderness at 125 and extension from 0 degrees with tenderness at 100 degrees. The examiner observed mild increase in pain without additional weakness, excess fatigability, incoordination, lack of endurance, or additional loss in range of motion with repetitive use. The examiner stated that he could not express without resorting to mere speculation as to the additional limitation due to repetitive use during a flare-up. Effusion, swelling, erythema, warmth, crepitus, snapping/popping, grinding, subpatellar tenderness, tenderness to palpation, and laxity of ACL, LCL, MCL, McMurray's test were all normal with the exception of snapping/popping, grinding, tenderness to palpation anteriorly of the lateral joint line, and 1+ LCL laxity McMurray's test was equivocal. An x-ray revealed a normal left knee. A diagnosis of musculoligamentous strain with previous left knee medial meniscus tear and mild left knee lateral collateral laxity was given. During the August 2009 VA examination, the Veteran's complained of left lateral knee pain located along the lateral joint line and lateral patellar facet. The Veteran endorsed pain with all activities. He also complained of catching and popping over the lateral compartment of the knee and a sense of instability that the knee will go out on him. He experienced activity-related flare-ups that resulted in increased pain, weakness, and fatigue. The Veteran did not use any corrective devices and was able to walk three miles and stand for 30 minutes with pain. Evaluation of the medial and lateral collateral ligaments at 0 and 30 degrees of flexion demonstrated no appreciable laxity of the medial or lateral collateral ligaments. He had a negative Lachman test with a firm endpoint. There was no appreciable translation. Medial testing of McMurray's of the meniscus was negative and lateral testing of McMurray's was positive for both pain and palpable clicks on examination. There was crepitus in the lateral compartment and over the lateral patellar facet. There was pain over the bipartite portion of the patella with popping and clicking, and crepitus present behind this aspect of the knee. The examiner specifically indicated that he did not appreciate any left knee and lateral collateral ligament laxity. He noted that a 2003 MRI demonstrated no lateral collateral laxity. The examiner found that the Veteran continued to have pain with bipartite patella and the Veteran had some crepitus behind this aspect of the knee. Intraoperative arthroscopy photos demonstrated no appreciable patellofemoral joint change but the lateral facet of the patella was not visualized with the images taken during the examination. The examiner noted that on evaluation that the Veteran demonstrated pain over his lateral compartment and had tenderness to palpation and a possible click along the lateral compartment consistent with a positive McMurray's test. The examiner suspected a re-tear of the lateral meniscus or a propagation of the previous tear. During the Veteran's January 2015 hearing, he reported that his left-knee gives out, pops, and buckles. He was unable to predict when this would occur, but stated it happens daily. He reported pain and swelling in the left knee joint. He described that he avoids going up and down stairs, and when he does so, he uses railings. He reported a history of falls. Following the Board's remand, the Veteran was provided a current VA examination in August 2015. The examiner diagnosed left knee with a previous left knee medial meniscus tear and mild left knee lateral collateral laxity. The examiner noted the following symptoms: He is describing ongoing left knee pain, stiffness, instability and giving way, as well as some popping and swelling of the left knee. He is on medications that include morphine and hydrocodone for various reasons and this does provide some degree of benefit for knee pain. He will utilize rest, stretching, hot tub, and activity limitation in addition to the medication as alleviating factors. He is right-handed determined by way of questioning. He uses no cane, brace or other orthopedic device with regards to the knee at this time. He reports that prolonged sitting and inactivity as well as overexertion and cold weather or changes in weather can aggravate and flareup the condition resulting in increased pain, decrease range of motion. Overall, he reports no periods of complete incapacity. He currently works in an office setting and reports that the knee condition at present does not preclude him from carrying out his occupational duties. He is currently working in insurance sales. Overall condition is persistent. In general this Veteran would have possible difficulty with performing occupational duties that would require bending, kneeling, squatting, twisting, carrying, going up and down stairs or inclines or sitting for prolonged periods without adequate breaks. However, this Veteran would not likely be precluded from following or maintaining substantially gainful employment of sedentary work or employment that would require only very light physical activity. During a flare-up, the Veteran reported increased pain, decreased range of motion, and difficulty with prolonged weight bearing. Following repeated use over time, he described additional functional loss/impairment due to pain. Range of motion testing revealed flexion from 0 to 130 degrees and extension to 0 degrees. The examiner described functional loss due to pain with flexion and extension testing. There was evidence of pain with weight bearing and localized tenderness in the anterior/lateral aspect of the left knee. There was no evidence of crepitus, and he was able to perform at least three repetitions causing limitation of flexion to 125 degrees and extension to 0 degrees due to pain. The examiner indicated that he was unable to state whether any pain, weakness, fatigability, or incoordination significantly limits functional ability with repeated use without speculating. In so noting, the examiner indicated that because "the veteran was not experiencing a flare up (nor is veteran being seen following repeated use over a period of time) at the time of this examination, an opinion regarding functional ability during a flare-up or following repeated use over a period of time cannot be rendered at this time." The Veteran had no limitation in strength in the left knee and had no atrophy. There was no ankylosis in the left knee joint. Joint-stability testing revealed no history of recurrent subluxation, but he had slight, lateral instability in the left knee. There was no history of joint effusion. He had normal anterior instability, posterior instability, and medical instability testing, but lateral instability showed "1+" (0-5mm). The examiner noted his history of meniscal tear causing frequent episodes of joint pain. He had a meniscus debridement in 2003 with residual pain. The examiner noted the 2009 x-ray of the left knee, which showed "[n]o acute osseous abnormality. Minor left-sided patellofemoral spurring." The examiner opined that the Veteran's left knee laxity did not impact his ability to perform any occupational task. Upon careful review of the evidence of record, the Board finds that a rating in excess of 10 percent for left knee laxity is not warranted. The preponderance of the evidence cited above demonstrates that the Veteran's left knee instability is no more than mild in severity. Simply put, at no time during the appeal period has the Veteran's left knee instability been moderate or severe in nature. The Board acknowledges that the Veteran is competent to attest to experiencing instability in his knee. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The Board has, accordingly, carefully considered the Veteran's credible reports of symptoms such as pain, popping, catching, buckling, and giving way; or difficulty with weightbearing. However, in regard to the severity of the symptoms, the evidence does not show that the Veteran's knee instability is of greater than mild severity. None of the examiners characterized the Veteran's knee instability in this manner; in fact the knee instability has been described as mild. Significantly, the most recent VA examination in August 2015 showed that the Veteran exhibited only mild, lateral instability and no periods of recurrent subluxation. The Board has considered lay statements of record relating to the severity of his left knee disability and finds that the results of these objective examinations by competent health care providers are the most probative evidence as to whether his left knee lateral instability is more than mild in nature, and greatly outweigh the Veteran's own reports of symptoms. The Board is cognizant that separate ratings may be assigned for knee disabilities under Diagnostic Codes 5257 and 5003 where there is recurrent subluxation or lateral instability in addition to X-ray evidence of arthritis. See generally VAOPGCPREC 23-97 and VAOPGCREC 9- 98. In the present case, the Veteran is has been assigned a separate evaluation for musculoligamentous strain of the left knee, status-post arthroscopy for lateral medial meniscus tear which has been evaluated under Diagnostic Code 5260 based on limitation of motion of the knee. As noted in the Introduction section above, the musculoligamentous strain of the left knee issue is not subject to the present appeal as the Veteran never perfected an appeal following the June 2012 Statement of the Case (SOC). The Board has also evaluated the Veteran's left knee laxity under other relevant criteria to determine whether an increased rating is warranted. The evidence does not support an award for an increased rating for the left knee under Diagnostic Code 5258 for dislocated, semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; Diagnostic Code 5259 for symptomatic removal of semilunar cartilage; Diagnostic Code 5262 for impairment of tibia and fibula; or Diagnostic Code 5263 for genu recurvatum as none of these disabilities have been demonstrated. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, 5263. The Board has additionally considered functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. See 38 C.F.R. § 4.45. In this case, higher ratings based on functional loss are not warranted at any time during the appeal period. The Veteran has complained of pain, decreased mobility, swelling, tenderness, and difficulty performing daily tasks due to his left knee disability. The Board notes, however, that the 10 percent rating for instability already assigned contemplates the degree of weakness and painful motion demonstrated here. As shown above, and as required by Schafrath, 1 Vet. App. at 594, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating higher than 10 percent for left knee laxity. Finally, the Board finds that additional staged ratings are inapplicable here. See Hart, 21 Vet. App. at 505. Additional Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2015). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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, Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected left knee instability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's left knee instability with the established criteria shows that the rating criteria reasonably describe his disability level and symptomatology with respect the symptoms he experiences. Specifically, the Veteran primarily reports pain, popping, catching, buckling, and giving way; or difficulty with weightbearing. The current 10 percent rating under Diagnostic Code 5257 is specific for such symptomatology inasmuch as his reported symptoms are mild. Thus, the Veteran's current schedular rating is adequate to fully compensate him for his disability on appeal. Under Johnson v. McDonald, 762 F.3d 1362 (2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Notably, the Veteran is also service connected for sleep apnea, thoracic/lumbar strain, frostbite, tinnitus, sinus/nose disability, scars, musculoligamentous strain of the left knee, left shoulder disability, left ankle stress, eczema, and microsmia. Neither the Veteran nor his representative has indicated any specific service-connected disabilities which are not captured by the schedular evaluations of the Veteran's individual service-connected conditions. After applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), the Board finds there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Finally, the Board has considered whether this appeal raises a claim of entitlement to a total disability evaluation based upon individual unemployability due to service-connected disability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447 (2009) (a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation). The Board notes that during his August 2015 VA examination, the examiner opined that the Veteran's left knee laxity did not cause occupational impact, nor has the Veteran contended he is unemployable solely due to his service-connected left knee laxity. Further, there is no suggestion, either from the Veteran or from the evidence itself, that the service-connected left knee laxity has a profound effect on his ability to work in and itself. Therefore, the Board finds that this appeal does not encompass a TDIU claim at this time. ORDER A disability rating in excess of 10 percent for left knee laxity is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs