Citation Nr: 1613789 Decision Date: 04/05/16 Archive Date: 04/13/16 DOCKET NO. 10-22 163 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a sleep disorder. 2. Entitlement to service connection for a lumbar spine disability, to include as secondary to bilateral knee patellofemoral syndrome. 3. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral pain syndrome. 4. Entitlement to a disability rating in excess of 10 percent for left knee patellofemoral pain syndrome. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. F. Brandau, Associate Counsel INTRODUCTION The Veteran has active duty service from December 1993 to December 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. These issues were remanded by the Board in December 2013. FINDINGS OF FACT 1. The Veteran's claimed sleep disorder is contemplated in the rating assigned for service-connected depression. 2. The probative, competent evidence does not establish that a current disability of the lumbar spine is causally or etiologically related to active duty service or causally related to or aggravated by the Veteran's service-connected bilateral knee patellofemoral syndrome. 3. The Veteran's right and left knee patellofemoral pain syndrome is primarily manifested by pain and limitation of flexion, but with flexion greater than 30 degrees. Recurrent subluxation, lateral instability, and left knee limitation of extension are not shown. 4. Right knee extension limited to 10 degrees is shown from November 14, 2011 to January 20, 2014. During the other periods on appeal limitation of right knee extension is not shown. CONCLUSIONS OF LAW 1. There no longer remains a case or controversy regarding the claimed sleep disorder. 38 U.S.C.A. § 7105 (West 2014). 2. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2015). 3. The criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261 (2015). 4. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261 (2015). 5. The criteria for a 10 percent, but no higher, rating for right knee limitation of extension have been met for the period from November 14, 2011 to January 20, 2014. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Dismissal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). In the Veteran's March 2009 claim he noted that the pain in his knees make sleep difficult. The RO interpreted this as a claim for service connection for a sleep disorder. In his September 2009 notice of disagreement, the Veteran relayed his belief that the sleep disorder may be related to depression and chronic pain in his knees. He echoed this belief in a March 2014 statement when he noted that chronic sleep impairment is a symptom of depression. In a March 2014 rating decision, VA's Appeals Management Center (AMC) granted service connection for depression and assigned an initial disability evaluation of 50 percent for that disability. In discussing the assignment of the disability rating, the AMC noted that the rating was based on multiple symptoms including chronic sleep impairment. In this case, the Veteran asserted that he has sleep impairment and he was subsequently awarded service-connection for depression which has been rated in a way that includes the Veteran's chronic sleep impairment. As such, the benefit sought by the Veteran has been granted and there no longer remains a case or controversy for the Board to resolve related to this matter. As such, the appeal as to this issue must be dismissed. Duty to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions with respect to the issues decided herein. 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); see also 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); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). A May 2009 letter satisfied the duty to notify provisions, to include notification of the regulations pertinent to the establishment of an effective date and disability rating. The Veteran's service treatment records, VA medical records, private medical treatment records, and lay evidence have been obtained and associated with the record. 38 U.S.C.A. § 5103(A); 38 C.F.R. § 3.159. The Veteran was provided VA examinations in July 2009, November 2011, and again in January 2014 pursuant to the December 2013 Remand order. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The VA examiners reviewed the evidence of record and performed physical examinations. Further, the examination reports provided sufficient information to rate the service-connected disabilities on appeal. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. 303. As such, when viewed together, the Board finds the examinations and opinions to be sufficient and adequate for rating purposes. Additionally, the Board finds that the Agency of Original Jurisdiction substantially complied with the December 2013 Remand directives with respect to the issues of entitlement to service connection for degenerative disc disease of the lumbar spine, to include as secondary to bilateral knee patellofemoral syndrome and entitlement to an increased disability ratings in excess of 10 percent for bilateral knee patellofemoral syndrome. See Stegall v. West, 11 Vet. App. 268 (1998). As noted, examinations were performed. In addition, the requested treatment records were obtained and the VA treatment records reflected that the MRI performed in 2009 was normal or negative. There is no indication in the record that any additional evidence relevant to the issues being adjudicated in this decision is available and not part of the record. See Pelegrini, 18 Vet. App. 112. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield, 20 Vet. App. 537; see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S.Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the record. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided herein. The Veteran should not assume that pieces of evidence not explicitly discussed herein have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Service Connection Service connection may be established for a disability resulting from diseases or injuries in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical, or in certain circumstances, lay evidence of 1) a current disability; 2) an in-service incurrence or aggravation of a disease or injury; and 3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). The Federal Circuit has held that continuity of symptomatology under 38 C.F.R. § 3.303(b) applies only to chronic diseases listed in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (2013). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309. Additionally, service connection may be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Veteran asserts that his current back pain is related to his bilateral knee pain that originated during active duty service. The Veteran reported hurting his knees when he was deployed to the Gulf, and he was diagnosed with patellofemoral pain syndrome in July 1997. He asserted in March 2009 that because he can no longer use his knees when lifting objects, he has had to overcompensate with his back which has caused strain. He also reported having back pain during active duty service. As it pertains to a current disability, the Veteran was diagnosed with mild degenerative spondylosis and degenerative disc disease in the lumbar spine at L2-L3 and L5-S1 after a spinal x-ray in November 2010. After VA examination in January 2014, the diagnoses included facet degenerative joint disease L4-5 and degenerative disc disease L5-S1. The Veteran reports continued back pain and has had medication management throughout the duration of the appeal. As such, the Board finds that the Veteran has established a current disability for service connection purposes. As it pertains to an in-service event or injury, the Veteran reported having low back pain in early 1995 after he was working on squats in the weight room. At the time his physical examination revealed spinal tenderness. The assessment was right lower back strain. He reports that his recurrent back pain stems from this event. Alternatively, he claims that his back pain has been exacerbated by the knee disability he developed during active duty service. As such, the Board finds that the Veteran has established an in-service event or injury for service connection purposes. As it pertains to a nexus between the Veteran's degenerative disc disease of the lumbar spine and active duty service, the only competent medical opinion is from the January 2014 VA examiner, who opined that although the Veteran complained of lower back pain during active duty service, there was no evidence of any lower back pain at separation from service. The VA examiner also noted that even though the Veteran instituted a low back disability claim within one year of separation, the subsequent VA examination and x-rays from September 1998 were essentially normal. He also referenced the Veteran's body habitus and prior work in construction and unloading trucks for the United States Postal Service in opining that it was less likely than not that the Veteran's degenerative disc disease of the lumbar spine was caused by or a result of intraservice events. As it pertains to secondary service connection, the only competent medical opinion is from the same January 2014 VA examiner, who opined that there was no objective evidence to support the Veteran's claim that his knee disability was responsible for his current back pain. The VA examiner rationalized that although there were some instances where severe lower extremity dysfunction with significant gait disturbance could aggravate the spine by causing muscle tension and spasms, but these would not contribute to any degenerative changes in the spine; the VA examiner noted that the Veteran's knee condition was very mild in this case. The VA examiner further opined that it was likely that the Veteran's post-service work history and body habitus with core deconditioning caused the back disability, and that the spinal x-ray findings were expected for a person of the Veteran's age. The Board notes that this opinion discusses causation as well as aggravation. The examiner clearly indicates that while there are instances where lower extremity dysfunction or gait disturbance could aggravate the spine in this case the knee condition is very mild. The Board affords significant weight to the January 2014 VA examiner's opinion as it is inclusive of all of the evidence and is supported by sufficient rationale. The VA examiner reviewed the Veteran's service treatment records, private treatment records, VA treatment records, and lay statements, and cited to the Veteran's service treatment records and lay statements in support of the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Moreover, the opinion provided an alternative etiology for the Veteran's degenerative disc disease of the lumbar spine. The Board acknowledges the Veteran's statements that his current low back disability is related to his service-connected bilateral knee patellofemoral syndrome and his active duty service. In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson, 581 F.3d 1313. However, the evidence does not show that the Veteran possesses the requisite training or credentials needed to render a competent opinion as to a medical matter. Here, the Board finds that any possible relationship between a current lumbar spine disability and an in-service event or injury or service-connected disability is not something for which a layman is competent to provide an opinion. See Barr, 21 Vet. App. at 307 (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). As such, the Veteran's lay opinion does not constitute competent medical evidence and lacks probative value. In this case, the competent, probative medical evidence provides a negative opinion concerning a nexus between a low back condition and active duty service and any low back condition and the service-connected bilateral knee patellofemoral syndrome. The Board also notes that arthritis (also called spondylosis or degenerative joint disease) is one of the conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Therefore, the Veteran's statements regarding continuity of symptomatology may be sufficient for purposes of establishing service connection. Walker, 708 F.3d at 1338. Here, however, the Board finds the evidence does not support the Veteran's assertions that he has experienced chronic back pain since any in-service event or injury. Although the Veteran made a claim for a lower back disability within one year of separation from service, as noted by the January 2014 VA examiner, the Veteran did not report having any back pain at separation from service. Moreover, even when the Veteran began his low back disability claim, his VA examination from September 1998 showed very few findings, suggesting that the condition did not manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Furthermore, the Board finds the VA examiner's conclusions regarding the nature of the Veteran's in-service injuries carries significant probative value. Therefore, the Board finds the Veteran's lay statements with respect to continuity of symptomatology are insufficient for purposes of establishing entitlement to service connection. Based on the foregoing, the Board finds the preponderance of the evidence is against a grant of service connection for a lumbar spine disability, to include as secondary to service-connected bilateral knee patellofemoral syndrome. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine is not applicable in the instant appeal, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. at 55-56 (1990). Increased Ratings The Veteran is service connected with 10 percent disability ratings for bilateral knee patellofemoral pain syndrome. He has been service connected for right knee patellofemoral pain syndrome with a 10 percent disability rating since December 6, 1997, and he has been service connected for right knee patellofemoral pain syndrome with a noncompensable disability rating beginning December 6, 1997, that was raised to 10 percent as of August 26, 2004. At all relevant times during the appeal, the Veteran has argued that his knee disabilities warrant a higher rating. 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 (2015). 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 (2015); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2015); 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 (2015); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10 (2015). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2015); see also 38 C.F.R. §§ 4.45, 4.59 (2015). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Diagnostic Code 5260 provides that flexion of the leg limited to 15 degrees warrants a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a 0 percent (noncompensable) rating. Diagnostic Code 5261 provides that extension of the leg limited to 45 degrees warrants a 50 percent rating; extension limited to 30 degrees warrants a 40 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 5 degrees warrants a 0 percent (noncompensable) rating. For comparison, normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability warrants a 10 percent rating, moderate recurrent subluxation or lateral instability warrants a 20 percent rating, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. 38 C.F.R. § 4.71a. VA's General Counsel has held that a claimant who has arthritis (resulting in limited or painful motion) and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, cautioning that any such separate rating must be based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). VA's General Counsel has further held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Throughout the duration of the appeal, the Veteran has had a 10 percent disability rating for each knee under Diagnostic Code 5260, which addresses limitation of flexion. See 38 C.F.R § 4.71a. To receive a higher disability rating for limitation of flexion, the objective evidence must show knee flexion limited to 30 degrees or less. Separate ratings could be assigned with evidence of knee extension limited to 10 degrees or more or slight recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261, 5257. In July 2009 the Veteran underwent VA examination in connection with his increased ratings claim, and at the time he asserted that he wore knee braces to help his knee pain and weakness and so they do not give out. During the physical examination the Veteran's left knee flexion was 70 degrees and his extension was normal, although the Veteran's flexion was reduced on repetition to 65 degrees. The Veteran's right knee flexion was 62 degrees and his extension was normal, although he exhibited pain and tenderness during the range of motion testing. Testing of the ligaments and meniscus was normal bilaterally. His gait was normal. Approximately one year later the Veteran had knee x-rays that showed a small patellar spurs bilaterally and possible internal derangement in the left knee. In November 2011 the Veteran again underwent VA examination in connection with his increased rating claim, and on physical examination the Veteran had right knee flexion to 110 degrees with pain beginning at 90 degrees, and his right knee extension was 10 degrees. The Veteran's left knee flexion was 110 degrees with pain beginning at 100 degrees, and his extension was normal. After repetition, flexion remained unchanged but right knee extension improved to 0 degrees. Both knees were stable on testing without a history of patellar subluxation or dislocation. The Veteran received ongoing treatment for his knee pain, and in July 2012 his physical examination showed tenderness in the knees but he was given medication and advised to return in one year. In April 2013 the Veteran had an MRI of the knees that showed a small amount of fluid in the joint, but that the joints were intact. His VA treatment provider indicated that the Veteran did not need an orthopedic evaluation and that he could just continue medication. Several months later in July 2013 the Veteran sought a private treatment evaluation of his knee pain, and the examiner noted that the physical findings were quite benign and that there was only minimal tenderness in the knees. As the MRIs were also normal, the private treatment provider recommended that the Veteran continue anti-inflammatory medication and home exercises with the knee braces, but that the Veteran did not need narcotic medication. In January 2014 the Veteran underwent VA examination again pursuant to the December 2013 Remand order, and on physical examination the Veteran exhibited bilateral flexion to 140 degrees with normal extension. Range of motion was the same after repetitions. MRI of the right knee showed anterior cruciate ligament laxity with a possible tear; articular cartilage was maintained. Testing revealed no instability and there was no evidence or history of recurrent patellar subluxation or dislocation. Upon review of the record, the Board notes that flexion in both knees is noncompensable under Diagnostic Codes 5260, even considering the Veteran's complaint of painful motion. In this regard, even considering that his pain begins at 60 degrees of flexion in the right knee, such finding supports only a 0 percent rating under Diagnostic Code 5260. Thus, a higher rating is not warranted based on limitation of flexion. A separate rating is not warranted based on recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. In July 2009, testing of the ligaments and meniscus was normal bilaterally. In November 2011, both knees were stable on testing without a history of patellar subluxation or dislocation. In January 2014, testing revealed no instability and there was no evidence or history of recurrent patellar subluxation or dislocation. As the preponderance of the evidence establishes that the Veteran does not have recurrent subluxation or lateral instability of either knee, separate ratings cannot be assigned under Diagnostic Code 5257. With the exception of testing in November 2011, extension of both knees has been normal. At the VA examination in November 2011, right knee extension was limited to 10 degrees but returned to normal after repetitive use. Resolving reasonable doubt in favor of the Veteran, the Board finds that limitation of right knee extension is shown as of the date of that examination - November 14, 2011. At the next VA examination on January 21, 2014 extension of the right knee was again normal. As such, a separate 10 percent, but no higher, rating is warranted for right knee limitation of extension from November 14, 2011 to January 20, 2014. The Board has also considered whether a higher rating could be assigned under other diagnostic codes. However, there is no competent evidence showing dislocation or removal of semilunar cartilage or nonunion/malunion of the tibia or fibula to warrant consideration under Diagnostic Codes 5258 and 5262. Moreover, as the Veteran has motion in the knees, a rating for ankylosis is not warranted under Diagnostic Code 5256. Other Considerations 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 a veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether a 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 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 Compensation Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. Here, the Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the rating assigned for this period inadequate. The Veteran's service-connected bilateral knee patellofemoral syndrome is evaluated as a musculoskeletal disability, the criteria of which is found by the Board to specifically contemplate the level of impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261. During the period on appeal, the Veteran's bilateral knee disability was primarily manifested by pain and limited range of motion. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the criteria for the evaluations assigned more than reasonably describe the Veteran's disability level and symptomatology during this period, and therefore, the schedular evaluation is adequate, and no referral is required. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261, 5257; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 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. Service connection is currently in effect for depression, right and left knee patellofemoral pain syndrome, and right hip disorder. In this case, the evidence of record, including lay statements, does not indicate any effect caused by a combination of the service-connected disabilities that is not already specifically contemplated by the individually assigned ratings. As such, further discussion of an extraschedular rating based upon the combined effect of multiple conditions is not necessary. The U.S. Court of Appeals for Veterans Claims has held that a TDIU claim is part and parcel of an increased rating claim when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As a result, the Board has jurisdiction to consider the Veteran's possible entitlement to a TDIU when the issue is raised by assertion or reasonably indicated by the evidence and is predicated, at least in part, on the severity of the service-connected disability in question, regardless of whether the RO has expressly addressed this additional issue. See VAOPGCPREC 6-96 (Aug. 16, 1996); see also Caffrey v. Brown, 6 Vet. App. 377 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993); EF v. Derwinski, 1 Vet. App. 324 (1991). Here, the Veteran has not asserted that he is unable to work as a result of his service-connected disabilities, nor has the issue otherwise been raised by the record. At the time of the January 2014 VA examination the Veteran was working for the United States Postal Service and had been doing so for the past 10 years. As such, the Board finds the issue of entitlement to a TDIU has not been raised. (CONTINUED ON NEXT PAGE) ORDER The appeal as to the issue of entitlement to service connection for a sleep disorder is dismissed. Entitlement to service connection for a lumbar spine disability, to include as secondary to bilateral knee patellofemoral syndrome, is denied. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral syndrome is denied. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral syndrome is denied. Entitlement to a 10 percent rating for right knee limitation of extension, from November 14, 2011 to January 20, 2014, is granted, subject to the applicable laws and regulations governing the payment of monetary benefits ______________________________________________ Nathan Kroes Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs