Citation Nr: 1621375 Decision Date: 05/26/16 Archive Date: 06/08/16 DOCKET NO. 10-27 591 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an initial compensable rating for mild patellar tendinosis of the left knee with lateral subluxation and effusion prior to July 31, 2012 and in excess of 10 percent from July 31, 2012. 2. Entitlement to an initial rating in excess of 10 percent for left knee flexion with painful motion, to include the period prior to July 31, 2012. 3. Entitlement to an initial compensable rating for a left knee surgical scar. 4. Entitlement to a 10 percent evaluation based upon multiple noncompensable service-connected disabilities. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Sorisio, Counsel INTRODUCTION The Veteran served on active duty from May 2006 to August 2007, with an unconfirmed prior period of active service from May 2003 to September 2003. These matters are before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Detroit, Michigan Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claims file is now in the jurisdiction of the Pittsburgh, Pennsylvania RO. A hearing was held before the undersigned in May 2011. A transcript of the hearing is of record. In December 2011, the appeal was remanded for further evidentiary development. Regarding the claim for an initial rating for a left knee disability, the June 2008 rating decision awarded service connection for residuals of a fracture of the left patella, evaluated as noncompensable, from August 23, 2007. On remand, an April 2015 rating decision recharacterized the Veteran's left knee disability as mild patellar tendinosis with effusion and slight lateral subluxation and increased the rating to 10 percent, effective July 31, 2012. This rating decision also awarded the Veteran a separate 10 percent rating for painful left knee flexion, effective July 31, 2012. Since the separate rating was assigned as part of the Veteran's appeal for an initial increased rating for the service-connected left knee disability and the overall rating is less than the maximum under the applicable criteria, both ratings are on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues have been characterized to reflect the increased and separately assigned ratings. FINDINGS OF FACT 1. Throughout the appeal period, left knee mild patellar tendinosis has been manifested by slight recurrent subluxation. 2. Throughout the appeal period, the Veteran's left knee disability has been manifested by painful limitation of flexion causing a functional loss. 3. The left knee surgical scar is not unstable or painful, and does not limit function or cause any disabling effects. 4. A compensable rating has been assigned for a service-connected disability and there is no longer a basis for the assignment of a 10 percent evaluation based upon multiple, noncompensable service-connected disabilities. CONCLUSIONS OF LAW 1. From August 23, 2007, the criteria for entitlement to a 10 percent, but no higher, evaluation for mild patellar tendinosis of the left knee based on recurrent subluxation have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5257 (2015). 2. From August 23, 2007, the criteria for entitlement to a 10 percent, but no higher, evaluation for limitation of flexion of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260, 5261 (2015). 3. The criteria for entitlement to an initial compensable rating for a left knee surgical scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.118, DCs 7800-7805 (prior to and from October 23, 2008). 4. Entitlement to a 10 percent evaluation based upon multiple, noncompensable service-connected disabilities is denied as a matter of law. 38 C.F.R. § 3.324 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Regarding the duty to assist, the Veteran most recently appeared for a VA examination to evaluate the severity of the left knee disabilities and surgical scar in July 2012. In an April 2016 Informal Hearing Presentation, the Veteran's representative stated that it was "largely conceivable" that the Veteran's conditions had worsened since the July 2012 VA examination and that "relying on an examination that is over three years old would deprive the Veteran of a fair and impartial decision that correlates to his current level of impairment." The United States Court of Appeals for Veterans Claims (Court) has held that a new examination is not required solely because of the passage of time; rather, there must be an indication of a worsening of the disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007). Here, the Veteran's representative's statement that it is "largely conceivable" that the Veteran's disabilities could have worsened since the July 2012 VA examination is phrased in speculative terms. He has not presented any evidence showing that there has actually been a worsening of the disabilities. Moreover, the Veteran has not indicated that there has been a worsening of the disabilities. Thus, there is no indication that the record does not adequately reveal the current state of the Veteran's disabilities. Additionally, the July 2012 VA examiner completed all necessary testing, examined the Veteran, and provided pertinent information regarding the severity of the disabilities. Therefore, the VA examination is adequate for evaluation purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, the Board finds that remanding the claims for a new examination is not required. The Board concludes VA has met all other statutory and regulatory assistance provisions. See 38 U.S.C.A. §§ 5103A; 38 C.F.R. §§ 3.102, 3.159, 3.326; see also Scott, 789 F.3d 1375. Accordingly, appellate review may proceed without prejudice to the Veteran with respect to his claims. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Legal Criteria and Analysis The Veteran seeks higher initial ratings for his left knee disability and a left knee surgical scar. Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. 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. 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. § 4.3. A. Increased Rating - Left Knee As noted in the Introduction, the June 2008 rating decision on appeal granted service connection for residuals of a fractured left patella, evaluated as noncompensable, from August 23, 2007 under hyphenated DC 5299-5257. Hyphenated DCs are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated DC indicates that the Veteran's left knee disability was rated, by analogy, under the criteria for recurrent subluxation and lateral instability. An April 2015 rating decision recharacterized the Veteran's left knee disability as mild patellar tendinosis with effusion and slight lateral subluxation and increased the rating to 10 percent from July 31, 2012 under DC 5257. That rating decision also awarded the Veteran a separate 10 percent rating for limitation of flexion based on painful motion under DC 5260 from July 31, 2012. For ease of analysis, the Board will first discuss the rating assigned for recurrent subluxation, then the rating assigned for limitation of flexion, and finally whether the Veteran is entitled to any other separate or higher rating for his left knee disability. 1. Recurrent Subluxation Under DC 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a. The words slight, moderate, and severe are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Here, the Board concludes that the Veteran is entitled to a 10 percent rating, but no higher, for slight recurrent subluxation and lateral instability throughout the appeal period (from August 23, 2007). Specifically, February 2011 MRI results reflect slight lateral patellar subluxation and tiny effusion. Additionally, in his June 2010 VA Form 9, the Veteran reported that he had been issued a knee brace for use when carrying a rucksack or a heavy load. At the May 2011 Board hearing, the Veteran testified that he has felt like his knee buckles, particularly when going down the stairs or when squatting. Additionally, he reported that he had just been provided with a knee brace and that sometimes he used a cane if he was standing for too long. Board Hearing Tr. at 8-11. A preponderance of the evidence is against a finding that the Veteran is entitled to a rating in excess of 10 percent based on subluxation or instability at any time during the appeal period. Although the Veteran has reported having instability and the February 2011 MRI results reflect slight lateral subluxation, there is no evidence indicating a greater level of instability or recurrent subluxation. The results of stability testing completed on May 2008 and July 2012 VA examinations were normal. On May 2008 VA examination, it was noted that there was no effusion present. August 2007 and November 2007 VA treatment records also reflect that testing revealed stable ligaments. The November 2007 VA treatment record indicates there was no effusion noted. In his June 2010 VA Form 9, the Veteran indicated that he had been able to stabilize his knee by completing rigorous low impact physical therapy. February and March 2011 private treatment records from Dr. S.J.T. note that the Veteran's ligaments were stable on examination. An April 2011 private treatment record from Dr. T.M.S. reflects the Veteran reported he had not experienced any giving way episodes for at least the last two years. Physical examination of the left knee revealed normal findings for all stability testing completed. As objective testing throughout the appeal period has not revealed any instability and the Veteran has reported that exercising has helped him to maintain knee stability, the Board concludes that a preponderance of the evidence is against a finding that the Veteran is entitled to a rating in excess of 10 percent under DC 5257 at any time during the appeal period. 2. Limitation of Flexion Limitation of flexion of the knees is evaluated under DC 5260. A 10 percent rating is warranted under DC 5260 where flexion is limited to 45 degrees, a 20 percent rating is available where flexion is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention 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; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). 38 C.F.R. § 4.59 does not require "objective" evidence, but can be satisfied with lay and other non-medical evidence. Petitti v. McDonald, 27 Vet. App. 415 (2015). Moreover, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Burton, 25 Vet. App. at 5. Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). Here, the Board concludes that the evidence reflects painful flexion of the left knee throughout the appeal period that is entitled to a minimum compensable rating under DC 5260 pursuant to 38 C.F.R. § 4.59. On May 2008 VA examination, the Veteran reported experiencing pain, stiffness, and limited motion of the left knee. The examiner noted that the Veteran's left knee disability caused him mild effects on exercise and sports and that he noticed most problems with pain and swelling at the end of the day or after strenuous exercise. The examiner indicated the Veteran had difficulty kneeling and putting his weight on his left knee. A February 2011 treatment record from Dr. S.J.T. reflects that the anterior of the left knee was tender and that there was mild lateral joint line tenderness. A subsequent March 2011 treatment record indicates the inferior pole of the left patella was mildly tender. An April 2011 treatment record from Dr. T.M.S. reflects the Veteran had a swollen left knee and knee pain. The distal pole of the patella was very tender to palpation. Resolving any reasonable doubt in the Veteran's favor, the Board concludes that this evidence objectively confirms that, throughout the appeal period (from August 23, 2007), the Veteran had painful limitation of flexion sufficient to warrant a compensable 10 percent rating under DC 5260 pursuant to § 4.59. A preponderance of the evidence is against a finding that he is entitled to a rating in excess of 10 percent based on limitation of flexion. An August 2007 VA treatment record reflects the Veteran had good strength with extension of the left knee. X-rays were normal with no evidence of tibial plateau fracture or patellar fracture. In October 2007, the Veteran reported experiencing increased knee pain in the last week without any change in activity. The examiner noted there was no swelling, redness, or drainage. The Veteran indicated the pain was not that bad and that he did not want a cane or knee brace. In November 2007, the treatment provider indicated the Veteran had been seen for left knee pain for months and that he was experiencing pain when he ran, but denied pain when he walked and climbed stairs. Range of motion was noted to be full. X-rays taken at that time were negative. A February 2008 treatment record shows the Veteran was seen for follow-up for his left knee pain. He reported the pain had not been very bad, except that since it was winter his ability to bike had decreased, so his activity had been limited. The Veteran reported that he used Motrin once or twice a week as needed. Examination revealed no local swelling. On May 2008 VA examination, flexion of the left knee was to 135 degrees with no pain on motion. There was also no loss of motion with repetitive movement due to fatigue, weakness, lack of endurance or incoordination. The Veteran did not report any swelling or flare-ups. Physical examination revealed no joint swelling or tenderness. The Veteran reported that he noticed most problems with pain and swelling at the end of the day or after exercising and that he required minimal medication for discomfort. In his June 2010 VA Form 9, the Veteran reported that he experienced soreness in his knee that limited his daily activities and caused him to lose sleep. He reported taking pain medication on a regular basis and having to limit his activities with his daughters because of his left knee. He also reported needing to sit while completing his teaching job; otherwise his knee would get very sore. He indicated that his knee became sore and hurt after walking on hard surfaces or hiking with heavy boots and that if he used his leg a lot one day, it would hurt for up to two days afterwards. He stated that kneeling put direct pressure on his bent knee and hurt to the point that he could not really kneel anymore. Physical examination in March 2011 by Dr. S.J.T. reflected good range of motion of the left knee. Physical examination in April 2011 by Dr. T.M.S. revealed full range of motion with no extensor lag. The Veteran reported that he experienced intermittent episodes of significant pain at the distal pole of the patella and pain when going up and down stairs, kneeling, and squatting. He reported experiencing a significant increase in pain when not actively biking. At the May 2011 Board hearing, the Veteran testified that if he is on his feet for more than 4 to 6 hours, his knee will hurt and be sore. He indicated that putting pressure on the knee, such as by kneeling, also makes it sore. He reported his left knee disability impacted his teaching job because he had to sit down to teach and if he ended up standing for long periods of time, he would sometimes use a cane. He also indicated that he could not bike as much as he used to, so his quadriceps muscle was not as strong. Board Hearing Tr. at 5, 8-11. On July 2012 VA examination, the Veteran reported that he had pain in his left knee when he stood all day. He indicated that his knee swelled after kneeling in his job as a wrestling coach and that his pain is the highest at a level of 6 when wrestling and coaching. He indicated that for the first couple of years after his injury the pain waxed and waned and that cold and rainy weather increased his soreness. He did not report any flare-ups. Physical examination revealed flexion to 135 degrees with pain at 130 degrees. He was able to perform repetitive use testing with flexion to 135 degrees. There was no additional limitation in the range of motion after repetitive use testing, but it was noted that he had functional loss based on pain on movement. His left knee was tender to palpation at the joint line or soft tissues. July 2012 X-rays revealed no acute fracture or dislocation, no remarkable degenerative changes, no intra-articular loose body, no remarkable findings in the soft tissue, and no osteolytic or blastic lesion. Even when considering functional loss during flare-ups or with repeated use under 38 C.F.R. §§ 4.40, 4.45, and 4.59 the Veteran's left knee disability has not met the criteria for a rating in excess of 10 percent under DC 5260. Specifically, flexion findings have at most been limited to 130 degrees. See May 2008 and July 2012 VA examination reports. These findings take into consideration the Veteran's complaints of pain and functional loss and do not more nearly approximate flexion limited to 30 degrees that would entitle the Veteran to a higher 20 percent rating. 3. Evaluation under Other Pertinent Criteria Turning to whether the Veteran is entitled to any separate ratings or a higher rating under any other DC, separate ratings under DC 5260 and DC 5261 may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (Sept. 17, 2004). Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. Under DC 5261, a 10 percent rating is available where extension is limited to 10 degrees, a 20 percent rating is warranted where extension is limited to 15 degrees, and a 30 percent rating is available where extension is limited to 20 degrees. 38 C.F.R. § 4.71a. Normal ranges of motion of the knee are to 0 degrees in extension, and 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. An August 2007 VA treatment record notes the Veteran had good strength with extension of the left knee. In October 2007, the Veteran reported it was painful to extend his left knee. On May 2008 VA examination, extension of the left knee was to 0 degrees. There was patellar grinding with extension, but no pain on motion and no loss of motion with repetitive movement due to fatigue, weakness, lack of endurance or incoordination. On July 2012 VA examination, physical examination revealed extension was full to 0 degrees with pain at 0 degrees. The Veteran was able to complete repetitive use testing with extension ending at 0 degrees. There was no additional limitation of extension after repetitive use testing, but he did have functional loss based on pain on movement after repetitive use. The Board finds that this evidence, along with the Veteran's reports of pain and functional loss described above in the section regarding limitation of flexion, does not reflect findings that more nearly approximate extension limited to 10 degrees that would warrant a compensable separate rating under DC 5261. The Board has also considered whether the Veteran is entitled to any higher or separate ratings under any other pertinent criteria. There is no evidence the Veteran has ankylosis, genu recurvatum, impairment of the tibia and fibula, symptomatic removal of the semilunar cartilage, or dislocated semilunar cartilage of the left knee; therefore, evaluation under DCs 5256, 5258, 5259, 5262, or 5263 is not appropriate. Finally, the Board has considered whether any staged rating is appropriate for the separately assigned ratings discussed above. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that evidence regarding limitation of flexion and instability of the left knee has been consistent with the assigned ratings for the entire relevant time period here on appeal. The record does not indicate any significant increase or decrease in such symptoms during the appeal period and symptoms warranting a higher rating have not been shown. Accordingly, staged ratings are not warranted for the left knee disability based on limitation of flexion or recurrent subluxation. B. Increased Rating - Left Knee Scar The June 2008 rating decision also awarded service connection for a residual left knee surgical scar, evaluated as noncompensable from August 23, 2007. The rating criteria used to evaluate scars were revised effective October 23, 2008. However, the revised criteria apply only to claims filed on or after October 23, 2008 unless the Veteran requests that the Agency of Original Jurisdiction (AOJ) review the claim under the 2008 revised criteria. Although the Veteran has not requested such review, the record reflects the AOJ has adjudicated the claim under the revised rating criteria. Therefore, to ensure there is no prejudice to the Veteran, the Board will consider the rating criteria effective both prior to and from October 23, 2008. Prior to and from October 23, 2008, DC 7800 addresses scarring of the head, face, or neck, while DC 7802 provides a 10 percent evaluation for scars with an area of 144 square inches (929 square centimeters) or greater. Neither of these criteria applies to the left knee surgical scar; hence, they will not be further discussed. Prior to October 23, 2008, DC 7801 evaluated scars that were deep or caused limited motion, while from October 23, 2008, DC 7801 evaluates deep and nonlinear scars. Although the surgical scar is noted to be nonlinear, there is no evidence it is deep or causes limited motion. Therefore, DC 7801 also will not be further discussed. Prior to October 23, 2008, DC 7803 provided a 10 percent rating for superficial, unstable scars. Note (1) indicated an unstable scar was one where, for any reason, there was frequent loss of covering of the skin over the scar. Note (2) indicated a superficial scar was one not associated with underlying soft tissue damage. DC 7803 was removed, effective October 23, 2008. Prior to October 23, 2008, DC 7804 provided a 10 percent rating for a superficial scar that was painful on examination. From October 23, 2008, DC 7804 was revised to provide a 10 percent rating for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) explains that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, 10 percent should be added to the evaluation that is based on the total number of unstable or painful scars. Note (3) states that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. Prior to October 23, 2008, DC 7805 provided that scars, other, could be rated based on limitation of function of the affected part. Similarly, from October 23, 2008, DC 7805 provides that any disabling effects not considered in a rating provided under DCs 7800-7804 can be considered under another appropriate DC. An August 2007 VA treatment record reflects that the left knee surgical scar was 14 centimeters and shaped like an upside down question mark. In October 2007, the Veteran reported experiencing pain on the scar and sides of the scar for the past week. Examination revealed a healed scar. A February 2008 VA record also reflects a healed scar. On May 2008 VA examination, the left knee surgical scar measured 12 by 1 centimeters. There was no tissue loss. There was a minor difference in color. There was numbness over and surrounding the scar, with no tenderness or skin breakdown, and no limitation of activity or motion. In his June 2010 VA Form 9, the Veteran reported that the scar was sensitive. He indicated that his left knee injury severed his nerve; hence, he experienced complete numbness over the left part of his knee. He reported that the very top and bottom of the scar were very sensitive and felt as if there were splinters going to his knee cap. He also indicated his belief that the pain to his knees when kneeling may be caused by scar tissue under the scar or patella. A February 2011 record from Dr. S.J.T. and an April 2011 record from Dr. T.M.S. reflect notations that physical examinations revealed a well-healed surgical scar. At the May 2011 Board hearing, the Veteran reported having numbness around the scar. He indicated that it was difficult to feel pain when he did not have any feeling in the knee. He testified that his scar tissue was deep and pulled at his kneecap. He indicated that anything to the left of the scar was numb, so if anything is wrong in that area, he was unable to feel it. Board Hearing Tr. at 25-26. On July 2012 VA examination, the examiner noted the Veteran had no painful or unstable scars. The left knee surgical scar was noted to be "S" shaped and 13 centimeters by 0 centimeters. It was flat, soft, and slightly hyperpigmented, with no pain to deep palpation. There was no keloid formation, no tissue loss, and it was not adherent to underlying tissue. There was no sloughing, no infection, and no inflammation. It was noted to be a stable surgical scar. Regarding DC 7803 effective prior to October 23, 2008, and DC 7804, effective prior to and from October 23, 2008, a preponderance of the evidence is against a finding that the Veteran's scar is painful or unstable. As described above, there is no evidence that the left knee surgical scar is unstable. Although the Veteran reported in August 2007 that he had been experiencing pain on the scar and sides of the scar for the last week, examination at that time did not reflect a painful scar. Also, to the extent the Veteran has reported pain at the scar site with motion, such as when kneeling, such is already being compensated under DC 5260; thus, providing a separate 10 percent rating under DC 7804 for symptoms of pain with motion would be pyramiding. 38 C.F.R. § 4.14. Furthermore, the Veteran has otherwise reported that he only feels numbness at the scar site. Therefore, the August 2007 report of pain appears to be inconsistent with the other evidence of record. The Veteran is not entitled to a 10 percent rating for a painful or unstable scar under DC 7804. Additionally, there is no evidence that the scar causes any limitation of function of the left knee or other disabling effects other than what he is already being compensated for under DCs 5257 and 5260; therefore, the Veteran is not entitled to a rating under DC 7805. The Board has also considered whether any staged rating is appropriate for the left knee surgical scar. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that evidence regarding the scar has been consistent with the assigned rating for the entire relevant time period here on appeal. The record does not indicate any significant increase or decrease in such symptoms during the appeal period and symptoms warranting a higher rating have not been shown. Accordingly, a staged rating is not warranted for the left knee surgical scar. In summary, a preponderance of the evidence is against a finding that the Veteran is entitled to a 10 percent rating for the left knee surgical scar. C. Extraschedular Evaluation The Board has also considered whether referral for extraschedular ratings is appropriate. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. 38 C.F.R. § 3.321(b). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). As explained in detail above, the Veteran's left knee disability been manifested by symptoms of limitation of flexion with pain causing some functional loss and recurrent subluxation. The pertinent diagnostic codes and associated rating criteria appropriately contemplate these symptoms. Hence, the rating criteria reasonably describe the Veteran's left knee disability. In short, there is no indication in the record that the average industrial impairment from his left knee disability would be in excess of that contemplated by the ratings provided in the rating schedule. The Veteran's left knee disability picture is not shown to be exceptional or unusual and referral for assignment of an extraschedular evaluation is not in order. Regarding the left knee surgical scar, the Veteran has reported that his scar is manifested by numbness over the scar site. The associated rating criteria do not rate scars based on numbness. Therefore, the available rating criteria for evaluating the Veteran's surgical scar are inadequate and the Board must next consider whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1). Related factors include "marked interference with employment" and "frequent periods of hospitalization." Id. Here, the evidence does not reflect any related factors. Although the Veteran has indicated that his left knee disability interferes with his employment as a teacher and coach, in that he has to sit down to teach and he experiences left knee pain when coaching, he has not indicated that any of these interferences are due to the surgical scar. Moreover, even if they were attributed to the surgical scar, they would not reflect marked interference with employment. There is also no evidence of frequent periods of hospitalization for the left knee surgical scar. Thus, the second step of the inquiry is not met, and referral for assignment of an extraschedular evaluation for the left knee surgical scar is not warranted. D. Evaluation under 38 C.F.R. § 3.324 Whenever a Veteran is suffering from two or more separate permanent service-connected disabilities that are of such character as to clearly interfere with normal employability, but are not found to be of compensable degree under the VA's Rating Schedule, the rating agency is authorized to apply a 10 percent evaluation, but not in combination with any other rating. 38 C.F.R. § 3.324. In this case, this decision establishes a compensable rating for the Veteran's left knee disability throughout the appeal period. Therefore, the Veteran may not be awarded a separate 10 percent disability evaluation for multiple noncompensable disabilities pursuant to 38 C.F.R. § 3.324. This claim is rendered moot by the awards provided and the appeal is denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). ORDER From August 23, 2007, a rating of 10 percent, but no higher, for mild patellar tendinosis of the left knee with subluxation and effusion is granted, subject to the regulations governing payment of monetary awards. From August 23, 2007, a rating of 10 percent, but no higher, for limitation of flexion of the left knee is granted, subject to the regulations governing payment of monetary awards. An initial compensable rating for a left knee surgical scar is denied. The claim for a 10 percent evaluation based on multiple noncompensable service-connected disabilities is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs