Citation Nr: 1610388 Decision Date: 03/15/16 Archive Date: 03/22/16 DOCKET NO. 10-00 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial disability rating in excess of 20 percent for residuals, ventral hernia. 2. Entitlement to a disability rating in excess of 10 percent for patellar bursitis, right knee. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Yvette Hawkins, Counsel INTRODUCTION The Veteran served on active duty from September 1982 to September 2008. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The claims were remanded to the Agency of Original Jurisdiction (AOJ) in May 2012 and December 2013, respectively, for additional evidentiary development, to include affording the Veteran new VA medical examinations to determine the severity of his service-connected disabilities. As there has been substantial compliance with the Board's remand directives, the Board finds there is sufficient evidence to adjudicate the claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998). This appeal was processed using the Veterans Benefits Management (VBMS) and Virtual VA paperless claims processing systems. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's residuals, ventral hernia, have been manifested by no greater than a small, well-supported by belt under ordinary conditions, healed ventral hernia. 2. Throughout the period on appeal, the Veteran's patellar bursitis, right knee, has been manifested by no greater than objective findings of pain, osteoarthrosis, osteoarthritis, iliotibial band friction syndrome, flexion limited to 95 degrees with pain at 90 degrees, and extension to zero degrees with pain at 5 degrees, but without instability, ankylosis or additional limitation of range of motion or function upon repetitive motion. 3. Beginning September 23, 2014, the Veteran presented with one superficial, non-linear, painful scar on the anterior trunk, mid-abdomen, 10 x 2 cm, without underlying tissue loss or other characteristics. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 20 percent for residuals, ventral hernia, have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.114, Diagnostic Code 7339 (2015). 2. The criteria for an initial disability rating in excess of 10 percent for patellar bursitis, right knee, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.27, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2015). 3. For the period beginning November 28, 2012, a disability rating of 10 percent, but no higher, for a superficial, non-linear, painful scar of the anterior trunk, resulting from the Veteran's ventral hernia surgery is warranted. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.118, Diagnostic Codes 7800-7805 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015). The Veterans Claims Assistance Act of 2000 (VCAA) notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Of particular importance, in Dingess/Hartman, the Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection is awarded. VA satisfied the notification requirements of the VCAA by means of a letter dated in October 2008, which advised the Veteran of the evidence necessary to substantiate his original service connection claims. The letter also satisfied the requirements of Dingess by advising him how VA determines the disability rating and effective date elements of a claim. However, this appeal arises from disagreement with an initial disability evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated and additional VCAA notice is not required; any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Nonetheless, a letter dated in March 2009 provided the Veteran with notice of how to substantiate an increased disability rating claim. Further, the claims were readjudicated in a November 2009 Statement of the Case (SOC), which provided him with the rating criteria under which his disabilities were rated. A second letter, dated in January 2010, also provided him with the aforementioned rating criteria. VA's duty to assist has been satisfied. The claims file contains the Veteran's service and post-service treatment records, as well as VA examination reports dated in October 2008 and September 2014. Additionally, the claims file contains the Veteran's statements and testimony in support of his claims. The Veteran has not referenced any outstanding, available records that he wanted VA to obtain that have not already been obtained and associated with the record. Review of the examination reports shows that the examiners reviewed the pertinent evidence of record, obtained a history of symptomatology and treatment from the Veteran, performed comprehensive examinations, along with reviews of available diagnostic test results, and provided the diagnostic criteria necessary to evaluate the severity of the Veteran's disabilities. Accordingly, the Board concludes that the examination reports are adequate upon which to base decisions in this case. As noted above, in October 2012, the Veteran was afforded a Travel Board hearing. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) 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. The Board finds that the hearing generally was held in compliance with the provisions of Bryant. Further, a review of the record also reveals no assertion, by the Veteran or his service organization representative, that VA or the VLJ failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any other prejudice in the conduct of the Board hearing. Moreover, the Veteran's statements, as well as those of his representative, demonstrate actual knowledge of the elements and evidence necessary to substantiate the claims because the statements focused on the evidence and elements necessary to substantiate the claims. Thus, in light of the Veteran's testimony at the hearing, the "clarity and completeness of the hearing record [is] intact," and there is no prejudicial error with regard to the hearing officer's duties under 38 C.F.R. § 3.103(c)(2) (2015). See Bryant v. Shinseki at 498. Analysis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, and by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries, and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). Separate Diagnostic Codes (DC) identify the various disabilities and the criteria for specific ratings. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2015). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2015). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2009). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2015). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). A. Entitlement to an initial disability rating in excess of 20 percent for residuals, ventral hernia. The Veteran's residuals, ventral hernia, are rated under 38 C.F.R. § 4.114, DC 7339, hernia, ventral, postoperative. Under this diagnostic code, massive, persistent, severe diastasis of rectimuscles or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable warrants a 100 percent rating. Large hernia, not well supported by belt under ordinary conditions, warrants a 40 percent rating. Small, not well supported by belt under ordinary conditions, or healed ventral hernia or postoperative wounds with weakening of abdominal wall and indication for a supporting belt warrants a 20 percent rating. Wounds, postoperative, healed, no disability, belt not indicated, warrants a noncompensable rating. 38 C.F.R. § 4.114, DC 7339. The Veteran's residuals, ventral hernia, stem from a 2006 incident during service. During his October 2008 VA examination, the Veteran complained of difficulty bending and an inability to do sit-ups. He said he was not receiving any treatment for the condition. On physical examination, the hernia was 11 x 4 cm, located at the midline of the abdomen. The examiner said it could be well-supported by truss or belt. There was no diastasis recti. The examiner opined that the hernia was inoperable. VA treatment records during the course of the appeal show that in November 2010, the Veteran underwent surgical repair of the hernia. Treatment reports immediately following surgery show that the Veteran was found to have a diastasis, which was to be treated conservatively with exercise to reduce his BMI, better nutrition and pain medications. In September 2014, the Veteran was afforded a second VA examination. The examiner noted that the hernia had been repaired and diagnosed persistent, moderate diastasis recti secondary to the hernia repair. She described the hernia as "small." The Veteran said that he experienced pain with any pressure over the surgical site, as well as when attempting a sit-up, eating a large meal or straining during a bowel movement. The clinician also noted the existence of a ventral abdominal scar secondary to his hernia repair surgery and postoperative infection. The Veteran said that it was painful under any external pressure, and with the tightening of the abdominal muscles, such as attempting a sit-up, straining, lifting or coughing. The scar was superficial and non-linear, located at the mid abdomen, and measured 10 x 2 cm. Applying the pertinent legal criteria to the facts of this case, the Board concludes that the probative evidence of record is against the Veteran's claim of entitlement to an initial disability rating in excess of 20 percent for residuals, ventral hernia, under 38 C.F.R. § 4.114, DC 7339. Because there was no probative evidence at any time during the course of the appeal of a large hernia, not well supported by belt under ordinary conditions, a higher, 40 percent disability rating is not warranted. Moreover, although the September 2014 VA examiner diagnosed the Veteran with a diastasis recti secondary to surgery, she described it as persistent and moderate. There is no indication that the diastasis recti is massive and severe, or that there is extensive, diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable. Accordingly, a 100 percent rating is not applicable. The Board has also considered whether other diagnostic codes are applicable to the Veteran's residuals, ventral hernia. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."). However, as there has been no probative evidence presented to show that he was ever diagnosed with an inguinal or femoral hernia, the remaining hernia diagnostic codes are inapplicable. However, as noted above, during the September 2014 VA examination, the clinician found that the Veteran had a mid abdominal scar resulting from his November 2010 ventral hernia surgery. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2015). According to Note (1), an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. According to Note (2), if one or more scars are both unstable and painful, VA is directed to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Because the Veteran has one scar that is painful, a separate disability rating of 10 percent for his ventral hernia postoperative scar under 38 C.F.R. § 4.118, DC 7804 is warranted. The treatment records show that the earliest date that the scar was actually noted and described was on November 28, 2012, when the Veteran was seen at the VA Medical Center (VAMC) with complaints of pain at the surgery site. The clinician observed the existence of a "well[-]healed supraumbilical surgical scar." Accordingly, the earliest effective date applicable for service connection for the Veteran's scar (i.e., the date entitlement arose) is November 28, 2012. See 38 C.F.R. § 3.400(b)(2)(i) (2015). In denying the claim for a higher disability evaluation, the Board has also considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule for Rating Disabilities 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 impractical 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. There is no evidence that the Veteran's residuals, ventral hernia, present such an exceptional disability picture that the available schedular evaluations are inadequate. The Veteran's disability has been evaluated under the applicable diagnostic code that has specifically contemplated the level of occupational impairment caused by the disability. Moreover, although the 2008 VA examiner found that the disorder prevented the Veteran from employment that required heavy lifting, there is no evidence that the disability has caused marked interference with employment, such that application of the regular schedular standards is rendered impracticable. While the Veteran has reported continuing pain at the hernia site, the 20 percent rating currently assigned contemplates the pain that is often associated with a ventral hernia before and after surgery. The Board further observes that, even if the available schedular evaluation for the disability were inadequate (which it manifestly is not), the Veteran does not exhibit other related factors, such as those provided by the regulation as "governing norms." Here, the record does not show that the Veteran has required multiple hospitalizations for his ventral hernia during the course of this appeal. Accordingly, referral of this claim for extraschedular consideration is not indicated. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). The Board has also carefully reviewed and considered the Veteran's statements regarding the severity of his residuals, ventral hernia disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. The U.S. Court of Appeals for the Federal Circuit has held that lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2014); 38 C.F.R. § 3.303(a) (2015); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this case, however, the competent medical evidence offering detailed, specific, specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms, including pain. The lay statements have been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Thus, for the reasons stated above, the Board finds that an initial disability rating in excess of 20 percent for residuals, ventral hernia, is not warranted. As such, the "benefit-of-the-doubt rule" enunciated in 38 U.S.C.A. § 5107(b) is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Staged ratings are not applicable. B. Entitlement to an initial disability rating in excess of 10 percent for patellar bursitis, right knee. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40 (2015). It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 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 innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the 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 seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. Id. With regard to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: less movement than normal; more movement than normal; weakened movement; excess fatigability; incoordination; impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2015). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2015). The Court has held that when evaluating loss in range of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40 ) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. The fact that the revised criteria include symptoms such as pain, stiffness, aching, etc., if present, means that evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). For VA compensation purposes, normal flexion of the knee is to 140 degrees, and normal extension is to zero degrees. 38 C.F.R. § 4.71a, Plate II (2015). Separate ratings may also be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). The Veteran's patellar bursitis, right knee, has been rated on limitation of motion of affected parts as degenerative arthritis. Under DC 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id; see also 38 C.F.R. § 4.59; Hicks v. Brown, 8 Vet. App. 417, 420 (1995) (citing Litchenfels v. Derwinski, 1 Vet. App. 484, 488 (1991)). A higher rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. 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. This is because "pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss." Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Limitation of motion of the knee is evaluated under 38 C.F.R. § 4.71, DCs 5260 and 5261. Under DC 5260, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a maximum 30 percent rating is warranted for flexion limited to 15 degrees. Under DC 5261, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. Separate ratings under DC 5260 and DC 5261 may be assigned for disability of the same joint. Specifically, where a veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). A claimant who has arthritis and instability of the knee may be rated separately under DC 5003 and DC 5257 (recurrent subluxation or lateral instability); rating a knee disability under both of these codes does not amount to pyramiding under 38 C.F.R. § 4.14 (2014). VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate rating must be based on additional compensable disability. During the Veteran's October 2008 VA examination, his posture and gait were within normal limits. The right knee showed tenderness, guarding of movement and locking pain. There were no findings of edema, effusion, weakness, redness and heat, subluxation, genu recurvatum or crepitus. Flexion was to 95 degrees with pain at endpoint, extension was to zero degrees without pain. After repetitive use, the joint function was additionally limited by pain. There was no fatigue, weakness, lack of endurance or incoordination. There was no additional limitation in degree of motion. The anterior and posterior cruciate, and medial and lateral collateral ligaments stability tests were within normal limits, as was the medial and lateral meniscus test. The right knee x-ray was within normal limits. The clinician opined that the impact on the Veteran's activities of daily living was knee and foot pain (the Veteran also has a service-connected status-post fracture of the right phalanges fifth toe). In September 2014, the Veteran was afforded a second VA knee examination. The examiner diagnosed him with osteoarthritis of the right knee and right iliotibial band friction syndrome. The Veteran reported knee pain with locking and feeling as if the knee will give way medially. The pain was worse with walking, standing or attempting to kneel or squat. He reported being given a knee brace, but could not tell if it helped with his feeling of instability. He reported flare-ups of increased pain and decreased endurance when the knee locks or gives way. Right knee flexion was to 115 degrees with pain at 90 degrees, extension was zero degrees with pain at 5 degrees. After repetitive testing, there was no additional limitation in range of motion, but he did have pain and less movement than normal, including pain to palpation. Muscle strength and joint stability tests were normal. There was no evidence or history of recurrent patellar subluxation/dislocation. There were no additional conditions or findings. The examiner opined that the Veteran's right knee disorder affected his ability to work in that he would be limited in those occupational requirements that include frequent or prolonged periods of walking, lifting or carrying heavy items, ascending and descending stairs or ramps, or squatting. He added that there would need to be frequent rest breaks to avoid prolonged standing and possibly modification to allow him to alternate extending his knees rather than sitting with them flexed. As to the Veteran's assertions of laxity in light of no objective findings of laxity upon examination testing, the examiner noted that his treatment records were in agreement with the tests, as they showed no evidence of laxity, subluxation or instability. However, she said that his feeling as though his knee moved with lateral knee pain was consistent with a diagnosis of iliotibial band friction syndrome. She further concluded that the iliotibial band friction syndrome and osteoarthritis found during the examination were evidence of a progression of the prior diagnosis. VA treatment records during the course of the appeal contain no additional findings pertinent to the rating criteria for the Veteran's right knee disability. A November 2009 primary care assessment showed several comorbid conditions, including a diagnosis of osteoarthritis "involving the knee," but did not indicate which knee. In October 2012, he was seen at the VAMC with complaints of increased right knee pain. X-rays, however, were negative and revealed no findings of fracture, dislocation, evident stress fracture, degenerative joint disease or loose joint body. Applying the pertinent legal criteria to the facts of this case, the Board concludes that the probative evidence of record is against the Veteran's claim of entitlement to an initial disability rating in excess of 10 percent for patellar bursitis, right knee, under 38 C.F.R. § 4.71a DCs 5003, 5260 or 5261. As noted above, under DC 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion of the specific joint or joints involved. Here, the Veteran's right knee limitation of flexion is noncompensable under DC 5260, as there was no probative evidence during the entirety of the period on appeal that he had limitation of flexion limited 30 degrees or less. As his right knee extension was found to be normal throughout the entirety of the period on appeal, with no evidence of limitation of extension limited to 15 degrees or less, a compensable disability rating for limitation of extension under DC 5261 is also not warranted. Moreover, because there is no x-ray evidence or involvement of 2 or more major joint groups or 2 or more minor joint groups with occasional incapacitating acerbations, the current disability rating of 10 percent for his right knee is the maximum disability rating applicable under these diagnostic codes. Further, despite the examiners' objective findings of right knee pain, as noted above, "pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss." Mitchell v. Shinseki, supra. Here, there was no evidence at any time during the period on appeal of any additional right knee symptoms that could constitute a functional loss, including no fatigue, lack of endurance, weakness, lack of coordination or decrease in degrees of range of motion upon repetitive motion, which, if present, could possibly warrant a higher disability rating. See Deluca, supra. The Board has also considered whether other diagnostic codes are applicable to the Veteran's right knee disability. See Butts v. Brown, supra. The remaining diagnostic codes relating to knee disabilities include 5256 (for ankylosis), 5257 (patellar subluxation), 5258 (for cartilage, semilunar, dislocated, with frequent episodes of "locking" pain and effusion into the joint), 5259 (for cartilage, semilunar, removal or, symptomatic) and 5263 (for genu recurvatum). However, because there has never been objective evidence during the appeal period of ankylosis, semilunar, dislocated cartilage with frequent episodes of locking pain and effusion, removal or symptomatic semilunar cartilage, or genu recurvatum, none of these diagnostic codes are applicable. In denying the Veteran's claim for a higher disability evaluation, the Board has also considered whether he is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule for Rating Disabilities will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, supra. In applying the three-step inquiry under Thun v. Peake, supra, for determining whether a veteran is entitled to an extraschedular rating, the Board observes that there has been no evidence presented during the period on appeal that the Veteran's right knee disorder has presented such an exceptional disability picture that the available schedular evaluations are inadequate. Further, the current 10 percent disability rating assigned contemplates the pain that is often associated with patella bursitis. Further, even if the available schedular evaluation for the disability were inadequate (which it manifestly is not), the Veteran does not exhibit other related factors, such as those provided by the regulation as "governing norms." Here, the record does not show that the Veteran has required any hospitalization or inpatient treatment for his left ankle disability during the course of this appeal. Accordingly, referral of this claim for extraschedular consideration is not indicated. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). The Board has also carefully reviewed and considered the Veteran's assertions regarding the severity of his patellar bursitis, right knee. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. The Court has repeatedly held that laypersons, such as the Veteran, are competent to describe symptoms of which they have first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Here, however, the competent medical evidence offering detailed, specific, specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms, including pain. The lay statements have been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Accordingly, for the reasons stated above, the Board finds that an initial disability rating in excess of 10 percent for patellar bursitis, right knee, is not warranted. As such, the "benefit-of-the-doubt rule" enunciated in 38 U.S.C.A. § 5107(b) is not applicable. See Gilbert v. Derwinski, supra; Ortiz v. Principi, supra. Staged ratings are not applicable. ORDER Entitlement to a disability rating in excess of 20 percent for residuals, ventral hernia, is denied. Entitlement to a disability rating in excess of 10 percent for patellar bursitis, right knee, is denied. For the period beginning September 23, 2014, a separate disability rating of 10 percent, and no higher, for a superficial, non-linear, painful scar of the anterior trunk, resulting from the Veteran's ventral hernia surgery is granted, subject to the criteria applicable to the payment of monetary benefits. ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs