Citation Nr: 1625985 Decision Date: 06/28/16 Archive Date: 07/11/16 DOCKET NO. 10-25 346 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for left knee strain, status post-arthroscopic surgeries. 2. Entitlement to an evaluation in excess of 10 percent for right knee strain with anserine bursitis, status post-arthroscopic surgeries. 3. Entitlement to a compensable evaluation for status post-umbilical hernia repair. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Matthew Miller, Associate Counsel INTRODUCTION The Veteran had active service in the U.S. Army from September 1988 to August 1996. Ther matter comes before the Board of Veterans' Appeals (Board) on appeal from regional office (RO) rating decisions of October 2008 and April 2010. In January 2015, the Veteran appeared at a hearing held at the RO before the undersigned (i.e., Travel Board hearing). A transcript of that hearing is of record. In April 2015, the Board remanded the claim for additional development. The claim has since returned to the Board for further consideration. Ther appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of the Veteran's case should take into account the existence of these electronic records. FINDINGS OF FACT 1. The Veteran's left knee strain, status post-arthroscopic surgeries, is characterized by slight instability and painful motion with extension to 0 degrees, and flexion to 130 degrees, but no frequent locking or effusion. 2. The Veteran's right knee strain, with anserine bursitis, status post-arthroscopic surgeries, is characterized by slight instability and painful motion with extension to 0 degrees, and flexion to 130 degrees, but no frequent locking or effusion. 3. The Veteran's post-operative umbilical hernia repair is manifested by no active hernia and does not require the need of a supportive belt or involve weakening of the abdominal wall. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 10 percent for painful motion of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5019, 5258, 5259, 5260, 5261 (2015). 2. The criteria for a separate 10 percent evaluation, but no higher, for instability of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.71a, Diagnostic Codes 5257 (2015). 3. The criteria for a rating greater than 10 percent for painful motion of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5019, 5258, 5259, 5260, 5261 (2015). 4. The criteria for a separate 10 percent evaluation, but no higher, for instability of the right knee have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.71a, Diagnostic Codes 5257 (2015). 5. The criteria for a compensable evaluation for status post-umbilical hernia repair have not been met or approximated. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 4.7, 4.114, Diagnostic Code 7339 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist In the case at hand, the notice requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met by correspondence dated March 2010. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate her claim, and, as warranted by law, affording adequate VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. The Veteran's statements in support of the claim are of record, including testimony provided at the hearing before the undersigned Veterans Law Judge. The Board hearing focused on the elements necessary to substantiate her increased ratings claim and the Veteran, through her testimony and her representative's statements, demonstrated that she had actual knowledge of the elements necessary to substantiate the claim for benefits. Thus, the material issues on appeal were fully developed in accordance with 38 C.F.R. § 3.103(c) (2015). Pursuant to the Board's April 2015 remand, the AOJ provided the Veteran with VA examinations and opinions which were responsive to the questions asked of the examiner, and issued a supplemental statement of the case in September 2015. Based on the foregoing actions, the Board finds that there has been substantial compliance with the Board's July 2015 remand. Stegall v. West, 11 Vet. App. 268 (1998). Finally, in reaching a determination, the Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting the decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to ther claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). If two disability evaluations are potentially applicable, the higher evaluation 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2015). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2015); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). While it is necessary to consider the complete medical history of the Veteran's condition in order to evaluate the level of disability and any changes in condition, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Francisco v. Brown, 7 Vet. App. 55 (1994). In deciding the Veteran's increased evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. 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. It is essential that the examination upon 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 innervation, 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 that 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. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. With respect 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: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) 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. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When X-ray findings of arthritis are present and a Veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling; unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling; extremely unfavorable, in flexion of an angle at 45 degrees or more, is rated 60 percent disabling. 38 C.F.R. § 4.71a . Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a . See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Malunion of the tibia and fibula with slight knee or ankle disability is rated 10 percent disabling; malunion of the tibia and fibula with moderate knee or ankle disability is rated 20 percent disabling; and malunion of the tibia and fibula with marked knee or ankle disability is rated 30 percent disabling. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated 40 percent disabling. 38 C.F.R. § 4.71a . Separate ratings can be assigned for the same knee joint for limitation of extension, limitation of flexion, and recurrent subluxation or lateral instability. However, to assign a separate compensable rating, the criteria for a compensable rating must be met under both sets of criteria. VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); VAOGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The selection of the proper diagnostic code is completely dependent upon the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). Left and Right Knee Disabilities The Veteran's left and right knee disabilities are currently rated as 10 percent disabling under Diagnostic Codes 5019, 5260, and 5261. Bursitis is rated as degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5019 and 5003. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. When the limitation of motion is noncompensable under the appropriate diagnostic code, a 10 percent rating is for application for each such major joint affected by limitation of motion, to be combined, not added under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Turning to the evidence of record, the Board finds that a combined rating of 20 percent, but no higher, is warranted. The Veteran injured her knees in 1990 during physical training. Her injury has required multiple arthroscopies since then. The Veteran continues to receive orthopedic therapy as well as private and VA treatment for her service-connected knee disabilities. In March 2010, the Veteran was provided a VA examination. The Veteran complained of knee instability and pain, and claimed use of bilateral knee braces to facilitate movement. The examiner found palpable crepitus on the Veteran's right knee extension, along with tenderness over her pes anserinus area. Compression testing was positive and shrug testing was negative. The examiner also found palpable crepitus on the Veteran's left knee extension. Compression and shrug testing were negative. The range of motion of the left knee and right knee joints for flexion was 0 to 140 degrees, without pain and extension at 0 degrees with pain. Bilateral knee joint function was not additionally limited after repetitive use. Bilateral knee X-rays were within normal limits. The examiner rendered a diagnosis of left knee strain, status post-arthroscopic surgeries, aggravated by patellofemoral pain syndrome and right knee strain with anserine bursitis, status post-arthroscopic surgeries, aggravated by patellofemoral pain syndrome. The Veteran was afforded another VA examination in March 2013. The Veteran stated that she uses a cane and knee braces. She complained of pain, swelling, and disturbance of locomotion for both knees. Her examination revealed right knee flexion of 0 to 130 degrees with pain from 110 degrees. Right knee extension was to 0 degrees, with no objective evidence of painful motion. The Veteran's left knee flexion was 0 to 130 degrees with pain from 130 degrees. Left knee extension was to 0 degrees, with no objective evidence of painful motion. Bilateral knee joint function was not additionally limited after repetitive use. Joint stability testing was normal. In regards to the Veteran's other medical records, an October 2012 orthopedic record reveals that the Veteran was evaluated for bilateral knee stabilizer braces. The Veteran reported that her knee caps buckled often and were very painful. In November 2012, the Veteran was fitted with bilateral knee stability braces. MRI and X-ray imaging has also been performed on the Veteran. February 2009 imaging of her right knee showed no acute fractures, dislocations, or knee joint effusion. A September 2009 study of her right knee showed a normal medial and lateral meniscus, with no collateral ligament abnormality. Although there was small joint effusion, there was no associated cartilage abnormality of the patella. September 2012 imaging of her right knee showed mild cartilage thinning, which had minimally progressed since 2009. All right knee tendons and ligaments were unremarkable. There was no joint effusion, meniscal tear, or ligamentous injury. Pursuant to the Board's April 2015 remand, the Veteran was provided with another VA examination in August 2015. The Veteran claimed to use knee braces all day while at work and use of a cane for the past 3 years. The Veteran also reported taking pain medication and use of hot and cold compresses for her knees. Additionally, the Veteran complained of occasional knee flare-ups, including times where she needed help getting out of bed. The Veteran stated that she avoided running, kneeling, or squatting, and noted a decrease in her ability to workout. She also referred to her knee joints as being "bone on bone." Her examination revealed right knee flexion of 0 to 130 degrees and extension 130 to 0 degrees. The Veteran's left knee flexion was 0 to 130 degrees and extension 130 to 0 degrees. Although the Veteran reported bilateral knee pain and tenderness, it did not result in or cause functional loss. Repetitive use testing resulted in pain, but range of movement results were unchanged. The examiner explained that, without resort to speculation, he could not determine functional loss during flare-ups without being present during such an episode. The Veteran was not then having a flare-up. Bilateral knee strength and stability testing were normal. X-ray testing showed essentially normal knees for the Veteran's age with "possible very early signs of arthritis." The examiner noted that the Veteran's reported medical history was inconsistent with objective findings shown by the X-ray studies. The examiner also noted that the Veteran's physical examination and X-ray findings "were consistent with a significantly higher level of function than reported" by the Veteran herself. After reviewing the record, the Board concludes that the competent evidence supports a separate 10 percent evaluation for slight instability of her knees under 38 C.F.R. 4.71a, DC 5257. Treatment records show findings of slight lateral instability, demonstrated by the Veteran's prescription and use of bilateral knee stability braces. The Veteran has reported that she continues to use the braces in order to facilitate movement and stabilize her knees. Therefore, the Board finds that a separate rating of 10 percent rating for each knee under Diagnostic Code 5257 is warranted for slight lateral instability of her knees. With regard to the Veteran's rating for painful motion of the knees, currently evaluated as 10 percent disabling, the Board finds that a higher rating is not warranted. There is no evidence of record indicating that she has limitation of flexion to 30 degrees or less to warrant a higher 20 percent rating under Diagnostic Code 5260. In fact, the Veteran had limitation of flexion to, at worst, 130 degrees based on the evidence of record. While the examiner noted some pain on motion, the maximum ranges of motion were not reduced on repetitive motion testing. Additionally, the evidence does not show that a compensable rating could be assigned for limitation of extension, as the evidence of record shows extension was to 0 degrees. Limitation of extension would have to get to 10 degrees to warrant a compensable rating, and even with consideration of pain on motion and other factors, this level of limited extension is not shown. 38 C.F.R. § 4.71a, DC 5261. Service records show that the Veteran had meniscus injuries to her knees in service with arthroscopic surgery performed. Despite her treatment for meniscus injuries, the record does not support additional compensation under either DC 5258 or DC 5259. With regard to DC 5259, all symptoms related to the Veteran's knees and any residuals of her surgeries in service are being compensated for in the 10 percent evaluation for painful motion and the separate 10 percent evaluation for instability. Thus, awarding an additional rating under DC 5259, which allows for a 10 percent rating for symptomatic residuals of removal of the semilunar cartilage would be pyramiding. Moreover, there is no evidence that cartilage was removed. With regard to DC 5258, the evidence does not demonstrate frequent episodes of locking and effusion into the joint. While there are occasional notes of mild effusion, there are also more frequent reports without any notation of effusion. Thus, a higher rating under DC 5258 is not appropriate. Moreover, X-ray and MRI imaging do not show any additional abnormalities of her knee tendons or ligaments. Additionally, there is no indication that the Veteran's bilateral knee disability warrants an increased rating under any other diagnostic code relating to the knees. The claims folder contains no medical evidence indicating that the Veteran's knee disability is manifested by ankylosis, impairment of the tibia and fibula, genu recurvatum, or symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 5256, 5262, or 5263. 38 C.F.R. § 4.71a. Additional compensation is not warranted for functional loss pursuant to 38 C.F.R. 4.40, and 4.45, as the Veteran's primary symptom, even during flare-ups, is painful motion, which is contemplated by her current 10 percent evaluation, and there is no evidence of additional functional loss on repetitive use for which additional compensation could be assigned. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus, an increased evaluation on this basis is not warranted. Consideration has been given to assigning staged ratings. The Board finds that at no time during the period in question has the Veteran's left and right knee disabilities warranted higher schedular ratings than those now assigned. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board acknowledges the Veteran's assertions that her disability is more severe than evaluated for the period at issue, to include her hearing testimony and lay statements of knee pain and instability. The Veteran is competent to report such symptoms, and the Board has recognized his reported symptoms with the assignment of a separate ratings for painful motion and instability under the appropriate Diagnostic Codes, which encompass these symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). Hernia The Veteran contends that she is entitled to a compensable rating for her service-connected hernia. The Board notes that the Veteran is separately compensated with a 10 percent rating for a painful scar associated with her umbilical hernia repair, and receives a 30 percent evaluation for chronic constipation. A post-operative, ventral hernia is evaluated as 100 percent disabling when there is massive, persistent, severe diastasis of recti muscles, or extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable. A large hernia that is not well supported by a belt under ordinary conditions is evaluated as 40 percent disabling. For a 20 percent evaluation, there must be a small hernia that is not well supported by a belt under ordinary conditions, or a healed ventral hernia or post-operative wounds with weakening of abdominal wall and indication for a supporting belt. Residuals consisting of post-operative, healed wound with the use of a belt not indicated are evaluated as noncompensable. 38 C.F.R. § 4.114, Diagnostic Code 7339. A review of the record reveals that the Veteran has had multiple surgical repairs for her umbilical hernia, with the most recent surgery performed in August 2006. The Veteran underwent a VA examination in November 2009. The Veteran complained of pain and flare-ups during exercise and bowel movements. Upon physical examination of the Veteran, the examiner found a 13 cm scar in the epigastric and umbilical area. There was also a 2 cm scar across the bottom of the umbilical area, as well as small 1.5 cm scars in the lateral abdomen from prior surgical intervention. The examiner noted some tenderness but did not detect any herniation. In April 2010, the Veteran was awarded a temporary 100 percent evaluation, effective October 13, 2005 to December 4, 2005 for her hernia based on surgical treatment necessitating convalescence. A noncompensable evaluation was assigned from December 5, 2005 to present. The Veteran was again provided a VA examination in May 2013. The Veteran stated that she was experiencing pain and problems with the mesh inserted during her 2006 hernia surgery. The examiner noted the Veteran's healed post-operative ventral hernia repair and did not indicate any need for a supporting belt. The Veteran's post-remand VA examination occurred in August 2015. The Veteran continued to complain of pain in her abdominal area, which has worsened since her most recent surgery in 2006. The examiner diagnosed a healed ventral hernia, but did not detect a current hernia. The examiner also determined that there was no indication for the Veteran to use a supporting belt. Although the examiner noted some surgical scarring, the scars were not painful and/or unstable and the total area of the scars was not greater than 39 square cm. In sum, a present or current umbilical hernia was not found during any of the Veteran's pertinent VA examinations or in treatment records, nor was there a weakening of the abdominal wall or any indication for a supporting belt. While the Veteran complains of pain related to her prior surgeries, it appears that her wounds have healed sufficiently and the repair is still intact, as indicated by her VA and private treatment records. Moreover, as noted above, her painful scar is receiving a separate 10 percent rating. For these reasons, the Board finds that the criteria for a compensable schedular rating under Diagnostic Code 7339 have not been met or more nearly approximated. 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7339. The Board has considered other potentially applicable diagnostic codes, such as DC 7338 governing inguinal hernias, however, the criteria are virtually the same as those under DC 7339, and a compensable rating is not available without an active hernia readily reducible and well supported by a truss or belt. 38 C.F.R. § 4.114, DC 7338. As none of these factors are present, a higher rating is not warranted under this provision. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating for status post-umbilical hernia repair. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Other Considerations According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b) for referral for an extraschedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Yancy v. McDonald, 27 Vet.App. 484 (2016). Accordingly, referral for consideration of 38 C.F.R. § 3.321(b)(1) on a collective basis is not warranted in this case. On an individual basis, the threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extraschedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). The record shows that the manifestations of the Veteran's left and right knee disabilities, as well as her post-surgical umbilical hernia repair are contemplated by the schedular criteria. There is no indication that the average industrial impairment from the disability has been in excess of that contemplated by the assigned rating. In addition, the evidence does not show frequent hospitalization beyond that envisioned by the currently assigned ratings. There is no indication that she is unable to work as a result of these disabilities, or that the disabilities cause a marked interference with employment beyond that contemplated by the currently assigned rating. Therefore, the Board finds that referral for extraschedular consideration is not warranted. ORDER An evaluation greater than 10 percent for left knee strain, status post-arthroscopic surgeries, based on painful motion is denied. A separate 10 percent rating for instability of the left knee, is granted, subject to the laws and regulations governing the payment of monetary benefits. An evaluation greater than 10 percent for right knee strain, status post-arthroscopic surgeries, based on painful motion is denied. A separate 10 percent evaluation for instability of the right knee is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a compensable evaluation for status post-umbilical hernia repair is denied. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs