Citation Nr: 1805416 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 03-03 466 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a rating in excess of 10 percent for patellofemoral syndrome of the right knee. 2. Entitlement to a rating in excess of 10 percent for patellofemoral syndrome of the left knee. REPRESENTATION Appellant represented by: Jeany Mark, Attorney-at-Law ATTORNEY FOR THE BOARD A.Yaffe, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from March 1987 until October 1996. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a February 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied increased ratings for the disabilities on appeal. In a December 2006 decision, the Board denied the Veteran's claims of entitlement to increased evaluations for his service-connected patellofemoral syndrome of the right and left knees. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2008 Order, the Court granted the parties' Joint Motion for Remand (JMR), and remanded the case to the Board with instructions to afford the Veteran a Decision Review Officer (DRO) hearing. Pursuant to the JMR, the Board remanded the case in October 2009 for the RO to schedule the Veteran's DRO hearing. In a November 2009 statement from the Veteran's representative, the Veteran withdrew his hearing request. In July 2010, the Board remanded the case again for additional development, to include obtaining up-to-date medical records and scheduling the Veteran for a new VA examination in connection with his claim. In September 2011, the Board remanded the case in order to obtain an addendum medical opinion that would contemplate the requested discussion under DeLuca v. Brown, 8 Vet. App. 202 (1995); specifically to discuss the functional impairment of the Veteran's reported flare-ups. In March 2014, the Board, as relevant, remanded the Veteran's claim after determining that the addendum opinion obtained was not adequate. In April 2016, the Board remanded the case again in order to obtain clarification as to whether or not the Veteran had ankylosis. The case has now returned to the Board for further appellate review. Moreover, the Board observes that, in November 2017, the Veteran submitted a notice of disagreement (NOD) with a November 2016 decision issued by the Pension Management Center that denied the Veteran's dependency claim. In December 2017, the RO acknowledged receipt of the NOD, as well as the Veteran's election of the traditional appeals process. As the RO has acknowledged receipt of the NOD and additional action is pending at the RO, this situation is distinguishable from Manlincon v. West, 12 Vet. App. 238 (1999), where a NOD had not been recognized. As the RO is properly addressing the NOD, no action is warranted by the Board. Also, during the pendency of the appeal, the Veteran separately appealed to the Court the Board's April 2016 denial of increased rating for bilateral pes planus prior to January 10, 2007, and thereafter, and declined to refer the case for extraschedular consideration. The Court, in a November 2017 Memorandum Decision, vacated the portion of the April 2016 decision that did not refer the pes planus case for extraschedular consideration. That issue is under a separate appeal stream. As such, a Board decision on the pes planus issue will be forthcoming in a separate decision. FINDINGS OF FACT 1. The Veteran's right and left knee disabilities are each productive of noncompensable limitation of motion even when considering objective evidence of pain on motion and other factors; bilateral knee flexion limited to 30 degrees or extension limited to 15 degrees is not demonstrated. 2. Objective medical evidence of recurrent subluxation or lateral instability is not demonstrated in either knee. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent for patellofemoral syndrome of the right knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5260 (2017). 2. The criteria for a rating higher than 10 percent for patellofemoral syndrome of the left knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a, DC 5260 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veteran, through his attorney, challenges the adequacy of the May 2017 VA examination. Specifically, he asserts that the examiner failed to provide a rationale for the opinion that pain, weakness, fatigability, or incoordination does not significantly limit functional ability, despite indicating that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during flare ups. The representative further argued that the examiner failed to address prior findings of decreased muscle strength and inability to perform repetition testing of the knees. However, the Board finds that the May 2017 VA examination is adequate to decide the issues as it is predicated on a review of the record, which includes the aforementioned lay statements and medical evidence, and a review of the Veteran's medical records, and evaluation of his bilateral knee disability. Furthermore, the Board notes that the purpose of the April 2016 remand was only to obtain clarification of the findings of the March 2015 VA examination. Specifically, the Board requested a clarification as to whether the Veteran had ankylosis of the knees. Therefore, to this extent, the examination report more than complied with the Board's remand directives as not only was the question of ankylosis answered, a full examination was also conducted. Furthermore, for reasons detailed below, the Board has considered the Veteran's reports regarding functional loss with repetitive use over time or during flare ups. Neither the Veteran nor his attorney has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating Claims - Applicable Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2017). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability 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. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2017). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, 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 conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has also held that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Right and Left Knee Disabilities - Analysis The Veteran is currently in receipt of separate 10 percent disability ratings for right and left patellofemoral syndrome, and he contends that higher ratings are warranted. The right and left knee disabilities are separately rated under 38 C.F.R. § 4.71a, DC 5299-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. In addition, codes ending in "99" are for all unlisted conditions. Here, the use of the Diagnostic Code 5299-5260 refers to a knee disability not specifically listed in the rating criteria which is rated analogous to a disability due to limitation flexion of the knee. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology, are closely analogous. 38 C.F.R. § 4.20. Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. DC 5260 provides for the evaluation of limitation of flexion of the knee. A non-compensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it 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. Under DC 5261, extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a. Turning to the evidence, the Veteran underwent a VA examination in October 2001, during which he complained of pain, weakness, swelling, heat, instability, knees "giving way," locking, fatigability, and lack of endurance. There was objective evidence of painful motion, but no evidence of edema, instability, weakness, or tenderness. His gait was "poor" and described as "decrepit." The Veteran reported flare-ups with excessive walking, which the examiner described as "10 percent additional functional impairment." Flexion of the left knee was to 113 degrees and to 116 degrees on the right. Extension was recorded as negative 20 degrees on the left and negative18 degrees on the right. It was indicated that knee "stability was excellent," and no subluxation was found. Diagnosis was arthralgia of both knees with loss of function due to pain. Treatment notes from 2001 to 2002 show consistent complaints of knee pain and progress notes from October 2002 indicated that the Veteran had a normal range of knee motion, bilaterally, with mild crepitus and no point tenderness. An additional progress note dated later that month indicated that the Veteran continued to complain of pain in both knees and stated that the knees were "giving out on him." X-rays of both knees were normal. In April 2003, the Veteran underwent an additional VA examination during which he reported knee pain, weakness, stiffness, swelling, heat, instability, giving way, locking, fatigability, and lack of endurance. The Veteran also indicated flare-ups when sitting, standing, or walking for a prolonged time, which the examiner described as "10 percent additional functional impairment." During physical examination, the examiner found evidence of painful motion, weakness, and tenderness, but no effusion, edema, heat, or subluxation. Flexion of the right knee was to 93 degrees and flexion on the left was to 88 degrees. Extension on the left was negative 6 and negative 5 on the right. The examiner noted "stability is good." The diagnosis was bilateral degenerative joint disease of the knees with loss of function due to pain. It was indicated that the Veteran wore knee braces. In August 2004, the Veteran underwent an additional VA examination, where he reported pain, stiffness, swelling, occasional sense of locking, popping, and snapping. It was noted that the pain was aggravated by prolonged walking, and especially with ascending and descending steps. On physical examination, the examiner noted that visually the knees looked normal. Range of knee motion was from 0 to 130 degrees, bilaterally. When the right knee was extended against moderate amount of resistance, there was a minimal amount of crepitus. The examiner concluded that the Veteran had chronic patellofemoral pain syndrome and indicated that repetitive use was not a problem. The Veteran was wearing metal knee braces. X-rays taken in August 2004 indicate small patellar osteophytes on the left knee. Joint spaces were intact with no acute fractures or dislocations, and no significant degenerative changes. There was no joint effusion and soft tissues were unremarkable. In the July 2010 remand, the Board directed that the Veteran be afforded a VA examination to determine the extent and severity of the Veteran's service-connected bilateral knee disabilities, as relevant here. Of particular significance, the examiner was requested to include a discussion or analysis of the degree, if any, of resulting functional impairment of the Veteran's disabilities under the 38 C.F.R. §§ 4.40, 4.59, and the holding in DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran underwent a VA knee examination later in July 2010. The examiner noted knee pain, stiffness, decreased speed of joint motion, and swelling. The Veteran was walking with an antalgic gait. The Veteran reported that he was able to stand for 15 to 30 minutes, but was unable to walk more than a few yards. Further examination of the knees revealed tenderness, pain at rest, and guarding of movement with patellar abnormality classified as "subpatellar tenderness." Range of knee motion testing showed flexion to 87 degrees on the right, and to 74 degrees on the left, with normal bilateral extension. After repetitive motion, flexion was reduced to 78 degrees on the right and 70 degrees on the left. There was no evidence of ankylosis. Guarding in all range of motion attempts was described as marked. The examiner provided a diagnosis of chronic bilateral knee strain. The examiner noted that the Veteran missed less than a week of work during the previous year due to his increased knee pain which caused decreased mobility. The Veteran was wearing knee braces he received from VA. In a February 2012 addendum opinion, the examiner clarified that the July 2010 examination showed loss of flexion, bilaterally, but no evidence of instability of either knee during the examination. The examiner further noted that there was no evidence of weakened movement, excessive fatigability, or incoordination that could be said to be caused by the diagnosed bilateral knee strain. With regards to the impact of flare-ups on the Veteran's range of motion, the examiner indicated that "there were no flare-ups that could be construed to cause additional loss of motion with regular use ambulating." In an August 2010 letter, the Veteran indicated that he has financial struggles, because he has to take off work frequently due to his foot and leg pain. He mentioned that the pain is so severe at times, which prevents him from walking. In July 2013, the Veteran underwent an additional VA knee examination. He reported increased knee pain, stiffness, and difficulty ascending and descending stairs. The Veteran reported flare-ups weekly with weather changes. Range of knee motion testing showed flexion to 100 degrees, bilaterally, and normal extension (0), bilaterally. After repetitive motion, there was no change in flexion or extension and there was no objective evidence of pain. The examiner noted that the Veteran had functional loss with less movement than normal, excess fatigability, pain on movement, and interference with sitting, standing, and weight bearing. There was no tenderness or pain to palpation for joint line or soft tissues, muscle strength showed active moment against some resistance, bilaterally. Joint stability was normal, bilaterally. There was no history of patellar subluxation was present. X-rays showed evidence of degenerative joint disease (DJD) in both knees with minimal degenerative change in the left knee patellofemoral joint space; the rest of the joints spaces were normal, there was no effusion, and soft tissues were unremarkable. The examiner concluded that the condition impacted the Veteran's ability to work as a full-time security guard, since there was pain with prolonged standing, bending, and climbing stairs. A diagnosis of DJD in both knees was continued. The Veteran underwent an additional VA examination in March 2015. The Veteran reported that he works as a security guard and is ambulatory for 6 hours out of an 8 hour shift. He noted knee stiffness and pain that is moderate-to-severe with an episodic increase of severity in one or the other. The Veteran stated that flare-ups are severe enough to cause him to miss work at least twice monthly for two days at a time. He added that the longer he ambulates, the more pain and subjective weakness he feels. Range of knee motion testing showed flexion to 90 degrees on the right, to 70 degrees on the left, and normal extension (0), bilaterally. Functional loss prevented the Veteran from squatting, kneeling, or sitting with his legs flexed; he had pain with both flexion and extension. There was evidence of pain with weightbearing, and of localized tenderness at the distal patellar aspect of the knee, bilaterally. Crepitus was not demonstrated. Observed repetitive-use testing was not completed since the Veteran was unable to tolerate the pain after two flexion/extension attempts. The examiner indicated that repetitive use over time would result in a 20 degree loss of motion on the right, and none on the left. The examiner also noted that the examination was not conducted during a flare-up, but was medically consistent with the Veteran's statements describing functional loss during flare-ups. Pain was indicated to significantly limit functional ability during flare-ups, but the examiner stated it was not possible to describe the loss in terms of range of motion. Additional factors that contributed to the Veteran's disability were less movement than normal due to ankylosis, adhesions, etc. that disturbed locomotion, and interference with standing. Muscle strength was normal. There was no knee ankylosis, and no history of recurrent subluxation, lateral instability, or recurrent effusion. Stability testing was normal. There was no history or current cartilage or meniscus condition. The examiner noted that the Veteran was using braces constantly. X-rays of the knees revealed degenerative arthritis, bilaterally. The examiner concluded that the Veteran's bilateral knee disability impacts his ability to work. The examiner opined that it was clear that the Veteran's knee disability impacted his life, both at home and at work. The examiner added that the only relief from pain was during weekends when he was able to sit for prolonged periods, but symptoms resumed as soon as he went back to work or did any activities of daily living. Diagnosis was bilateral patellofemoral pain syndrome. In response to the 2015 findings, the Board's requested clarification with regard to the question of ankylosis. It appears that the requested examiner was not available, as the Veteran was instead provided with an additional examination. During this additional VA examination conducted in May 2017, the Veteran reported that his knees hurt him all the time and that his right knee "buckles on him" at times. He reiterated that he worked full-time as a bailiff at the courthouse where he is on his feet most of the day either walking or standing, and he stays off his feet as much as possible when not at work. The Veteran further noted that he wears knee braces only at home since they were "too stiff" for use when ambulatory. The Veteran reported flare-ups of knee pain and stated that two weeks prior to the examination he woke up in a lot of pain and could not move much that day. He further mentioned that he could no longer mow his lawn; he tries to take it easy on weekends so he could function on Monday at work. On examination, range of knee motion was from zero to 90 degrees, bilaterally. Knee pain was noted on flexion, bilaterally, but did not result in additional loss of motion. There was no indication of pain with weightbearing and no objective evidence of tenderness, pain to palpation, or crepitus. The Veteran was able to perform repetitive-use testing and the examiner noted that there was no additional functional loss after three repetitions in either knee. The Veteran was not examined immediately after repetitive use or during a flare-up. The examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time for during flare-ups. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups. There were no additional factors contributing to disability in either knee. Muscle strength testing was normal, as was joint stability testing. There was no evidence of ankylosis in either knee. The examiner noted the Veteran's occasional use of knee braces. X-rays of the knees showed evidence of arthritis and bilateral small osteophytes at the proximal tibia/tibial spines and off of the posterior patella at the patella femoral space on the left. The examiner continued a diagnosis of bilateral patellofemoral pain syndrome. The examiner concluded that the functional impact of the Veteran's knee disability would impair loadbearing activities. As aforementioned, the Veteran's knee disabilities are separately rated as 10 percent disabling under DC 5260 for arthritis with pain on motion pursuant to 38 C.F.R. § 4.59. The next-higher 20 percent rating under DC 5260 is assigned when flexion is limited to 30 degrees, and such as not been demonstrated throughout the appeal period. Rather, the evidence shows that on standard range of motion testing, the Veteran had, at worst, right knee flexion to 78 degrees and left knee flexion to 80 degrees, which occurred during the July 2010 VA examination; the remaining examinations of record show even better results. In fact, during the most recent examination in 2017, knee flexion was to 90 degrees, bilaterally. A disability rating in excess of 10 percent is not warranted for limitation of flexion of either knee under DC 5260. With regard to limitation of extension, while the October 2001 VA examination showed considerable negative extension, none of the subsequent range of motion tests have substantiated the findings of that initial examination. Instead, all the remaining range of motion findings recorded during the appeal period show full or near-full extension, and are taken as accurate representations of the Veteran's knee extension, bilaterally. Therefore, a disability rating in excess of 10 percent is not warranted under DC 5261 for limitation of extension of either knee. The Board considered whether a higher disability rating for either knee is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See also DeLuca. Here, there has been no evidence of additional loss of motion after repetitive-use or during flare-ups on the above-noted VA compensation examinations during the appeal period; the only exception being the March 2015 VA examination, during which an additional 20 degree loss of right knee motion was anticipated during repetitive motion over time (left knee flexion was 70 degrees on regular range of motion, with no evidence of additional loss over repeated motion or during a flare-up). This anticipated additional loss would result in a reduction of right knee flexion from 90 to 70 degrees. Again, limitation of flexion to 30 degrees must be demonstrated or approximated to the meet the next-higher rating of 20 percent under DC 5260. The Board acknowledges that the Veteran's bilateral knee disability has caused pain, stiffness, weakness, swelling, and excess fatigability, which has restricted overall motion, but even taking into account the 20 degrees of additional loss in the right knee, the criteria for a 20 percent criteria are not more nearly approximated. The current 10 percent ratings contemplate the functional impairment that the Veteran experiences. Based on the above, the degree of functional impairment does not warrant higher separate ratings based on limitation of right and left knee motion. DC 5257 provides ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee which is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a. The Veteran does not contend, nor does the record show, that he experiences subluxation of either knee. Instead, he complains of a feeling of knee instability or "giving way." DC 5257 explicitly refers to "lateral instability," which is a specific type of instability demonstrated by clinical testing for ligament laxity. Upon review of the evidence of record, the Board finds that the objective medical evidence in this case shows that all ligamentous testing has been consistently normal. Treatment records similarly fail to show any objective evidence of instability of either knee. Although the Veteran emphasizes that he has had to wear knee braces throughout the course of the appeal, during the most recent examination, he specifically indicated that he does not wear them at work because they are too bulky to walk in. As the record is negative for any objective evidence of knee instability, there is no basis for a rating under DC 5257 based on any right or left knee instability. The Board also considered other Diagnostic Codes relating to the knees; however, the Board finds that they are not applicable. The Board remanded the claim in 2016 to inquire as to whether ankylosis was shown because the March 2015 VA examiner checked the box indicating that there were additional factors that contributed to the Veteran's right and left knee disorder, including less movement than normal due to ankylosis and adhesions, etc. that disturbed locomotion and interfered with standing. The inclusion of the term "etc." suggests that the term ankylosis was simply inserted into the boilerplate as an example and not necessarily a finding. Under the section titled, "Ankylosis," the March 2015 examiner clearly checked the box indicating "No" to the presence of ankylosis, and this finding has been consistent throughout the appeal period. There is entirely no objective evidence of ankylosis in either knee, and the Veteran does not assert otherwise. The Veteran still retains motion in both knees, albeit limited to some extent. For these reasons, DC 5256 is not for application. Moreover, the record does not demonstrate any evidence of cartilage removal, or dislocation (DC 5258, 5259); impairment of the tibia and fibula (DC 5262); or genu recurvatum (DC 5263). As such, these DCs are also not for application. Based on this body of evidence, the Board concludes that separate ratings in excess of 10 percent are not warranted for right and left knee disabilities, and the Veteran's increased rating claims on a schedular basis are denied. Extraschedular Referral Consideration The Board also considered whether an extraschedular rating is warranted for the service-connected right and left knee disabilities. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service connected disability or disabilities. The governing norm in these exceptional cases is: 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321 (b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). The Veteran raises the issue of extraschedular consideration on account of the fact that he experiences flare-ups of knee symptoms during weather changes. He also indicates that his knee disabilities have caused him to miss some work and that he needs complete rest over the weekend so he can function at work the following week. With respect to the first prong of Thun (adequacy of the schedular rating criteria), the Veteran's right and left knee disabilities have been primarily productive of patellofemoral pain syndrome, DJD, painful limitation of motion, some swelling, weakness, and excess fatigability, as well as flare-ups of pain during certain weather changes. The resultant functional limitations are reported as difficulty with prolonged walking, ascending and descending stairs, squatting, kneeling, and sitting with knees flexed greater than 90 degrees. The schedular rating criteria specifically contemplate such symptomatology, findings, and functional limitations. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261; DeLuca, 8 Vet. App. 202. Further, any functional limitations imposed by the Veteran's knee disabilities are primarily the result of the knee pain or weakness; therefore, consistent with DeLuca, the effects of the Veteran's knee pain and associated limitations on occupational and daily life are specifically contemplated by the schedular criteria. Because the schedular rating criteria are adequate to rate the Veteran's right and left knee disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. As the first prong of Thun is not satisfied, the Board does not reach the second prong (exceptional factors such as marked interference with employment). Referral is not required. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321 (b)(1). ORDER A rating in excess of 10 percent for right knee disability is denied. A rating in excess of 10 percent for left knee disability is denied. ____________________________________________ S. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs