Citation Nr: 20032896 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 12-34 297 DATE: May 12, 2020 ORDER An increased rating for service-connected right knee disability, evaluated as 20 percent disabling for patellofemoral pain syndrome and 10 percent disabling for instability, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321, is denied. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s right knee disability is manifested by symptomatic removal of semilunar cartilage with joint line pain, effusion, and stiffness, with extension limited to no more than 15 degrees and flexion limited to no more than 110 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, and no more than slight lateral instability, without ankylosis, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 2. The Veteran’s right knee disability does not result in marked interference with employment or frequent periods of hospitalization. CONCLUSION OF LAW The criteria for an increased rating for service-connected right knee disability, evaluated as 20 percent disabling for patellofemoral pain syndrome and 10 percent disabling for instability, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5261, 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from December 1996 to December 2000. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in February 2010 by a Department of Veterans Affairs (VA) Regional Office (RO), which denied a compensable rating for the Veteran’s patellofemoral pain syndrome of the right knee. In a February 2015 decision, the Board, as relevant, awarded a 10 percent rating, but no higher, for the Veteran’s right knee disability. Thereafter, he appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In December 2015, the Court granted a November 2015 Joint Motion for Partial Remand (JMPR), which vacated and remanded the Board’s decision to the extent that it denied a rating in excess of 10 percent for the Veteran’s right knee disability, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321. In February 2016, April 2017, and July 2018, the Board remanded such claim for additional development and it now returns for further appellate review. In this regard, the Board notes that, during the course of the appeal, a September 2016 rating decision awarded a 20 percent rating for patellofemoral pain syndrome of the right knee and a separate 10 percent rating for instability of the right knee as of March 23, 2009, the date of receipt of the Veteran’s increased rating claim. However, inasmuch as higher ratings are available for such disability, and he is presumed to seek the maximum available benefit for a disability, his claim for higher ratings has remained on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Entitlement to an increased rating for service-connected right knee disability, evaluated as 20 percent disabling for patellofemoral pain syndrome and 10 percent disabling for instability, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. 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. Pyramiding, the evaluation 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 disability. 38 C.F.R. § 4.14. 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. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 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. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The appeal period for rating the Veteran’s right knee disability begins on March 23, 2009, the date VA received his claim for an increased rating, plus the one-year look-back period. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). During the appeal period, the Veteran’s patellofemoral pain syndrome of the right knee was originally rated pursuant to Diagnostic Code 5260-5024; however, such was changed to Diagnostic Code 5260-5003 in the March 2015 rating decision that implemented the Board’s award of a 10 percent rating in the February 2015 decision. Such was again changed to Diagnostic Code 5003-5261, and a separate rating was assigned pursuant to Diagnostic Code 5257, in the September 2016 rating decision that increased the rating for patellofemoral pain syndrome to 20 percent and awarded a separate 10 percent rating for instability. In this regard, the hyphenated Diagnostic Code in this case indicates that the service-connected disability of arthritis (Diagnostic Code 5003) is rated based on residual limitation of extension of the leg (Diagnostic Code 5261). 38 C.F.R. § 4.27. Pursuant to Diagnostic Code 5003, arthritis established by x-ray findings will be rated on the basis of limitation of motion of the specific joint involved. When, however, the limitation of motion of the specific joint involved 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of two or more major joints or two or more minor joints warrants a 10 percent evaluation. 38 C.F.R. § 4.71a. For the purpose of rating disability from arthritis, the knee is considered a major joint. See 38 C.F.R. § 4.45. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where extension is limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. VA’s General Counsel has stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Furthermore, pursuant to VAOPGCPREC 23-97 and VAOPGCPREC 9-98, a separate 10 percent rating for instability was awarded under Diagnostic Code 5257. In this regard, such Diagnostic Code provides for the assignment of a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating is assigned where there is moderate recurrent subluxation or lateral instability, and a 30 percent rating is assigned where there is severe recurrent subluxation or lateral instability. Descriptive words “slight,” “moderate” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. Prior to the appeal period, private treatment records from Kaiser Permanente reflect that, in August 2007, the Veteran underwent a right knee arthroscopy, partial medial and lateral meniscectomies, removal of loose bodies, microfracture of medial femoral condyle, and endoscopic assisted anterior cruciate ligament (ACL) reconstruction with quadrupled hamstring autograft. Such surgery was performed to repair a torn ACL with medial meniscal tear and chondral defect resulting from a soccer injury in April 2007. September 2009 and June 2014 VA examiners found that the Veteran’s ACL injury was unrelated to his service-connected patellofemoral pain syndrome and, thus, his related meniscus tear and instability were not part of such disability. However, the parties to the JMPR found that the evidence was inadequate to delineate the Veteran’s symptoms related to his patellofemoral pain syndrome in light of the totality of the evidence of record. Following an April 2016 VA examination scheduled to address such matter, the September 2016 rating decision found that, as it was not possible to separate the effects of the Veteran’s service-connected right knee disability from his post-service ACL tear, all signs and symptoms were attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Such determination resulted in the award of an increased rating of 20 percent for the Veteran’s patellofemoral pain syndrome and a separate rating of 10 percent for his instability for the entire appeal period. Thus, the Board will consider the totality of the Veteran’s right knee symptoms in the adjudication of the instant appeal. In this regard, the Veteran underwent a VA examination in order to determine the nature and severity of his right knee disability in September 2009. At such time, he reported intermittent right knee pain, limited range of motion, popping, and grinding. The Veteran reported he can only do a fast walk and no running, he starts to limp following repetitive activities that aggravate his knee, walking on uneven surfaces is painful, 30 to 40 minutes of sitting will cause the knee to get stiff, and he is able to walk 1/8th of a mile before his knee starts to bother him. He experiences flare-ups several times a day that last a few minutes to several hours. The Veteran denied swelling, locking, episodes of giving way, or incapacitating episodes. He utilizes a knee brace and orthotics but no other assistive devices. Examination revealed tenderness to palpation of the medial joint line, medial femoral condyle, and medial tibial plateau. However, there was no popliteal fossa tenderness, no lateral joint line tenderness, and no patella border tenderness. The Veteran had flexion to 125 degrees and extension to zero degrees. There was no increased pain and no change in range of motion following repetitive testing. However, the examiner noted that he would expect an approximately 10 to 15 degrees loss of overall range of motion, mild weakness, mild fatigability, and mild loss of coordination secondary to repetitive activity and painful flare-up episodes. Varus, valgus, Lachman’s, posterior drawer, and McMurray’s tests were negative. There was a firm symmetric endpoint on Lachman’s exam of the right ACL compared bilaterally, and there was 2+ crepitus on joint movements. On VA examination in January 2014, the Veteran reported that his right knee felt better stability-wise after the aforementioned surgery. His pain was worse during colder weather and he experienced episodes of aching pain, which became throbbing pain with prolonged sitting. The Veteran reported popping, grinding, and stiffness, but denied episodes of locking or giving way. Heavy squatting or lifting aggravates his right knee, and he no longer ran. The Veteran reported experiencing flare-ups that resulted in more limping and sitting. Range of motion testing revealed right knee flexion to 135 degrees and extension to zero degrees without pain. There was no further limitation in range of motion or function loss/impairment following repetitive use testing. However, the examiner indicated that the Veteran would experience 10 to 15 degrees loss of overall range of motion, mild weakness, mild to moderate fatigability, and mild loss of coordination due to repetitive activity and painful flare-ups of the right knee. There was pain on palpation. Muscle strength testing was normal. The Veteran had anterior instability (Lachman test) to 1+ on the right knee; however, posterior instability (posterior drawer test) and medial-lateral instability (valgus/varus) were not present. It was further noted that the Veteran had undergone a meniscectomy and arthroscopic surgery in August 2007 and had residual joint pain and limited range of motion due to such surgeries. Upon VA examination in June 2014, it was noted that, following the Veteran’s August 2007 surgery, he experienced symptoms of anterior instability and joint line pain, effusion, and stiffness with a sore ache with standing. The Veteran also reported that he experienced swelling with increased activity and standing, could no longer play sports or run, and had grinding and occasional catching, but no locking or instability. He reported flare-ups described as increased pain following standing or running. Range of motion testing revealed right knee flexion to 135 degrees and extension to zero degrees without pain. There was no further limitation in range of motion following repetitive use testing, but he had functional loss/impairment described as less movement than normal and swelling. However, the examiner indicated that the Veteran would experience a loss of an additional 5 degrees of extension and 10 degrees of flexion, as well as mild overall loss of strength, coordination, and fatigue, due to repetitive movement and flare-ups due to pain. There was pain on palpation. Muscle strength testing was normal. The Veteran had anterior instability (Lachman test) to 1+ on the right knee; however, posterior instability (posterior drawer test) and medial-lateral instability (valgus/varus) were not present. It was further noted that the Veteran had undergone a prior meniscectomy and arthroscopic surgery and had residual joint line pain and effusion due to such surgeries. At an April 2016 VA examination, the Veteran reiterated similar complaints to those recorded at the 2014 VA examinations. He also indicated that he experienced flare-ups described as decreased range of motion secondary to increased pain and functional loss/impairment related to repeated use over time described as less motion and more pain. Range of motion testing revealed right knee flexion to 120 degrees and extension to zero degrees with pain on flexion and less motion than normal that contributed to functional loss. There was also pain on weight-bearing and crepitus. There was no further limitation in range of motion or function loss/impairment following repetitive use testing. However, upon repeated use over time and flare-ups, it was noted that the Veteran reported pain, weakness, and reduced range of motion. Such limitation was not expressed in terms of degrees as such conditions were not present at the examination. Muscle strength testing was normal. There was no recurrent subluxation; however, he had occasional effusion. The Veteran had anterior instability (Lachman test) to 1+ on the right knee; however, posterior instability (posterior drawer test) and medial-lateral instability (valgus/varus) were not present. It was further noted that the Veteran had undergone a prior meniscectomy and arthroscopic surgery and had increased episodes of pain and stiffness residual to such surgeries. However, as the April 2016 VA examination did not include all relevant findings as required by Correia, supra, thereby rendering it inadequate only to the extent of such failure, the Veteran was afforded another VA examination in May 2017. At such time, it was noted that, following the Veteran’s August 2007 surgery, he had done very well without any ACL instability. He reported that his right knee hurt with running, bending, standing, or lifting. The pain was in the kneecap area only, without swelling, joint line pain, or locking. The Veteran reported flare-ups described as pain in front of the knee with lifting, bending, and climbing stairs or ladders. He indicated that he had functional loss/impairment described as taking more time and lifting less due to pain. Range of motion testing revealed right knee flexion to 130 degrees and extension to zero degrees with decreased motion due to pain on flexion that contributed to functional loss. There was also pain on weight-bearing, non-weight-bearing, and passive motion, mild localized tenderness of peripatellar pain on palpation, and crepitus. There was no further limitation in range of motion or function loss/impairment following repetitive use testing, and the examination was consistent with the Veteran’s statements describing functional loss with repeated use over time. However, the examiner could not offer an opinion as to whether pain, weakness, fatigability, or incoordination significantly limit his functional ability with repeated use over time as he was not being examined under such conditions. The Veteran’s range of right knee motion was limited to 125 degrees of flexion and zero degrees of extension during flare-ups. Muscle strength testing was normal. There was no lateral instability or recurrent subluxation, and stability testing was normal. It was further noted that the Veteran had undergone a prior meniscectomy and arthroscopic surgery, but had no residuals. Upon review of the foregoing, the Board finds a rating in excess of 20 percent for the Veteran’s patellofemoral pain syndrome of the right knee is not warranted. Specifically, such rating has been assigned pursuant to Diagnostic Code 5261 and contemplates limitation of extension to 15 degrees. Thus, in order to warrant a higher rating, extension must be limited to at least 20 degrees. Furthermore, to warrant a separate compensable rating under Diagnostic Code 5260, which contemplates limitation of flexion, flexion must be limited to at least 45 degrees. However, at no point during the appeal period has the Veteran’s extension been limited to more than 15 degrees and/or his flexion has been limited to more than 110 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Specifically, at the September 2009 VA examination, the Veteran had right knee flexion to 125 degrees and extension to zero degrees, but would experience an additional 10 to 15 degrees loss of overall range of motion secondary to repetitive activity and painful flare-up episodes. Thus, at most, the Veteran’s flexion would be limited to 110 degrees and his extension would be limited to 15 degrees. Similarly, at the January 2014 VA examination, he had right knee flexion to 135 degrees and extension to zero degrees, but would experience an additional 10 to 15 degrees loss of overall range of motion due to repetitive activity and painful flare-ups. Thus, at most, the Veteran’s flexion would be limited to 120 degrees and his extension would be limited to 15 degrees. However, at the June 2014 VA examination, the Veteran had right knee flexion to 135 degrees and extension to zero degrees, and would only experience a loss of an additional 5 degrees of extension and 10 degrees of flexion due to repetitive movement and flare-ups due to pain. Thus, at most, the Veteran’s flexion would be limited to 125 degrees and his extension would be limited to 5 degrees. Further, at the April 2016 VA examination, range of motion testing revealed right knee flexion to 120 degrees and extension to zero degrees without further limitation in range of motion or function loss/impairment following repetitive use testing. However, while the Veteran reported reduced range of motion with repeated use over time and flare-ups, such limitation was not expressed in terms of degrees as such conditions were not present at the examination. Finally, at the May 2017 VA examination, range of motion testing revealed right knee flexion to 130 degrees and extension to zero degrees, which was noted to be limited to 125 degrees of flexion and zero degrees of extension during flare-ups. Thus, based on the foregoing, the Veteran’s patellofemoral pain syndrome of the right knee resulted in extension limited to, at most 15 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, which is consistent with the currently assigned 20 percent rating under Diagnostic Code 5261. Therefore, a higher rating is under such Diagnostic Code is not warranted. Furthermore, the Veteran’s patellofemoral pain syndrome of the right knee resulted in flexion limited to, at most 110 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Thus, as such does not meet the criteria for a compensable rating under Diagnostic Code 5260, a higher or separate rating for limitation of flexion is not warranted. The Board also finds a rating in excess of 10 percent for the Veteran’s instability of the right knee is not warranted. Specifically, such rating has been assigned pursuant to Diagnostic Code 5257 and contemplates slight lateral instability or recurrent subluxation. Thus, in order to warrant a higher rating, there must be at least moderate lateral instability or recurrent subluxation. In this regard, objective stability testing performed at the September 2009 and May 2017 VA examinations were normal while such performed at the January 2014, June 2014, and April 2016 VA examinations revealed only slight, measured at +1, anterior instability with no evidence of posterior instability or medial-lateral instability. Furthermore, while he wore a brace, the Veteran denied episodes of locking or giving way at such examinations. Consequently, the Board finds that the Veteran’s instability of the right knee results in no more than slight lateral instability. Therefore, a rating in excess of 10 percent is not warranted under Diagnostic Code 5257. The Board further notes that, prior to the appeal period, the Veteran underwent a meniscectomy in August 2007. Therefore, the Board has considered the applicability of Diagnostic Code 5259, which provides a single 10 percent rating for symptomatic removal of semilunar cartilage. In this regard, the foregoing VA examinations reflects that the Veteran’s residuals of his meniscectomy include joint line pain, effusion, stiffness and limited range of motion. However, the Board finds that, to assign a separate rating under Diagnostic Code 5259 would be tantamount to pyramiding as the Veteran would be compensated twice for the same symptomatology. See 38 C.F.R. § 4.14; Esteban, supra. Specifically, under Diagnostic Code 5259, the criteria is based on symptomatic residuals, which in plain language, means the Veteran reports residuals. There is no objective findings required other than the removal of the cartilage. In the instant case, the Veteran’s reported residuals of joint line pain, effusion, stiffness and limited range of motion result in functional impairment of limited motion. In this regard, pain, effusion, and stiffness may limit the Veteran’s range of knee motion pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59. Specifically, 38 C.F.R. § 4.45 indicates that, with respect to joints, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. Moreover, pursuant to VAOPGCPREC 9-98, limitation of motion is contemplated in Diagnostic Code 5259, pertinent to the removal of the semilunar cartilage or meniscus. The opinion finds that such removal may resolve restriction of movement caused by tears and displacements of the menisci; however, the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, the opinion states that limitation of motion is a relevant consideration under Diagnostic Code 5259. Therefore, the Board finds that the Veteran’s residual joint line pain, effusion, stiffness and limited range of motion are considered in the evaluation assigned under Diagnostic Code 5261. Consequently, a separate rating under Diagnostic Code 5259 is not warranted as such would result in impermissible pyramiding. Additionally, as there is no evidence of ankylosis, dislocation of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum, Diagnostic Codes 5256, 5258, 5262, and 5263 are not for application. Moreover, while the Veteran has scars associated with his right knee disability, a separate noncompensable rating for right knee surgical scars was awarded in a March 2018 rating decision. Furthermore, as directed by the JMPR, the Board has considered whether an extra-schedular rating pursuant to 38 C.F.R. § 3.321 for the Veteran’s right knee disability is warranted. In this regard, an extra-schedular rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as “marked interference with employment” and “frequent periods of hospitalization.” Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant’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 Compensation Service to determine whether, to accord justice, the Veteran’s disability picture requires the assignment of an extra-schedular rating. Id. As noted in the JMPR and the July 2018 Board remand, the Veteran’s right knee disability results in popping and grinding, which are not explicitly contemplated by Diagnostic Code 5003-5261 or Diagnostic Code 5257. However, while the July 2018 Board remand did not address whether such was accompanied by related factors such as marked interference with employment and/or frequent periods of hospitalization, it nonetheless referred the matter to the Director of Compensation Service for extra-schedular consideration pursuant to 38 C.F.R. § 3.321. In a January 2020 advisory opinion, the Director noted that, as reported at the May 2017 VA examination, the Veteran worked as a plumber full-time without limits other than pain in the knee with running, bending, standing, and lifting, and such pain did not limit his work or activities of daily living. She further found that a review of the cumulative evidence of record supported a finding that the established schedular criteria adequately described the severity and symptoms of the Veteran’s right knee disability, and such did not present an exceptional or unusual disability picture such as marked interference with employment or frequent periods of hospitalization. Thus, she denied an extra-schedular rating for the Veteran’s right knee disability under 38 C.F.R. § 3.321. Upon a review of the evidence, the Board likewise finds that such is not warranted. Specifically, the Board finds that the Veteran’s right knee disability does not result in marked interference with employment or frequent periods of hospitalization. In this regard, the Veteran himself has not alleged that such disability results in marked interference with his work as a security guard or plumber, the positions he has held during the appeal period, or causes frequent periods of hospitalization. Furthermore, the September 2009 VA examiner found that the Veteran’s activities of daily living were unaffected by his right knee disability, he was managing his schooling adequately, and he did not have any incapacitating episodes within the prior year, even while working as a plumber. Similarly, at the January 2014 examination, it was noted that the Veteran had been working as a security officer for four years and his right knee disability did not impact his ability to work. Further, at the June 2014 VA examination, it was noted that the Veteran worked as a plumber and did well. He was able to perform all activities of daily living and the examiner found that his right knee disability did not impact his ability to work. At the April 2016 VA examination, it was observed that the Veteran worked as a plumber and, while he had knee pain off and on while working, he did not have to call in sick due to knee pain. Finally, at the May 2017 VA examination, it was again noted that the Veteran worked as a plumber full-time without limits at work or in activities of daily living. The examiner indicated that, while stairs or ladders were expected to cause pain, he was tolerating working as a plumber full-time and expected to continue. Furthermore, the record is entirely negative for any hospitalizations related to the Veteran’s right knee disability at any point pertinent to the appeal period. Thus, based on the lay and medical evidence of record, the Board finds that the Veteran’s right knee disability does not in marked interference with employment or frequent periods of hospitalization. Rather, as noted, the evidence demonstrates the Veteran has been able to maintain full-time employment as a security officer and plumber and has not been hospitalized for his right knee disability at any point during the appeal period. Thus, an extra-schedular rating pursuant to 38 C.F.R. § 3.321 is not warranted. In reaching its conclusions in the instant case, the Board acknowledges the Veteran’s belief that his right knee disability is more severe than as reflected by the current assigned disability ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than his own reports regarding the severity of his disability. The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected right knee disability; however, the evidence indicates the severity of such disability has remained stable throughout the period on appeal. Therefore, assigning staged ratings for such disability is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claim addressed herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Thus, the Board finds an increased rating for the Veteran’s service-connected right knee disability, evaluated as 20 percent disabling for patellofemoral pain syndrome and 10 percent disabling for instability, to include on an extra-schedular basis pursuant to 38 C.F.R. § 3.321, is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against such claim, the benefit of the doubt doctrine is not applicable in such regard and the Veteran’s increased rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Allison Payne The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.