Citation Nr: 0002034 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 97-17 406 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE Entitlement to an increased rating for a post operative right knee disability currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and J. M. ATTORNEY FOR THE BOARD L. McCain Parson, Associate Counsel INTRODUCTION The veteran served on active duty from October 1968 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1997 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho, which granted a 30 percent disability rating for the post operative right knee disability and assigned an effective date of July 1, 1996. The veteran filed a notice of disagreement as to the effective date assigned in July 1997. By Hearing Officer decision in February 1998, an earlier effective date of January 1, 1996 was assigned for the 30 percent rate based on VA treatment records. The record does not contain a notice of disagreement as to the January 1996 effective date assigned for the 30 percent rate, and thus, this matter is not in appellate status at this time. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). During the pendency of this appeal, the RO granted temporary total ratings following right knee surgery effective May 1997 to July 1997 and January 1998 to March 1998 returning to the 30 percent rate thereafter. See 38 C.F.R. § 4.30 (1999). In July 1997 and May 1998, the veteran sought to extend these benefits. By an October 1998 rating decision, the RO granted special monthly compensation benefits under 38 U.S.C.A. § 1114 (West 1991) for the post operative right knee disability effective May 1997 to July 1997 and January 1998 to March 1998. The veteran has not challenged this rating decision or the effective dates assigned. Therefore, these matters are not in an appellate status before the Board. See Grantham, supra. Additionally, the Board observes that a review of the evidence of record appears to have reasonably raised the issue of entitlement to service connection for post surgical scars of the right knee. As this claim has not been developed for appellate review, it is referred to the RO for appropriate action. See Suttman v. Brown, 5 Vet. App. 127, 132 (1993). Effective March 1, 1999, the United States Court of Veterans Appeals changed its name to the United States Court of Appeals for Veterans Claims (hereinafter, "the Court"). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this claim has been obtained by the RO. 2. The postoperative right knee disability is characterized by anterior cruciate ligament repair x 4, chronic strain, and severe impairment of the right knee, history of instability, and history of wearing of a long leg hinged knee brace. 3. The post operative right knee disability is also manifested by objectively confirmed pain and limitation of motion of the right knee joint, with x-ray findings of moderate degenerative joint disease of the medial knee compartment. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 30 percent for a post operative right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.71, 4.71a, Diagnostic Code (DC) 5257 (1999). 2. Resolving all reasonable doubt in favor of the veteran, the criteria for a separate 10 rating for degenerative joint disease of the right knee, as a residual of the post operative right knee disability, have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.25(b), 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5010, 5261 (1999); VAOPGCPREC 23-97 (July 1, 1997); VAOPGCPREC 9-98 (August 14, 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board notes that the provisions of 38 U.S.C.A. § 5107 have been met, in that the claim is well-grounded and adequately developed. This finding is based on the veteran's evidentiary assertion that his service-connected disability has increased in severity. See Drosky v. Brown, 10 Vet. App. 251, 254 (1997) (citing Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992)). No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). I. Pertinent Law and Regulations Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. The primary focus in rating disabilities is on functional impairment. See 38 C.F.R. § 4.10. 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. In particular, 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. See 38 C.F.R. § 4.40 (1999). The provisions of 38 C.F.R. §§ 4.45 and 4.59 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the VA Schedule for Rating Disabilities to recognize actually painful, unstable, or mal-aligned joints, due to healed injury, as at least minimally compensable. See 38 C.F.R. §§ 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995) (functional loss due to pain "on use or due to flare-ups). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability therefrom, and above all, coordination of the rating with impairment of function will be expected in all cases. See 38 C.F.R. § 4.21 (1999). Disabilities of the knee and leg are rated in accordance with 38 C.F.R. § 4.71(a), Diagnostic Codes (DCs) 5256 through 5263. The range of motion of these joints is provided at 38 C.F.R. § 4.70, Plate II (1999). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. See 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31, 35 (1999) (All relevant and adequate medical data of record that falls within the scope of the increased rating claim should be addressed). With these regulations and the Court's precedent in mind, the Board provides the following history and evaluation of the service-connected right knee disability within the scope of this appeal. Service connection is not in effect for the left knee. II. Factual Background VA treatment records dated between January 1996 and October 1996 reflect that the veteran underwent anterior cruciate ligament repair in 1990 and 1991 with cadaver grafts. He sustained a twisting injury in January 1996. On evaluation in January, there was mild tenderness to palpation of the lateral and medial knee distally and to the anterior shin proximally. Thereafter, the right knee was grossly unstable on Lachman's test to anterior posterior stress. The veteran was wearing a knee brace to get around. The magnetic resonance imaging (MRI) reflects marginal osteophyte formation of the bone and moderate sized joint effusion and that the anterior cruciate ligament repair had completely disappeared. The report of the October 1996 VA examination reflects that he could weight bear, but it hurt. He complained that "the legs go out." The knee was minimally swollen at the subpatellar level. There were multiple scars involving all quadrants of the right knee area. They were well healed and non-keloid. The joint was tender, particularly about the subpatellar area. Flexion of the knee was painful at 110 degrees and extension was comfortable at 0 degrees. There was laxity of the joint with a positive Lachman's test, which was not affected by anxiety. The diagnosis was chronic strain, post multiple surgeries, right knee, severe impairment. The October 1996 social and industrial survey reflects that the veteran has had difficulty in securing and maintaining employment due to physical and mental symptoms. He did report losing employment due to a job related knee injury. VA treatment records for the period of November 1996 to February 1997 reflect a history of discomfort with catching and instability of the knee. He continued to have multiple problems with his back and knee, which was affecting his sleep. The MRI obtained in September 1996 demonstrated no evidence of an anterior cruciate ligament and no medial meniscus. The veteran complained of pain in the right anterior aspect of the knee joint. His examination was significant for anterior cruciate ligament/ anterior posterior instability with ambulation. The instability could not be produced on examination. Muscle strength of the quadriceps and hamstrings was 5/5. He was fitted with an unweighting thigh corset lacer to help stabilize and off weight the knee. A physician noted in November 1996 that given the unlikelihood of surgical intervention, this may provide the best non surgical symptomatic improvement. The brace was described as being made from stainless steel. The brace has drop locks and a caliper type stirrup. The thigh section is made of leather and it is molded. The molded leather thigh section extends distally to around the knee, for stability and unloading. He is walking with the knee locked. The hinged brace helped with the pain. The gait was circumducted. X-ray studies of the right knee reflect moderate medial knee compartment narrowing and osteophytosis that are consistent with moderate degenerative joint disease. VA treatment records dated from May 1997 to June 1997 reflect left anterior cruciate ligament deficiency. The veteran underwent revision of the right anterior cruciate ligament reconstruction with hamstring graft - knee arthroscopy/ surgery for failed right anterior cruciate ligament reconstruction x 2. The veteran reported marked instability of his right leg, which limited his ability to work. The clinical findings were that the knee was grossly unstable with a Grade III pivot shift. Arthroscopy demonstrated no abnormalities in the subpatellar pouch or other patellofemoral joint. The medial compartment demonstrated evidence of early osteoarthritis with some osteochondritis dissecans of the medial femoral condyle. Examination of the notch demonstrated marked scarring with a markedly attenuated posterior collateral ligament. Exuberant scar tissue was noted in the distribution of the anterior cruciate ligament without the presence of a reconstructed ligament. On discharge, the right lower extremity manifested surgical scars about the medial and the lateral joint line with tenderness and crepitance on range of motion. He had no endpoint on Lachman testing. The right knee was stable to varus and valgus stress. He was placed in a hinged knee immobilizer blocking 15 degrees of terminal extension that he would wear for six weeks. The May 1997 x-ray study of the right knee reflects post operative changes with mild to moderate degenerative change. The discharge instructions reflect no pivoting, twisting, or planting for 12 weeks with weight bearing as tolerated to the right lower extremity. All exercises/ activities were to be performed in the brace, which limited the right knee range of motion to 15-120 degrees. A June 1997 physical therapy note reflects that active range of motion of the right knee was 14 to 99 degrees, that the range of motion was limited to 15-120 degrees by long leg hinged brace, and that he used a stationary bicycle. He was medicated for his pain. A June 1997 request for a second opinion regarding back pain reflects that the veteran sleeps in a chair because of his back pain. Testimony from the July 1997 personal hearing reflects that the wearing of the postoperative demobilizer is like having ankylosis of the knee. He asserts that his knee is ankylosed. He is unable to bend his knee. He has worn a rotation brace [on the right knee] for 19 years to keep the [knee] locked in place. He testified that the joint was not aligned and resulted in crushing tissue between the bone [causing] shooting pains. He is not supposed to put his foot down with weight, or to perform twisting or pivoting motions. He is undergoing physical therapy to improve his range of motion. His right knee has stopped him from any kind of work since January 1996. VA treatment records dated between August 1997 and November 1997 reflect that the veteran was no longer using a crutch and was hobbling around with a hinged long leg right knee brace. Isometrics caused severe back pain and he could not do more serious physical therapy for his knee. He was approved for less supervised pool therapy. Range of motion was 0-110 degrees. There was a Grade I Lachman with firm end point. In mid -November, he was very active. He pivoted quickly and felt pain. On examination, the right knee manifested some effusion. The anterior cruciate ligament was lax with an anterior drawer and Lachman's but with a definite endpoint. The veteran had a lot of apprehension type guarding with range of motion. He was sleeping in a chair because the whole lower half of his body hurt. A CAT scan of the lumbar spine revealed no evidence of nerve compression. Serial examinations in December 1997 reflect that range of motion of the knee was between 0-100 degrees and 0-110 degrees. There was a positive McMurray, a stable Lachman, a negative pivot, and positive medial and lateral joint line tenderness. The assessments included right knee status post anterior cruciate ligament repair, recent pivoting type strain - probable knee strain, increased laxity "?", and possible meniscal tear. He was medicated for the pain. VA treatment records dated between January 1998 and February 1998 reflect that the veteran underwent a right knee arthromeniscectomy/ knee arthroscopy in January 1998 for right knee medial and lateral meniscal tears. Prior to arthroscopy, his range of motion was characterized as full. The post operative note reflects that the veteran had been doing well until he sustained a minor twisting injury and complained of once again experiencing pain, swelling, as well as mechanical symptoms of popping, locking, and catching, as well as effusions. The clinical findings on arthroscopy included 1) Grade II-IV chondromalacia in the medial and lateral compartment; 2) a Grade IV lesion in the trochlea with sparing of the patella; 3) a large degenerative tear of the lateral portion of the anterior horn with degenerative changes; 4) a small degenerative tear of the posterior horn of the lateral meniscus which was unstable; 5) no loose bodies in the suprapatellar or medial or lateral gutters; and 6) that the anterior cruciate ligament graft appeared functional upon Lachman testing under direct vision. There was no graft impingement when the knee was brought into full extension. The arthroscopy report reflects that after the procedure there was no meniscus displaced into the joints. The discharge instructions reflect 1) minimize physical activity, 2) use crutches as needed, 3) weight bearing as tolerated, and 4) keep ace wrap on the knee for 1-2 days without reference to a knee brace. Right knee range of motion in February 1998 was 5 to 85 degrees with pain. There were no symptoms of infection. The surgical site was healing well. The right lower extremity was stable to varus and valgus stress. The assessment was scarring in the right knee, status post multiple procedures, no sign of infection, and healing ongoing. A February 1998 physical therapy referral refects a request for range of motion, quadriceps strengthening, scar massage, and modalities as appropriate for the right knee. The report of the VA examination for post traumatic stress disorder conducted in June 1998 reflects that the veteran walked with a cane and that he was unemployable based on his PTSD symptoms. III. Analysis Currently, the veteran's right knee disability is evaluated as a single disability under 38 C.F.R. § 4.71a, DC 5257. This regulatory provision authorizes the VA to assign a schedular rating for other impairment of the knee, including recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a. Notably, however, the evidence of record in this case reflects other manifestations of the right knee disability, degenerative joint disease. See 38 C.F.R. § 4.71a, DCs 5003-5010. Although evaluating the same disability or the same manifestations of a service-connected disability under different diagnoses is to be avoided, separate disability ratings are possible in cases in which the veteran has separate and distinct manifestations of the same injury. See 38 C.F.R. §§ 4.14, 4.25(b) (1999); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The critical element is that none of the symptomatology for the disability is duplicative or overlapping with the symptomatology of the other disability. Id. Moreover, the General Counsel of the Department of Veterans Affairs issued a precedent opinion, dated July 1, 1997, concerning multiple ratings for knee disability. In that precedent opinion, the VA General Counsel held that a separate rating under DC 5003 for arthritis may be assigned for a knee disorder already rated under DC 5257 for instability (and vice versa), where additional disability is shown by the evidence of record. See VA O.G.C. Prec. 23-97, slip op. at 2-3 (July 1, 1997) (concluding that the evaluation of knee dysfunction under both DC 5257 and 5003 does not constitute impermissible pyramiding under 38 C.F.R. § 4.14 (1996), citing Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994)). In determining whether additional disability is shown, for purposes of a separate rating, the veteran must meet, at minimum, the criteria for a noncompensable rating under either of those codes. Otherwise, "there is no additional disability for which a rating may be assigned." Id. at slip op. at 3. The Board is bound by this regulatory construction of 38 C.F.R. § 4.71a, which authorizes multiple ratings under Diagnostic Codes 5003 and 5257. With these considerations in mind, the Board will address whether the veteran is entitled to not only an increased disability rating as regards the right knee disability, but also whether separate ratings are warranted for the service- connected right knee disability. A. Other impairment of the right knee Under DC 5257, other impairment of the knee, including recurrent subluxation or lateral instability, is rated as slight, moderate, or severe. A 30 percent disability rating is warranted for severe impairment. See 38 C.F.R. § 4.71a. This is the maximum allowable benefit under this Diagnostic Code. At the outset, the Board observes that DC 5257 provides for the rating of recurrent subluxation and instability of the knee without reference to limitation of motion, and; therefore, the provisions of 38 C.F.R. §§ 4.40 and 4.45, with respect to pain, do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996); see also VA O.G.C. Prec. 23-97 (July 1, 1997); VA O.G.C. Prec. 9-98 (August 14, 1998). In pertinent part, the evidence of record reflects several twisting injuries to the right knee that resulted in acute symptoms, surgical intervention, and rehabilitation. VA treatment records reflect that the post operative right knee disability is characterized by multiple repairs of the anterior cruciate ligament, chronic strain, instability, the wearing of a long leg hinged knee brace, and severe impairment of the right knee. The most recent clinical evidence reflects not only a repair of the medial and lateral meniscus, but that no loose bodies in the suprapatellar or medial or lateral gutters were noted on arthroscopy and that the anterior cruciate ligament graft appeared functional upon Lachman testing under direct vision. There was no graft impingement when the knee was brought into full extension. The arthroscopy report reflects that after the procedure there was no meniscus displaced into the joints. The Board observes that the January 1998 post operative discharge instructions reflect use crutches as needed and weight bearing as tolerated without reference to a knee brace or ankylosis. It is apparent that the knee was functional because not only was the veteran discharged with only an ace wrap dressing the surgical site, but weight bearing and ambulation were encouraged. The Board acknowledges that there was pain with range of motion in February 1998 and that the convalescent range of motion was 5 to 85 degrees. Therefore, the Board finds it reasonable to conclude that the totality of the pertinent medical evidence of record is reflective of severe impairment of the right knee to warrant the present 30 percent rating under DC 5257. As noted above, the maximum disability rate under DC 5257 is 30 percent. B. Degenerative joint disease of the right knee On complete review of the evidence of record, the Board observes that the veteran's degenerative joint disease of the right knee demonstrates an additional ratable disability beyond that of subluxation or instability. As noted above, a separate rating is warranted where a disability presents with separate and distinct manifestations. See Esteban v. Brown, supra; VA O.G.C. Prec. 23-97. Under DC 5010, traumatic arthritis is to be evaluated under DC 5003, which in turn, provides that degenerative (hypertrophic or osteoarthritis) arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, limitation of motion of the specific joint involved is non-compensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint group or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a. Under DC 5260, a zero percent rating is warranted for flexion of the leg that is limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. For a 20 percent rating, flexion must be limited to 30 degrees. See 38 C.F.R. §§ 4.71, 4.71a, DC 5260, Plate II (1999). Under DC 5261, a zero percent rating is warranted where extension of the leg is limited to 5 degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. See 38 C.F.R. §§ 4.71, 4.71a, DC 5261, Plate II (normal knee extension and flexion ranges from 0 to 140 degrees, respectively). When the medical evidence is evaluated under the VA's Schedule for Rating Disabilities it is apparent that the veteran is not entitled to a compensable disability rating based on limitation of motion of the right knee under DCs 5260 or 5261. Between October 1996 and January 1998, the veteran's range of motion was reported as ranging from 0 to 100 degrees to full range of motion except in June 1997 and February 1998, the convalescent periods. The most recent clinic evaluations in February 1998 and June 1998 reflect that the veteran's range of motion was 5 to 85 degrees during his convalescence and that he walked with a cane. On review of this evidence, the 85 degrees of flexion does not warrant a non-compensable disability rating under DC 5260. However, leg extension limited to 5 degrees would entitle the veteran to a non-compensable rating. See 38 C.F.R. §§ 4.71, 4.71a, DCs 5261, Plate II; VA O.G.C. Prec. 23-97 (July 1, 1997). The evidence of record, as demonstrated by VA treatment, indicates that in the presence of mild to moderate degenerative joint disease of the right knee, there is also satisfactory evidence of painful motion. According to 38 C.F.R. § 4.59, it is the intent of the Schedule for Rating Disabilities to recognize actually painful joints due to a healed injury as being entitled to at least the minimum compensable rating for the joint. Therefore, in view of the foregoing, the Board determines that a 10 percent rating is warranted for objectively confirmed limitation of motion of the right knee, based on x-ray evidence of degenerative joint disease, and objective evidence of painful motion involving the right knee. See 38 C.F.R. §§ 4.59, 4.71a, DC 5010-5003; Hicks v. Brown, 8 Vet. App. 417, 420 (1995). As such, this evidence creates a question as to the most appropriate rating for the veteran's degenerative joint disease of the right knee. See 38 C.F.R. § 4.7. Considering the objective findings of painful motion and resolving all reasonable doubt in favor of the veteran, the Board finds that the symptomatology associated with the veteran's degenerative joint disease of the right knee more nearly approximates that of a 10 percent rating under DCs 5010-5003 (as contemplated by the criteria of DC 5261 for limitation of extension). See generally DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59. At this juncture, the Board acknowledges the fact that prior to the January 1998 arthromeniscectomy, the veteran wore a knee brace that limited extension and flexion. However, not only has the veteran not been diagnosed as having ankylosis of the right knee joint to warrant a higher rating under DC 5256 for ankylosis, but the post surgical evidence of record does not reflect the use of any prosthesis other than a cane. Since extension of the right knee is not limited to 15 degrees or flexion limited to 30 degrees to warrant a 20 percent rating under DCs 5260 or 5261, the Board finds that the veteran's degenerative joint disease of the right knee is appropriately rated as 10 percent disabling under DCs 5010- 5003. C. Other considerations Pursuant to 38 C.F.R. § 3.321(b)(1) (1999), an extra- schedular rating is in order where there exists such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization [due exclusively to service- connected disability] such as render impractical the application of the regular schedular standards. The test is a stringent one for, the Court has held, "it is necessary that the record reflect some factor which takes the claimant outside of the norm of such veteran. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough." See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). According to the pertinent provision, the evidence of record reflects not only that the veteran suffers from a post operative right knee disability with instability and degenerative joint disease, but also back strain and PTSD which are service-connected. The July 1997 personal hearing transcript aggregated with VA treatment records reflect that conditions other than the right knee disabilities have interfered with his employment. As such, the Board cannot conclude that interference with the veteran's employment has been due exclusively to the service-connected right knee disabilities. The Board does acknowledge that the right knee surgeries with convalescent periods would interfere with any employment efforts. In that regard, the veteran did receive temporary total ratings during each 2-month convalescent period. Thus, the record thereafter does not reflect interference with the veteran's employment status to a degree greater than that contemplated by the regular schedular standards (which are based on the average impairment of employment, due to loss of working time from exacerbations or illness proportionate with the severity of the several grades of disability). See 38 C.F.R. §§ 4.1, 4.10. Nor does it reflect frequent periods of hospitalization because of the service-connected right knee disability. Therefore, the record does not present such an exceptional case where the separate disability ratings currently assigned for the veteran's right knee disability (i.e., instability and degenerative joint disease) are found to be inadequate. See Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. at 363 (noting that the disability evaluation itself is recognition that industrial capabilities are impaired). In the absence of factors establishing an exceptional or unusual disability picture, the Board determines that the criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An increased rating in excess of 30 percent for a post operative right knee disability is denied. A separate 10 percent rating for degenerative joint disease of the right knee, as a residual of the post operative right knee disability, is granted, subject to the applicable laws and regulations concerning the payment of monetary benefits. Deborah W. Singleton Member, Board of Veterans' Appeals