Citation Nr: 0006887 Decision Date: 03/14/00 Archive Date: 03/17/00 DOCKET NO. 95-08 500 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial compensable evaluation for limited motion of the right knee secondary to surgery from November 14, 1991 to April 13, 1999, and in excess of 30 percent on and after April 14, 1999. 2. Entitlement to an initial compensable evaluation for postoperative status subtotal gastrectomy for chronic peptic ulcer disease from November 14, 1991 to October 29, 1999, and in excess of 40 percent on and after October 30, 1997. REPRESENTATION Veteran represented by: James W. Stanley, Jr., Attorney WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD Maureen A. Young, Associate Counsel INTRODUCTION The veteran had active military service from January 22, 1991 to November 13, 1991. He also served on active duty for training and inactive duty training in the Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 1993 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Little Rock, Arkansas. The RO granted entitlement to service connection for limited motion of the right knee secondary to surgery with assignment of a 10 percent evaluation effective from November 14, 1991, and for postoperative status, subtotal gastrectomy for chronic peptic ulcer disease, aggravated by active duty, with assignment of a noncompensable evaluation effective from November 14, 1991. The RO determined that the veteran's gastrointestinal disability was productive of impairment to a degree of not more than 20 percent prior to entrance onto active duty. By rating action dated in October 1999 the RO granted service connection for depression and assigned a 30 percent evaluation effective March 21, 1996. This was a full grant of the benefit sought. If the veteran disagrees with the evaluation or the effective date assigned for his service- connected depression, he must submit a notice of disagreement to the RO. See Grantham v. Brown, 114 F.3d (Fed. Cir. 1997). In October 1999 the RO granted entitlement to a total disability rating for compensation purposes on the basis of individual unemployability (TDIU). This was a full grant of the benefit sought by the veteran. Therefore, the issue of entitlement to a TDIU is not before the Board for appellate review. See Mintz v. Brown, 6 Vet. App. 277 (1994) (the Board does not have jurisdiction to review a case if no benefit would accrue to the claimant). In addition, in October 1999, the RO denied eligibility to dependents' educational assistance as the evidence did not show that the veteran currently has a total service-connected disability, permanent in nature. A notice of disagreement with this rating action has not been filed. Therefore, the issue of dependents' educational assistance is not before the Board for appellate review. In February 1993 and December 1997 the Board remanded, inter alia, the issues of a right knee disability and postoperative status subtotal gastrectomy for chronic peptic ulcer disease for further development. These cases were returned to the Board for further appellate review. In October 1999 the RO increased the disability ratings for limited motion of the right knee secondary to surgery to 30 percent effective April 14, 1999 and postoperative status subtotal gastrectomy for chronic peptic ulcer disease to 40 percent effective October 30, 1997, as the maximum allowable benefit in these instances have not been awarded the Board will proceed with an appellate review of these issues. At the October 1999 hearing, the veteran submitted a letter from his private physician to the Board for consideration and waived (via written notice) initial review of such document by the RO. FINDINGS OF FACT 1. The right knee disability was productive of not more than slight impairment from November 14, 1991 to April 13, 1999. 2. The right knee disability was productive of not more than severe disablement from April 14, 1999. 3. The veteran's postoperative status subtotal gastrectomy for chronic peptic ulcer disease has been productive of not more than severe disablement since November 14, 1991. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent from November 14, 1991 to April 13, 1999, and in excess of 30 percent on and after April 14, 1999 for limited motion of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (1999). 2. The criteria for an initial compensable evaluation of 40 percent for postoperative status subtotal gastrectomy for chronic peptic ulcer disease from November 14, 1991 have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.322, 4.1, 4.7, 4.20, 4.110, 4.114, Diagnostic Code 7308 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Right Knee Disability The veteran served in the United States Army Reserves for approximately 14 years before entering active duty in January 1991. In May 1990, the veteran was not in the line of duty when he sustained a fracture to his right acetabulum and right femur as a result of a motor vehicle accident. The right femur fracture was treated with intramedullary (IM) nail. Subsequently, he had a malunion of his right femur fracture with external rotation of the distal femur. Upon examination of his right lower extremity, he had approximately 105 degrees of external rotation and approximately -15 degrees of internal rotation. In November 1990 the veteran underwent removal of the right femoral nail and three hip screws with IM rotational osteotomy mid shaft femur, and placement of IM Grosse-Kemp nail with distal and proximal interlocking screws. Rotation of his right lower extremity was confirmed at 60 degrees of external rotation and 45 degrees of internal rotation, indicating a correction of approximately 45 degrees. X-rays of the right knee taken in February 1991 showed evidence of osteopenia secondary to immobilization or limited exercise. There was no fracture, joint effusion or any other bone pathology of the knee. X-ray of the right knee, in March 1991, showed some demineralization present around the knee area. While on active duty, in March 1991, the veteran underwent an undynamizing procedure to remove the screws of a distal interlocking IM nail. In April 1991 he was examined for the purpose of a Medical Board evaluation. On physical examination, he had well-healed surgical scars in the area of the left hip and right distal thigh. He had a range of motion, which was normal in his hips and his knee. There was mild atrophy and a 1/2 inch shortening noted on the right side. The diagnosis was status post fracture of the left hip and fracture of the right femur with open reduction internal fixation. It was recommended that he be found unfit because his medical condition precluded the satisfactory performance of duty. In June 1991, records of the physical therapy clinic indicated that the veteran was rechecked after removal of the hardware and his range of motion in his hips and knees was equal. The diagnosis was status post hardware removal. On examination in August 1991 the veteran had normal range of motion of the right knee without pain. Examination report dated in August 1992 showed range of motion of 0 to 100 degrees in the right knee. At his personal hearing in September 1992 the veteran testified that after he entered active duty, he started experiencing problems with his leg. He said his knee would buckle if he picked up a duffel bag. He testified that a doctor told him that surgery could be performed to remove the interlock from his leg. After the surgery was performed, the veteran stated that he started having constant pain. Hearing Transcript (Tr.), p. 4. He further testified that he had to use a cane to walk because his knee would give away. Tr., p. 5. VA Medical Center (MC) examination in January 1994 revealed that the veteran had right knee pain. On examination, he had full internal and extended external rotation of the leg. There was no rotational deformity. At his personal hearing in June 1994 the veteran testified that his knee locks approximately 20 to 50 times within a week. Tr., p. 1. He further testified that his knee swells about every other day. He stated that he cannot stick his knee out straight nor can he fold it back. Tr., p. 2. He further stated that he wears a brace everyday. Tr., p. 3. The veteran underwent VA orthopedic examination in December 1994. On examination, the physician noted that the veteran has an obvious internal rotation deformity of the femur, causing the right leg to be internally rotated. The veteran's knee, when fully extended and flexed to 135 degrees was equal on both sides. All ligaments of the knee were intact and nontender to stress. There was no tenderness to palpate about the knee. There was no effusion, redness, or swelling. Lachman and Mcmurray were with normal limits. There was internal rotation of 90 degrees on the right lower extremity and external rotation of 40 degrees, whereas on the left there was 70 degrees of external rotation and 40 degrees of internal rotation. X-ray of the knee in the anterior-posterior and lateral projection demonstrated the joint surface to be intact. There was no arthritis or other changes and no loose bodies. It was further noted that the veteran has some internal rotation of the right lower extremity as a result of the fractures. The knee was normal, and there was no permanent impairment of the knee. Progress notes in October and November 1995 show that the veteran had complaints of knee pain. In November 1995 he was diagnosed with knee pain. Examination at VA hospital on April 14, 1999 revealed that the veteran walks with a stiff knee gait on the right. He used a cane in the left hand, which takes most of the weight off the right lower extremity. It was noted that he had a halting, limping gait. It was further noted that he complains on weight bearing of pain about the right knee. It was revealed that the veteran has a ten-degree lag in extension, which can passively be overcome on the right knee. From that position he can flex to an angle of 55 degrees. It was noted that the veteran was extremely apprehensive, even when the knee is lightly palpated. There was no evidence of knee joint effusion. Stress testing of the knee joint supportive ligaments was not completed as it induced pain and the examination was stopped. Multiple films of the right knee revealed that the veteran had a medullary nail in position. The knee joint had no evidence of pathological process. The diagnosis was partial ankylosis of the right knee, secondary to effects of trauma. The physician noted that the veteran does not have a knee joint effusion, which would indicate low-grade inflammatory process outside of the joint, but still related to the femoral fracture. He further noted that a normal range of motion for the veteran's age group is 0 to 140 degrees. The veteran's restricted range of motion created a marked functional loss in limitation due to pain. At his personal hearing in October 1999, the veteran testified that on a scale of 1 to 10, the level of pain he experiences in his right knee is about a 7 or 8. He further stated that his knee feels like it's popping and it becomes unstable or lax and causes him to fall. Tr., p. 10. Submitted was current correspondence from a private physician noting treatment of the veteran for severe right knee symptomatology. Postoperative Status, Subtotal Gastrectomy for Chronic Peptic Ulcer Disease In November 1989, prior to entering active duty, the veteran was diagnosed with intractable peptic ulcer disease (chronic peptic ulcer disease with acute exacerbation and upper gastrointestinal bleeding). He underwent truncal vagotomy, hemigastrectomy, and gastrojejunostomy. VA examination of the veteran's digestive system was conducted in May 1993. The veteran reported that he started having problems with heartburn, gas, and epigastric distress and weight instability after he entered active duty. He also reported that he eats three meals a day. He did not complain of diarrhea. He stated that he is occasionally constipated and occasionally vomits. Since his surgery, he has not complained of hematemesis or melena. He stated that when he is under stress, he has more problems with gas and heartburn. On examination, there was no evidence of enlargement of the liver or spleen. There was no evidence of abdominal tenderness or mass. There were no symptoms of a dumping syndrome. The diagnosis was postoperative status, subtotal gastrectomy for chronic peptic ulcer disease, aggravated by active duty during the Desert Storm crisis. At his personal hearing in June 1994, the veteran testified that he has a dumping syndrome; when he eats, it comes back up. He further testified that he passes blood through his mouth approximately three times a month and through his stools regularly. Tr., p. 5. Examination by VA in December 1994, revealed that the veteran, on occasion, has noted some blood in his stools. He continued to take Cimetidine (Tagamet) for the control of those symptoms. He stated that his weight is essentially stable. The physician noted moderate tenderness in the epigastrium. There was no visceromegaly or mass identified. The veteran's bowel sounds were felt to be normally active. The diagnosis was residuals of surgery for complications of peptic ulcer disease. The veteran's physician, Dr. H.J., in a May 1995 letter wrote that the veteran was recently hospitalized and diagnosed with small bowel obstruction and obstruction of the afferent loop. He further noted that the veteran underwent surgeries consisting of gastrojejunostomy, resection for gastric outlet obstruction, small and bowel resection. The physician stated that the veteran was physically unable to work and to engage in any substantial gainful activity because he is 100 percent physically disabled. On October 30, 1997 the veteran was seen at VAMC for increased symptoms of reflux, heartburn, epigastric pain and episodes of bloody stools. The last bloody stool was approximately two months earlier. The veteran had nausea. He denied having fever, chills, weight loss, anorexia, diarrhea, or constipation. At his personal hearing in December 1998 the veteran testified that he is currently anemic. He stated that he was told that he has had so many surgeries on his stomach that his body will not create iron. Tr., p. 15. He further stated that he takes medication for his ulcers and they cause him discomfort. The veteran testified that he has such symptoms as nausea and constipation. Tr., p. 16. He further testified that he has a problem keeping down spicy foods. He stated that he infrequently coughs-up blood. Tr., p. 17. Progress notes in June 1998 revealed that the veteran complained of severe pain. He reported that he had not seen any blood in his stools. He was diagnosed with peptic ulcer disease. Progress notes dated in November 1998 indicated that the veteran was on iron replacement and he was no longer anemic. The veteran complained of having hard stools. He was diagnosed with iron deficiency anemia most likely secondary to gastrectomy and constipation secondary to iron treatment. VA examination in March 1999 revealed that the veteran infrequently has constipation and occasionally has diarrhea. He stated that some days may pass without him being bothered with his stomach, but most days he has some nausea, which usually occurs after meals. He further stated that his weight fluctuates within a 10 to 15 pound range. The diagnosis was postoperative status, subtotal gastrectomy for chronic peptic ulcer disease, with subsequently iron deficiency anemia, currently on iron therapy. The physician noted that the veteran has significant problems with ulcer disease. However, at the time of the examination, the veteran's ulcer condition was stable. The physician further noted that in his clinical judgment, the veteran's ulcer problem does not preclude gainful employment. At his personal hearing in October 1999 the veteran testified that he is taking an iron building medication and medication for his peptic acid ulcer disease. He further testified that he has symptoms of bloating, diarrhea and nausea. Tr., pp. 3-4. Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (1999). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. §4.2 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). When an unlisted condition is encountered it will be 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. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (1999). 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. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (1999). The United States Court of Appeals for Veterans Claims (Court) has held that an appellant may not be compensated twice for the same symptomatology as "such a result would overcompensate the appellant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). 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 evaluations 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 extra-schedular evaluation 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) (1999). Right knee disability The Rating Schedule provides a compensable rating for impairment of the knee when there is evidence of slight (10 percent), moderate (20 percent), or severe (30 percent) recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999). The words "slight," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that the use of terminology such as "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (1999). A 10 percent evaluation may be assigned for limitation of flexion of a leg to 60 degrees, 10 percent to 45 degrees, 20 percent to 30 degrees, and 30 percent to 15 degrees. 38 C.F.R. § 4.71a; Diagnostic Code 5260. A 10 percent evaluation may be assigned for limitation of extension of a leg to 10 degrees, 20 percent to 15 degrees, 30 percent to 20 degrees, 40 percent to 30 degrees, and 50 percent to 45 degrees. 38 C.F.R. § 4.71a; Diagnostic Code 5261. Under 38 C.F.R. § 4.71a, Diagnostic Code 5256, knee ankylosis, if extremely unfavorable, in flexion at an angle of 45 degrees or more, is assigned a 60 percent disability evaluation; if in flexion between 20 degrees and 45 degrees, 50 percent is assignable; if in flexion between 10 degrees and 20 degrees, 40 percent is assignable. When at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees, 30 percent is assignable. Id. 38 C.F.R. § 4.71, Plate II, indicates that normal range of motion for the knee in a sitting position is from 0 degree extension to 140 degrees flexion. As regards the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight- bearing are related considerations. 38 C.F.R. § 4.45 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology, and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (1999). In cases of evaluation of orthopedic injuries there must be adequate consideration of functional impairment including impairment from painful motion, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.10, 4.40, 4.45, and 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). In cases of functional impairment, evaluations are to be based upon lack of usefulness, and medical examiners must furnish, in addition to etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, a full description of the effects of the disability upon the person's ordinary activity. 38 C.F.R. § 4.10 (1999). The General Counsel for VA issued a precedent opinion in July 1997, which held that a claimant who had arthritis and instability of the knee may be, rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97. When the knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion which at least meets the criteria for a zero percent rating under Diagnostic Codes 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating if arthritis is clinically demonstrated. In August 1998, VA General Counsel issued VAOPGCPREC 9-98. In this opinion, General Counsel, citing Lichtenfells v. Derwinski, 1 Vet. App. 484, 488 (1991), held that even if the claimant technically has full range of motion but the motion is inhibited by pain, a compensable rating for arthritis under Diagnostic Code 5003 and § 4.59 would be available, assuming of course that arthritis is clinically demonstrated. Degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when 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 major joint affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71(a), Diagnostic Code 5003 (1999). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (1999). Postoperative Status Subtotal Gastrectomy for Chronic Peptic Ulcer Disease Service connection is presently in effect for postoperative status subtotal gastrectomy for chronic peptic ulcer disease, which has been assigned a 40 percent disability evaluation. 38 C.F.R. § 4.110 provides that experience has shown that the term ``peptic ulcer'' is not sufficiently specific for rating purposes. Manifest differences in ulcers of the stomach or duodenum in comparison with those at an anastomotic stoma are sufficiently recognized as to warrant two separate graduated descriptions. In evaluating the ulcer, care should be taken that the findings adequately identify the particular location. Id. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code, which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114 (1999). Post-gastrectomy syndrome productive of severe functional limitation or disability, associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia warrants a 60 percent rating. Moderate functional impairment, with less frequent episodes of epigastric disorders and with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss is evaluated as 40 percent disabling. Mild functional impairment, with infrequent episodes of epigastric distress and with characteristic mild circulatory symptoms or continuous mild manifestations warrants a 20 percent rating. 38 C.F.R. § 4.114, Diagnostic Code 7308 (1999). For a marginal (gastrojejunal) ulcer a 10 percent evaluation is warranted where there are mild symptoms with brief episodes of recurring symptoms once or twice yearly. A 20 percent evaluation is warranted where for a moderate gastrojejunal ulcer with episodes of recurring symptoms several times per year. A 40 percent evaluation is warranted where there are moderately severe symptoms with intercurrent episodes of abdominal pain at least once a month partially or completely relieved by ulcer therapy, mild and transient episodes of vomiting or melena. A 60 percent rating contemplates severe symptoms, which are the same as pronounced with less pronounced and less continuous symptoms with definite impairment of health. Finally, a 100 percent rating contemplates pronounced symptoms with periodic or continuous pain unrelieved by standard ulcer therapy with periodic vomiting, recurring melena or hematemesis, and weight loss. Totally incapacitating. 38 C.F.R. § 4.114, Diagnostic Code 7306 (1999). Examination reports must be interpreted in light of the whole-recorded history of the disabling condition. Various reports should be reconciled into a consistent picture so that the current rating may accurately reflect the elements of disability present. Each disability must be considered from the point of view of the veteran working or seeking work. If a diagnosis is not supported by the findings on the examination report or if the report does not contain sufficient detail the report must be returned as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (1999). (a) Aggravation of preservice disability. In cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree of disability existing at the time of entrance into active service, whether the particular condition was noted at the time of entrance into active service, or whether it is determined upon the evidence of record to have existed at that time. It is necessary to deduct from the presented evaluation the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule except that if the disability is total (100 percent) no deduction will be made. If the degree of disability at the time of entrance into service is not ascertainable in terms of the schedule, no deduction will be made. 38 C.F.R. § 3.322 (1999). The evaluation of the level of disability is to be 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). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt doctrine in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis The Board notes that the veteran's claims for a right knee disability and postoperative status, subtotal gastrectomy for chronic peptic ulcer disease are "well-grounded" within the meaning of 38 U.S.C.A. § 5107; that is, his claims are plausible. Murphy, supra. In general, an allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of his disabilities (that are within the competence of a lay person to report) are sufficient to conclude that his claims for an increased evaluation for those disabilities are well grounded. King v. Brown, 5 Vet. App. 19 (1993). Where the veteran has presented a well-grounded claim, VA has a duty to assist the veteran in the development of facts pertinent to his claims. Godwin v. Derwinski, 1 Vet. App. 419 (1991). The Board is satisfied that all relevant facts have been properly developed. White v. Derwinski, 1 Vet. App. 519 (1991). Therefore, no further assistance to the veteran is required to comply with the duty to assist him, as mandated by 38 U.S.C.A. § 5107(a) (West 1991). Right Knee Disability The Board's review of the evidentiary record discloses that the RO rated the appellant's right knee disability as 10 percent disabling by analogy to slight recurrent subluxation or lateral instability of a knee under diagnostic code 5257 from November 14, 1991 through April 13, 1999. The evidentiary record during this time period shows that when seen by VA on an outpatient basis in January 1994 the veteran complained of pain but had no rotational deformity and demonstrated full internal and extended external rotation of the leg. At the June 1994 hearing he complained of locking and swelling, inability to stick his knee out and need of a brace. The December 1994 VA examination disclosed full extension, flexion of 135 degrees, 90 degrees internal rotation, and 40 degrees of external rotation. X-ray studies were negative for arthritis. Progress notes in 1995 show the veteran was seen with complaints of pain. The above evidentiary record is negative for a showing of moderate right knee impairment consistent with subluxation or lateral instability as such were not shown by the evidentiary record. There was no limitation extension to 15 degrees to warrant a 20 percent evaluation under diagnostic code 5261, nor was there limitation of flexion of the knee to 30 degrees to warrant assignment of a 20 percent evaluation under diagnostic code 5260. The VA medical examination and outpatient treatment reports were negative for functional loss due to pain, incoordination, fatigability, weakness, etc., so as to warrant assignment of an increased evaluation pursuant to the criteria of 38 C.F.R. §§ 4.40, 4.45, 4.59. Overall, the Board finds that the 10 percent evaluation adequately compensated the veteran for the demonstrated right knee disablement during the period from November 14, 1991 until April 13, 1999. The RO assigned an increased evaluation of 30 percent for the right knee disability again by analogy to severe subluxation or lateral instability of a knee under diagnostic code 5257 effective April 14, 1999, the date of the VA examination. The Board's review of the evidentiary record does not permit a conclusion that a higher evaluation is warranted. In this regard the Board notes that 30 percent is also the maximum schedular evaluation under diagnostic code 5260 for limitation of flexion to 15 degrees. As reported earlier, the veteran can flex the right leg to 55 degrees. For the next higher evaluation of 40 percent under diagnostic code 5261, the veteran would have to have limited extension of his knee to 30 degrees. The April 14, 1999 VA examination disclosed he had a lag of 10 degrees of extension. Accordingly, increased evaluation under this diagnostic code is not warranted. Ankylosis of the right knee was not found on the April 1999 VA examination thereby precluding assignment of an increased evaluation of 40 percent under diagnostic code 5256. Radiographic studies disclosed no evidence of a pathological process. As arthritis with corresponding limitation of flexion and/or extension of the right knee is not shown by the evidentiary record, a separate evaluation for arthritis with application of the General Counsel opinion VAOPGCPREC 23-97 is not warranted. As the veteran is in receipt of the maximum schedular evaluation of 30 percent under diagnostic code 5257, application of the criteria under 38 C.F.R. §§ 4.40, 4.45, 4.59 for functional loss due to pain is not warranted. No question has been presented as to which of two evaluations would more properly classify the severity of the veteran's right knee disability. 38 C.F.R. § 4.7. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for a compensable evaluation for the right knee disability from November 14, 1991 to October 29, 1997, and an evaluation in excess of 30 percent on and after October 30, 1999. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board notes that the veteran has contended that he is unable to work due to his service connected disability; this therefore, warrants mention of extraschedular consideration. However, under Floyd v. Brown, 9 Vet. App. 88 (1996), although the Board may be obliged to raise the issue of potential extraschedular consideration, based upon a liberal reading of the documents of record, the Board cannot make that determination in the first instance. Id. An extraschedular rating would require 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 Board further notes that the RO provided the veteran with the criteria under 38 C.F.R. § 3.321(b)(1) for assignment of an increased evaluation on an extraschedular basis. The RO determined that the veteran's claim for an increased evaluation for his service-connected right knee disability did not warrant referral to the appropriate official for consideration of an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1). The Board agrees with the RO's determination. It is noted, however, that the evaluations assigned under the Rating Schedule are already based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (1999). Postoperative Status, Subtotal Gastrectomy for Chronic Peptic Ulcer Disease As the Board noted earlier, the RO's grant of service connection for the veteran's postoperative status subtotal gastrectomy for chronic peptic ulcer disease was predicated on aggravation of a preexisting gastrointestinal disability. The RO determined that his gastrointestinal disability was productive of disablement to a degree of 20 percent, but at the time of his claim and the evidentiary record reviewed pursuant to issuing of the rating decision was productive of disablement to a noncompensable degree effective from November 13, 1991 through October 29, 1997. In October 1999 the RO determined that the veteran's gastrointestinal disability at that time was productive of disablement to a degree of 40 percent. The rating action of October 1999 did not take into consideration the previously determined 20 percent level of gastrointestinal impairment as noted on the November 1991 rating decision. The RO has rated the veteran's gastrointestinal disability as 40 percent disabling by analogy to postgastrectomy syndromes under diagnostic code 7308 of the VA Schedule for Rating Disabilities. The current 40 percent rating contemplates moderate disablement with less frequent symptomatology contemplated in the maximum schedular evaluation of 60 percent. The 60 percent evaluation requires severe post gastrectomy syndromes associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. 38 C.F.R. § 4.114; Diagnostic Code 7308. The Board agrees that the criteria under diagnostic code 7308 most closely reflect the veteran's gastrointestinal disability. The Board does not agree that the 40 percent evaluation adequately contemplates the veteran for the nature and extent of severity of his gastrointestinal disability manifested by peptic ulcer disease. The Board's evaluation of the evidentiary record in the aggregate permits the conclusion that the veteran has been suffering from severe gastrointestinal disablement since his separation from service which permits assignment of a 60 percent evaluation, minus 20 percent to account for preservice disablement, for a 40 percent evaluation to be made effective from November 14, 1991, the date of the original grant. In this regard the Board notes that the veteran's gastrointestinal symptoms were determined to have been aggravated by his service when he was initially seen for VA examination in 1991. While disabling symptomatology was not then specifically detailed, the evidentiary record shows that overall the veteran had been experiencing all along rather severe impairment to include anemia most recently diagnosed and one of the requisites for the 60 percent evaluation. The Board finds that the noncompensable evaluation effective from November 1991 to 1997 did not satisfactorily compensate the veteran for the nature and extent of severity of his gastrointestinal disability. The Board acknowledges that the medical evidentiary record overall was not unequivocal, but was sufficiently complete to show that the veteran did in fact experience compensable disablement warranting a compensable evaluation. The Board finds that the evidentiary record in the aggregate to include hearing testimony supports an interpretation of severe disablement to warrant assignment of the maximum evaluation of 60 percent retroactive to the effective date of the grant of service connection, November 14, 1991. The Board has reviewed the diagnostic criteria for the other applicable rating code and finds that at no time during the rating period in question was the veteran totally disabled due to his gastrointestinal disability so as to warrant a 100 percent evaluation. In this regard, the veteran did not have a pronounced marginal ulcer requisite for the 100 percent evaluation under diagnostic code 7306. Turning to the question of an extraschedular rating, as mentioned earlier, it is provided under 38 C.F.R. § 3.321(a) that the provisions contained in the rating schedule will represent as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from disability. As noted above, under § 3.321(b)(1) there is an additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. 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. It is further provided in subsection (c) that in cases in which application of the schedule is not understood or the propriety of an extraschedular rating is questionable may be submitted to Central Office for advisory opinion. The regulation provides an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. In this instance, the RO determined that the veteran's claim for an increased evaluation for his service- connected postoperative status subtotal gastrectomy for chronic peptic ulcer disease did not warrant referral to the appropriate official for consideration of an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1). The evidence reveals that the veteran has not been recently hospitalized for his service-connected ulcer disease and the VA physician in March 1999 found that the veteran's ulcer problem does not preclude him from engaging in gainful employment. There is nothing in the disability picture presented that indicates that the regular rating criteria is not sufficient, therefore, the Board agrees with the RO's determination. As shown above, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating. The veteran's case involves an appeal as to the initial ratings assigned for his right knee disability and his postoperative status, subtotal gastrectomy for chronic peptic ulcer disease on the occasion of the grant of service connection by the RO in November 1993, rather than an increased rating claim where entitlement to compensation had previously been established. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial rating cases, a separate rating can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Id. at 9. In the case at hand, the Board finds that staged ratings are not appropriate. ORDER Entitlement to an evaluation in excess of 10 percent for limited motion of the right knee secondary to surgery from November 14, 1991 to April 13, 1999, and in excess of 30 percent on and after April 14, 1999 is denied. Entitlement to an initial compensable evaluation of 40 percent from November 14, 1991 for postoperative status subtotal gastrectomy for chronic peptic ulcer disease is granted, subject to applicable criteria governing the payment of monetary benefits. RONALD R. BOSCH Member, Board of Veterans' Appeals