BVA9507261 DOCKET NO. 89-23 886 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an increased rating for chronic pain syndrome and left patellofemoral pain syndrome with tear of the posterior horn of the left medial meniscus, currently assigned a 10 percent evaluation. 2. Entitlement to an increased (compensable) rating for patellofemoral pain syndrome of the right knee. 3. Entitlement to an increased rating for degenerative changes of the cervical spine with C5 radiculopathy, currently assigned a 10 percent evaluation. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. P. Harris, Counsel INTRODUCTION The appellant had active service from May 1970 to October 1979 and September 1985 to August 1987. This matter came before the Board of Veterans' Appeals (Board) on appeal from an August 1988 rating decision of the San Diego, California, Regional Office (RO), which granted service connection and assigned 10 percent evaluations for chronic pain syndrome of the left upper extremity with bilateral patellofemoral pain syndrome, and for degenerative changes of the cervical spine, each effective August 6, 1987. In April 1990, the Board remanded the case for procedural development. By a rating decision in January 1991, the 10 percent evaluations assigned for each of the aforementioned disabilities were confirmed, effective August 6, 1987, and the RO classified these disabilities as chronic pain syndrome and bilateral patellofemoral pain syndrome with tear, posterior horn, left medial meniscus; and degenerative changes of the cervical spine with C5 radiculopathy. In May 1992, the Board remanded the case for additional medical and procedural development. In a January 1993 rating decision, the RO confirmed the 10 percent evaluations assigned for the aforementioned disabilities. However, the RO previously rated the aforementioned chronic pain syndrome as a psychophysiologic disability, rated under Diagnostic Code 9505. In the January 1993 decision the RO rated the disability under Diagnostic Code 5257-9505, designated it as chronic pain syndrome and left patellofemoral pain syndrome with tear, posterior horn, left medial meniscus, and confirmed the 10 percent rating assigned thereto. However, it assigned a separate noncompensable rating for right patellofemoral pain syndrome, effective August 6, 1987. Statements by the appellant's representative, dated in December 1994 and February 1995, are construed as a possible intention to raise the issue of entitlement to a total rating based upon individual unemployability. Since this issue has not been developed by the RO, it is referred to the RO for appropriate action. Kellar v. Brown, 6 Vet.App. 157 (1994). CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in essence, that his psychophysiologic chronic pain syndrome, including involvement of the knees, and his cervical spine disability are of such severity as to warrant higher evaluations. He asserts that he experiences pain and tenderness of the knees, particularly after standing or ambulation, and he has limitation of motion of the knees. It is argued that his knees occasionally give way, and he requires the use of a cane. Additionally, he contends that he has numbness of the left side of the neck and left upper extremity, and his left arm is painful and weak. His representative asserts that the cervical spine disability would more appropriately be rated under Diagnostic Code 5293 for intervertebral disc syndrome. He further argues that the RO improperly assigned a separate rating for the right knee disability, since by doing so, it discontinued the service-connected chronic pain syndrome component involving that knee. It is asserted that there are more recent Department of Veterans Affairs (VA) outpatient treatment reports regarding the knees which have not been associated with the claims folder. It is requested that applicable regulatory provisions be considered, including 38 C.F.R. § 4.7, pertaining to the higher of two evaluations, and that the benefit of the doubt doctrine be applied. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the appellant's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence is in equipoise to warrant increased ratings of 20 percent for chronic pain syndrome and left patellofemoral pain syndrome with tear of the posterior horn of the left medial meniscus, 20 percent for degenerative changes of the cervical spine with C5 radiculopathy, and 10 percent for patellofemoral pain syndrome of the right knee. However, the preponderance of the evidence is against allowance of evaluations in excess of 20 percent for chronic pain syndrome and left patellofemoral pain syndrome with tear of the posterior horn of the left medial meniscus, 20 percent for degenerative changes of the cervical spine with C5 radiculopathy, and 10 percent for patellofemoral pain syndrome of the right knee. FINDINGS OF FACT 1. All available, relevant evidence necessary for disposition of the appeal has been obtained by the RO. 2. The organic component of the appellant's service-connected psychophysiologic disability is manifested primarily by a very small tear of the left medial meniscus, and positive patellar grinding test results with respect to each knee. Neither knee has more than 90 degrees limitation of flexion or 5 degrees limitation of extension. There is no recent clinical evidence of effusion, ligamentous laxity, instability, or significant joint pathology of either knee. No more than moderate impairment of the left knee or more than slight impairment of the right knee has been shown. 3. The psychogenic component of the appellant's service- connected psychophysiologic disability, chronic pain syndrome, is manifested primarily by somatic complaints including pain, tenderness, and numbness which are disproportionate to objective clinical findings. His psychophysiologic disability results in no more than mild social and industrial inadaptability. 4. The appellant's service-connected cervical spine disability is manifested primarily by complaints of pain, tenderness, and some objective evidence of cervical radiculopathy affecting the left upper extremity. The recent clinical evidence does not show more than moderate overall restricted motion of the cervical spine or more than moderate intervertebral disc syndrome. CONCLUSIONS OF LAW 1. The criteria for a 20 percent evaluation for chronic pain syndrome and left patellofemoral pain syndrome with tear of the posterior horn of the left medial meniscus have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, 4.129, 4.130, 4.132, Codes 5257, 5260, 5261, 9505 (1994). 2. The criteria for an evaluation in excess of 20 percent for chronic pain syndrome and left patellofemoral pain syndrome with tear of the posterior horn of the left medial meniscus have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, 4.129, 4.130, 4.132, Codes 5257, 5260, 5261, 9505 (1994). 3. The criteria for a 10 percent evaluation for patellofemoral pain syndrome of the right knee have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, 4.129, 4.130, 4.132, Codes 5257, 5260, 5261, 9505 (1994). 4. The criteria for an evaluation in excess of 10 percent for patellofemoral pain syndrome of the right knee have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, 4.129, 4.130, 4.132, Codes 5257, 5260, 5261, 9505 (1994). 5. The criteria for a 20 percent rating for degenerative changes of the cervical spine with C5 radiculopathy have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, Codes 5003, 5290, 5293 (1994). 6. The criteria for an evaluation in excess of 20 percent for degenerative changes of the cervical spine with C5 radiculopathy have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, Codes 5003, 5290, 5293 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board finds that the appellant's claims with respect to the issues on appeal are "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a), in that he has presented a claim which is plausible, particularly in light of the partial allowance of these increased rating issues. This being so, the Board must examine the record and determine whether the VA has any further obligation to assist in the development of his claim. 38 U.S.C.A. § 5107(a). After reviewing the record, the Board is satisfied that all relevant facts have been properly developed and no useful purpose would be served by again remanding the case with directions to provide further assistance to the appellant. A comprehensive medical history and detailed findings with respect to his service-connected psychophysiologic and cervical spine disabilities over the years are documented in the medical evidence. Pursuant to the Board's May 1992 remand, VA orthopedic and psychiatric examinations were conducted to determine the current nature and severity of the disabilities in issue. The psychiatric examination that was conducted in June 1992 reported various psychiatric findings. VA orthopedic examinations were conducted in July 1992, March 1993, and March 1994, and included measurements of the degrees of motion of the knees and cervical spine, and clinical description of any abnormal neurologic findings. There are numerous recent VA outpatient reports dated as contemporaneously as 1994, which adequately document the nature and severity of his disabilities, and include sophisticated diagnostic studies with respect to cervical disc disease. The appellant's representative asserts that the cervical spine disability would more appropriately be rated under Diagnostic Code 5293 for intervertebral disc syndrome. The Board concurs, and will consider that Code, since the service-connected cervical spine disability includes cervical radiculopathy, a neurologic manifestation. The appellant's representative further argues that the RO improperly assigned a separate rating for the right knee disability, since by doing so, it discontinued the service- connected chronic pain syndrome component involving that knee. It appears that the RO, when it assigned a separate noncompensable rating, properly rated the chronic pain syndrome component involving that knee as "patellofemoral pain syndrome", which encompasses the appellant's psychogenic and organic chronic right knee pain. Therefore, the Board has framed these issues on appeal as "entitlement to an increased rating for chronic pain syndrome and left patellofemoral pain syndrome with tear of the posterior horn of the left medial meniscus, and entitlement to an increased (compensable) rating for patellofemoral pain syndrome of the right knee", encompassing psychogenic and organic components with respect to each knee. While the appellant's representative, in a December 1994 statement, asserted that there are VA outpatient treatment reports dated since September 1994 regarding the knees which have not been associated with the claims folder, these records have not been shown or even contended as material or necessary for deciding the issues on appeal. Of substantial import is the fact that neither the appellant nor his representative asserts that these records, even assuming they exist, reflect any significant worsening of the disabilities in issue. Additionally, the clinical evidence of record reflects that the psychogenic and organic components of his disability of the knees have not considerably worsened in recent years. Moreover, in that same statement, his representative requested that the appeal be expeditiously decided, which suggests that these additional records may not be deemed by him as material or critical for appellate determination of this case. The Board notes that the issues on appeal have been in appellate status for more than six years. A delay of justice is troubling to the Board, and to order another remand for the RO to further develop the evidentiary record and rerate the disabilities would likely significantly add to the delay. The Board concludes that the evidence is sufficient for purposes of reaching a fair and well-reasoned decision of the issues on appeal, and that the duty to assist the appellant as contemplated by 38 U.S.C.A. § 5107(a) has been satisfied. Therefore, based upon the evidence currently in the claims folder, the Board has applied the relevant laws and regulations, and decided these issues. Disability evaluations are determined by application of a schedule of ratings which is based on average impairment of earning capacity under the VA's Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Board will consider the appellant's service-connected disabilities on appeal in the context of the total history of those disabilities, particularly as they affect the ordinary conditions of daily life, including employment, as required by the provisions of 38 C.F.R. §§ 4.1, 4.2, 4.10 and other applicable provisions. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). I and II. Increased Ratings for Chronic Pain Syndrome and Left Patellofemoral Pain Syndrome with Tear of the Posterior Horn of the Left Medial Meniscus, and for Patellofemoral Pain Syndrome of the Right Knee The appellant's service-connected psychophysiologic disability includes psychogenic as well as organic components, and therefore the provisions of Diagnostic Code 9505, pertaining to a psychophysiologic disability, where psychological factors affect musculoskeletal condition, are applicable. NOTE (2), following 38 C.F.R. § 4.132, Code 9505 states, in pertinent part: When two diagnoses, one organic and the other psychological or psychoneurotic, are presented covering the organic and psychiatric aspects of a single disability entity, only one percentage evaluation will be assigned under the appropriate diagnostic code determined by the rating board to represent the major degree of disability. In the Board's opinion, it is arguable whether the appellant's chronic pain syndrome, insofar as it embodies a psychogenic component, represents the major degree of disability, or whether the organic component of the chronic pain stemming from the left medial meniscal tear and tenderness of the patellae predominates over the psychogenic aspect of the pain. For this reason, the Board will consider the diagnostic codes applicable to organic pathology of the knees (including Codes 5257, 5260, 5261) in addition to the diagnostic code for rating the psychogenic component of the pain (Code 9505), and will apply whichever is more beneficial to the appellant. Slight impairment of either knee, including recurrent subluxation or lateral instability, may be assigned a 10 percent evaluation. A 20 percent evaluation requires moderate impairment. A 30 percent evaluation requires severe impairment. 38 C.F.R. Part 4, Code 5257. Limitation of flexion of either leg to 45 degrees may be assigned a 10 percent evaluation. A 20 percent evaluation requires that flexion be limited to 30 degrees. 38 C.F.R. Part 4, Code 5260. Limitation of extension of either leg to 10 degrees may be assigned a 10 percent evaluation. A 20 percent evaluation requires that extension be limited to 15 degrees. 38 C.F.R. Part 4, Code 5260. The appellant's service medical records reflect that he had numerous somatic complaints, including of the lower extremities. However, a medical board examination report dated in April 1987 indicated that his complaints of pain were not of an anatomical pattern, and were therefore felt to be of psychogenic origin. Evaluation of his knees during service revealed diffuse tenderness and complaints of pain, and mild patellofemoral pain syndrome was diagnosed. Similar complaints and findings were reported on VA orthopedic and neurological examinations in April 1988. At that time, he had various complaints of pain, and his knees were essentially unremarkable, except for mild discomfort on patellar compression. VA outpatient treatment reports reflect that in June 1990, there was moderate effusion and diminished motion of the left knee, and an arthroscopy of that knee was performed in August 1990. Significantly, the arthroscopy revealed no significant joint pathology, except for a very small tear of the medial meniscus, which was not surgically excised. Subsequent VA hospital reports dated in September 1990 and January 1991 reflect complaints related to chronic pain. A VA examination report in March 1991 revealed complaints of pain and tenderness of the knees. However, the knees had normal range of motion, albeit with pain on extremes of flexion. See 38 C.F.R. § 4.71, Plate II, which provides that normal range of motion of the knee is 0 degrees extension and 140 degrees flexion. Furthermore, there was no evidence of effusion, ligamentous laxity, or instability, although he had an antalgic gait, favoring the left lower extremity. It was indicated that he had begun using a cane shortly after the left knee arthroscopy. However, the gait impairment had been clinically described as only mildly antalgic during the January 1991 VA hospitalization. Subsequent clinical records, including VA orthopedic examinations in July 1992 and March 1993, and more recent VA outpatient treatment reports, reflect similar complaints and findings. The July 1992 VA examination revealed that the appellant's knees had 0 degrees extension and 135 degrees flexion, with pain on extremes of flexion, but no evidence of ligamentous laxity or instability; and radiographic findings revealed no knee pathology. While the March 1993 VA examination reflected patellae "snapping" sensation on motion, and some limitation of motion of the knees, full range of motion was reported on subsequent VA hospitalization in May 1993. October 1993 VA outpatient treatment reports reflect that although there was decreased flexion and extension of each knee, nevertheless flexion was 90 degrees, bilaterally, and extension was 5 degrees on the left and 0 degrees on the right. This degree of restricted knee motion would not warrant a higher evaluation under Codes 5260 or 5261. However, the positive evidence includes the complaints of knee pain on motion, slight limitation of motion of each knee, a very small left meniscal tear, and a mildly antalgic gait. With resolution of reasonable doubt in his favor, the Board concludes that the symptomatology reasonably attributable to the organic disability of the left knee more nearly approximates the criteria for a 20 percent rating under Diagnostic Code 5257. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.71a, Codes 5257. With regard to the right knee, no significant pathology has been shown, but considering the limitation of motion and complaints of pain along with the provisions of 38 C.F.R. §§ 4.40, 4.45, the Board concludes that the symptomatology more nearly warrants a 10 percent rating. However, in light of the absence of any ligamentous laxity, instability, significant pathology of either knee except for a very small left meniscal tear, more than slight restricted motion of either knee, or more than mildly antalgic gait, the Board finds that the organic component of the appellant's psychophysiologic disability does not more nearly approximate the criteria for ratings in excess of 10 percent and 20 percent for the right and left knees, respectively. The Board has considered the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45, with respect to painful motion and dysfunction caused by pain and weakness of the affected joints. However, the recent clinical evidence does not show more than slight or moderate impairment of the right and left knees, respectively, even when considering chronic pain as derived from knee dysfunction. It is reiterated that since organic and psychological or psychoneurotic diagnoses are presented covering the organic and psychiatric aspects of a single disability entity, only one percentage evaluation will be assigned under the appropriate diagnostic code(s) that represent the major degree of disability. It is unclear to the Board whether the chronic pain syndrome, insofar as it embodies a psychogenic component, represents the major degree of disability, or whether the organic component of the chronic pain stemming from the left medial meniscal tear and tenderness of the patellae predominates over the psychogenic aspect of the pain. Therefore, the Board will consider the diagnostic code for rating the psychogenic component of the pain (Code 9505), to the extent that this may be more beneficial to the appellant. The VA's Schedule for Rating Disabilities provides a general rating formula for psychophysiologic disorders, including Diagnostic Code 9505, based upon the degree of incapacity or impairment: "Mild" social and industrial impairment warrants a 10 percent evaluation; "definite" warrants a 30 percent evaluation; "considerable" warrants a 50 percent evaluation; and "severe" warrants a 70 percent evaluation. A 100 percent evaluation requires that attitudes of all contacts except the most intimate be so adversely affected as to result in virtual isolation in the community and there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic, and explosions of aggressive energy) associated with almost all daily activities resulting in a profound retreat from mature behavior; and the veteran is demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132. In Hood v. Brown, 4 Vet.App. 301 (1993), the United States Court of Veterans Appeals (Court) stated that the term "definite" in 38 C.F.R. § 4.132 was "qualitative" in character, whereas the other terms were "quantitative," and invited the Board to "construe" the term "definite" in a manner that would quantify the degree of impairment for purposes of meeting the statutory requirement that the Board articulate "reasons or bases" for its decision. 38 U.S.C.A. § 7104(d)(1) (West 1991). In a Precedent Opinion, dated November 9, 1993, the General Counsel of the VA concluded that "definite" is to be construed as "distinct, unambiguous, and moderately large in degree." It represents a degree of social and industrial inadaptability that is "more than moderate, but less than rather large." VA O.G.C. Prec. Op. No. 9-93 (Nov. 9, 1993). The Board is bound by this interpretation of the term "definite." 38 U.S.C.A. § 7104(c) (West 1991). Additionally, in Hood, the term "considerable" was declared as meaning "rather large in extent or degree." It is reiterated that the appellant's service medical records reflect numerous somatic complaints, including pain, and a psychophysiologic disability was diagnosed. The postservice clinical evidence reveals continued psychogenic component to this disability, including pain and associated symptoms. For example, despite arthroscopic findings in August 1990 which were very minimal with regard to his left knee, he nevertheless displayed a mildly antalgic gait and used a cane. See August 1990 and January 1991 VA hospital reports. During March 1991 VA examination, he indicated that he could not ambulate without a cane, which to the Board appears disproportionate to the relatively minor degree of organic lower extremity impairment objectively shown. During a June 1992 VA psychiatric examination, the appellant denied psychiatric problems, but referred to numerous somatic complaints pertaining to his knees, cervical spine, and left shoulder. It should be pointed out that in addition to his service-connected psychophysiologic disability, service connection is in effect for a cervical spine disability and for supraspinatus tendonitis of the left shoulder, status post acromioplasty for acromioclavicular arthritis with impingement, currently rated 20 percent disabling. Even assuming arguendo that current chronic pain involving those joints is partially of psychogenic origin, the degree thereof is so mild that it would not warrant a higher rating based upon the psychogenic component of his psychophysiologic disability. While on that examination the appellant stated that he had depression, anxiety, and irritability, clinically there was no particular depression or anxiety apparent, cognitive functioning was intact, and he reported an active social life. An adjustment disorder (by definition, an acute psychiatric condition) was the sole psychiatric condition diagnosed. See psychiatric nomenclature set forth in the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (3rd ed. 1987) (hereinafter DSM-III), referred to and adopted by 38 C.F.R. § 4.125(1994), which describes adjustment disorders as: "the disturbance begins within three months of onset of a stressor and lasts no longer than six months." Id., 330. Multiple somatic complaints were diagnosed under Axis III, which represents a physical illness diagnosis. See DSM III generally. The examiner noted that the appellant had been unemployed since 1987 and was only capable of odd jobs. However, the basis for this opinion is unclear, and appears to be based solely upon the history given by appellant on that examination, and not supported by the actual clinical findings, which were noted as a basically normal mental status examination. See also 38 C.F.R. § 4.130, which states, in pertinent part: The examiner's classification of the disease...is not determinative of the degree of disability....Ratings are to be assigned which represent the impairment of social and industrial adaptability based on all of the evidence of record. The positive evidence includes the long-standing history of somatic complaints, including psychogenic pain, which obviously have adversely affected social and industrial adaptability to some extent. However, the negative evidence outweighs the positive, and includes the lack of clinical findings reflecting that the psychogenic component of his psychophysiologic disability, in and of itself, is more than mild in degree overall, particularly in light of the essentially negative June 1992 psychiatric examination findings. The Board concludes that the severity of the psychogenic component of his psychophysiologic disability may not be reasonably characterized as "distinct, unambiguous, and moderately large in degree." 38 C.F.R. §§ 4.7, 4.132, Code 9505. The Board notes that complaints of pain have been considered in assigning the increased rating for each knee on an organic basis. In summary, the Board is granting increased ratings of 10 percent and 20 percent for the right and left knees, respectively, representing the organic component of the appellant's psychophysiologic disability. These 10 percent and 20 percent ratings for the organic component of that disability represent the major degree of disability presented by the organic and psychiatric aspects of the single disability entity at this time. 38 C.F.R. § 4.132, Code 9505, NOTE (2). In reaching this determination, the Board has applied the provisions of the Schedule for Rating Disabilities in a manner most beneficial to the appellant. Rating disabilities is not an exact science, as indicated by the Schedule for Rating Disabilities: The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disabilities. 38 C.F.R. § 4.1. An extraschedular evaluation is not warranted, since the evidence does not show that the psychophysiologic disability presents such an unusual or exceptional disability picture as to render the application of the regular schedular standards impractical. 38 C.F.R. § 3.321(b)(1). The appellant has not been frequently hospitalized for his psychophysiologic disability, nor has it been shown, in and of itself, to have markedly interfered with all forms of gainful employment. The Board has also considered the appellant's testimony during a hearing held in June 1989, wherein he testified that his knees in particular precluded employment requiring certain strenuous activities. See hearing transcript, at T. 8. It appears that he has concluded that he is unable to ambulate without a cane, even though the objective clinical findings do not reflect serious disability. In any event, the disability would not markedly interfere with all types of gainful employment, particularly nonstrenuous, sedentary activities. III. An Increased Rating for Degenerative Changes of the Cervical Spine with C5 Radiculopathy In pertinent part, 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. 38 C.F.R. Part 4, Code 5003. Slight limitation of motion of the cervical segment of the spine may be assigned a 10 percent evaluation. A 20 percent evaluation requires moderate limitation of motion. A 30 percent evaluation requires severe limitation of motion. 38 C.F.R. § 4.71a, Code 5290. It is common knowledge that most individuals without cervical spine pathology or disability have the ability to bend the neck forward (forward flexion) to approximately one-third of a right angle position (30 degrees). It is common knowledge that backward movement of the neck (backward extension), side-to-side movement of the neck (lateroflexion), and twisting movement of the neck (rotation) are possible to a slightly greater extent. Additionally, for informational purposes without reliance thereon, measurement of normal ranges of motion of the cervical spine are the following: 30 degrees' forward flexion; 30 degrees' backward extension; 40 degrees' lateroflexion [bilaterally]; and 55 degrees' rotation [bilaterally]. See VA Physician's Guide for Disability Evaluation Examinations, IB 11-56, Chapter 2, Section VII, paragraph 2.23(a) (Mar. 1, 1985). A 20 percent evaluation may be assigned for moderate intervertebral disc syndrome with recurring attacks. A 40 percent evaluation requires severe intervertebral disc syndrome with recurring attacks with intermittent relief. A 60 percent evaluation requires pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy (i.e., with characteristic pain and demonstrable muscle spasm and an absent ankle jerk or other neurological findings appropriate to the site of the diseased disc) and little intermittent relief. 38 C.F.R. Part 4, Code 5293. The appellant's service medical records during the second period of service reflect that in late 1986 and early 1987, he had complaints of cervical and left upper extremity pain and numbness, and diagnostic testing including CT scans revealed some degenerative changes and cervical disc bulging without nerve root/cord impingement. However, a cervical myelogram was negative. Cervical radiculopathy was not definitely confirmed, despite extensive neurologic evaluation in service and for a number of years post service. A report of VA examination in April 1988 reflects that clinically, the cervical spine had full range of motion without muscle spasm. VA outpatient treatment reports in August 1990 revealed that mild left cervical radiculopathy was confirmed on electromyographic study. During VA hospitalization in September 1990, the appellant had only a trace of weakness of the left upper extremity musculature, but muscle tone and bulk were normal. There was some diminished sensation of the left upper extremity reported on VA hospitalization in January 1991, but left upper extremity motor strength was only minimally diminished. On VA examination in March 1991, there was essentially normal range of motion of the neck, except for minimal limitation of rotation, albeit with some generalized tenderness. Furthermore, there was no radiating pain of the neck or evidence of diminished sensation or pathologic reflexes of the left upper extremity, and muscle power was described as good. Reports of July 1992 and March 1993 VA orthopedic examinations revealed no more than slight limitation of overall motions of the cervical spine, without significant neurologic findings. VA hospitalization in May 1993 was primarily for left shoulder surgery. VA MRI study in June 1993 revealed some cervical disc herniation or protrusion and degenerative changes, but spinal stenosis was for the most part mild to moderate, without impingement shown. VA outpatient treatment reports in August and October 1993 and January 1994 reflect that neurologic findings were unremarkable, except for slight sensory diminishment in the left upper extremity. However, overall ranges of motion of the cervical spine were rather severely restricted. Significantly, there were no paracervical muscle spasms, although some tenderness was reported. A November 1993 outpatient treatment report referred to a review of CT myelogram and MRI as showing no significant foraminal or central stenosis. A January 1994 outpatient treatment report assessed chronic neck pain without radicular symptoms. It is significant that the recent VA orthopedic examination in March 1994 revealed essentially normal forward flexion and backward extension, and no more than mildly restricted lateral flexion and rotation. When combining the essentially normal forward flexion and backward extension, with mildly restricted lateral flexion and rotation, the overall degree of restricted motion of the cervical spine cannot be reasonably characterized as more than mild. However, the recent VA outpatient treatment reports reflect episodic instances of severely restricted motion of the cervical spine. With resolution of reasonable doubt in the appellant's favor, the Board concludes that the mild overall ranges of cervical motion shown on that March 1994 examination, when considered with the severe episodic overall limitation of cervical motion shown by recent outpatient records, more nearly represents a moderate overall degree of cervical limitation of motion. Therefore, the criteria for a 20 percent rating for the cervical spine disability under Diagnostic Codes 5003 and 5290 have been more nearly approximated. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, Codes 5003, 5290. However, after weighing all the evidence, the Board finds that since no more than moderate overall limitation of motion of the cervical spine has been clinically shown, an evaluation in excess of 20 percent for the service-connected cervical disability is not warranted under Diagnostic Code 5290. The appellant's cervical pain and pain down the left upper extremity is also recognized by the provisions of the rating schedule, particularly 38 C.F.R. § 4.40. In pertinent part, in describing functional loss involving disability of the musculoskeletal system: 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 the part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. Part 4, § 4.40. The appellant's cervical radiculopathy affecting the left upper extremity is primarily sensory, not motor, in nature, and has been medically described as relatively mild. See also aforementioned VA outpatient treatment reports dated in 1993 and 1994. Moreover, the March 1994 VA examination report revealed normal sensory and motor status. Thus, the appellant's cervical radiculopathy may not be characterized as representing more than moderate intervertebral disc syndrome. 38 C.F.R. Part 4, § 4.7, Code 5293. Parenthetically, while the appellant appears to have some left shoulder limitation of motion, this is reasonably attributable to the service-connected left shoulder disability (for which a separately assigned 20 percent rating is currently in effect), rather than the cervical disability in issue. In conclusion, the 20 percent rating that the Board is granting for the service-connected cervical arthritis with cervical radiculopathy adequately compensates for the commensurate degree of severity, since no more than moderate limitation of motion or moderate intervertebral disc syndrome of the cervical spine has been clinically shown, for the reasons previously explained. An extraschedular evaluation is not warranted, since the evidence does not show that the service-connected cervical disability presents such an unusual or exceptional disability picture as to render the application of the regular schedular standards impractical. 38 C.F.R. § 3.321(b)(1). The appellant has not been frequently hospitalized for his cervical disability, nor has it been shown, in and of itself, to have markedly interfered with employment, particularly given the no more than moderate cervical symptomatology. ORDER Increased ratings of 20 percent for chronic pain syndrome and left patellofemoral pain syndrome with tear of the posterior horn of the left medial meniscus, 20 percent for degenerative changes of the cervical spine with C5 radiculopathy, and 10 percent for patellofemoral pain syndrome of the right knee, are granted, subject to the applicable regulatory provisions governing payment of monetary awards. HOLLY E. MOEHLMANN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.