Citation Nr: 0007530 Decision Date: 03/21/00 Archive Date: 03/28/00 DOCKET NO. 96-20 267 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana THE ISSUES 1. Entitlement to a higher initial evaluation for the residuals of a laceration of the left knee, currently evaluated as 10 percent disabling. 2. Entitlement to a higher initial evaluation for degenerative changes of the left knee, currently evaluated as 10 percent disabling. 3. Entitlement to a higher initial evaluation for laceration scar, left knee, currently evaluated as 10 percent disabling. 4. Entitlement to a compensable initial evaluation for tibial deformity, left knee. 5. Entitlement to a compensable initial evaluation for tenderness of the distal anterior femoral cutaneous nerve, left knee. 6. Entitlement to a compensable initial evaluation for tenderness of the neuroma, proximal saphenous nerve, left knee. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L.J. Bakke, Associate Counsel INTRODUCTION The veteran served on active duty from May to October 1990 and from November 1990 to May 1991. This appeal initially arose before the Board of Veterans' Appeals (Board) from a rating decision in which service connection was granted for the residuals of, inter alia, injury to the left knee. A zero percent evaluation was then assigned. Subsequently, the RO granted a 10 percent evaluation for this disability, effective in September 1994. However, the veteran's appeal concerning this issue remains before the Board. Cf. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The Board notes that the U.S Court of Veterans Appeals (now the U.S. Court of Appeals for Veterans Claims, hereinafter the Court), in Fenderson v. West, 12 Vet. App. 119 (1999) held, in part, that the RO never issued a statement of the case concerning an appeal from the initial assignment of a disability evaluation, as the RO had characterized the issue in the statement of the case as one of entitlement to an increased evaluation. Fenderson involved a situation in which the Board had concluded that the appeal as to that issue was not properly before it, on the basis that a substantive appeal had not been filed. This case differs from Fenderson in that the appellant did file a timely substantive appeal concerning the initial rating to be assigned for the disability at issue. The Board observes that the Court, in Fenderson, did not specify a formulation of the issue that would be satisfactory, but only distinguished the situation of filing a notice of disagreement following the grant of service connection and the initial assignment of a disability evaluation from that of filing a notice of disagreement from the denial of a claim for increase. Moreover, the appellant in this case has clearly indicated that what he seeks is the assignment of a higher disability evaluation. Consequently, the Board sees no prejudice to the veteran in either the RO's characterization of the issue or in the Board's characterization of the issue as one of entitlement to the assignment of a higher disability evaluation. See Bernard v. Brown, 4 Vet. App. 384 (1883). Therefore, the Board will not remand this matter solely for a re-characterization of the issue in a new statement of the case. In Floyd v. Brown, 9 Vet. App. 88 (1996), the Court held that the Board does not have jurisdiction to assign an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. The Board is still obligated to seek out all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the laws and regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court clarified that it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1) or from reaching such a conclusion on its own. Moreover, the Court did not find the Board's denial of an extraschedular rating in the first instance prejudicial to the veteran, as the question of an extraschedular rating is a component of the appellant's claim and the appellant had fully opportunity to present the increased-rating claim before the RO. Bagwell, at 339. Consequently, the Board will consider whether this case warrants the assignment of an extraschedular rating. FINDINGS OF FACT 1. All relevant evidence necessary for a fair and informed decision has been obtained by the originating agency. 2. The veteran's service-connected residuals of a laceration to the left knee are manifested by no more than mild anterior lateral rotary instability and secondary subluxation. 3. The veteran's service connected degenerative changes of the left knee are manifested by limited and painful motion, with extension of at least 5 degrees and flexion of at least 60 degrees. 4. The veteran's service connected laceration scar, left knee, is manifested by pain in the scar, without ulceration or limitation of function. 5. The veteran's service connected tibial deformity, left knee, is asymptomatic. 6. The veteran's service connected tenderness of distal anterior femoral cutaneous nerve, left knee, is manifested by less than mild incomplete paralysis. 7. The veteran's service connected tenderness of the neuroma, proximal saphenous nerve, left knee, is manifested by severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 10 percent for the service-connected residuals of a laceration of the left knee are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5257 (1999). 2. The criteria for an initial rating greater than 10 percent for the service-connected degenerative changes of the left knee are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (1999). 3. The criteria for an initial rating greater than 10 percent for the service-connected laceration scar, left knee, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.31, 4.118, Diagnostic Codes 7803, 7804, and 7805 (1999). 4. The criteria for an initial compensable rating for the service-connected tibial deformity, left knee, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5262 (1999). 5. The criteria for an initial compensable rating for the service-connected tenderness of the distal anterior femoral cutaneous nerve, left knee, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.31, 4.124a, Diagnostic Code 8526 (1999). 6. The criteria for an initial 10 percent rating, and no greater, for the service-connected tenderness of the neuroma proximal saphenous nerve, left knee, are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.31, 4.124a, Diagnostic Code 8527 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran has presented well-grounded claims for higher initial disability evaluations for his service-connected disabilities within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). When a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well-grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). In December 1997, the Board remanded the claim for further development, including the procurement of additional service medical and private medical treatment records, and consideration of various manifestations of the veteran's left knee disability under VAOPGCPREC 23-97 (7/1/97) and Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The RO granted service connection for separate manifestations of the veteran's left knee disability in a June 1999 rating decision, and confirmed and continued the 10 percent evaluation for the service-connected left knee disability evaluated under Diagnostic Code 5299-5257. The RO provided the veteran a supplemental statement of the case in July 1999, notifying him of these actions and of the criteria required to obtain higher initial evaluations for the additional service-connected disabilities. The RO, in July 1998, requested further information from the veteran in order to obtain additional service medical and private medical treatment records. The veteran did not respond. The Court has stated "[t]he duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The veteran has not alleged that any other records of probative value that may be obtained, and which have not already been associated with his claims folder, are available. Accordingly, the Board finds that all relevant facts have been properly developed and the duty to assist him, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), has been satisfied. In considering the severity of a disability, it is essential to trace the medical history of the disability. 38 C.F.R. §§ 4.1, 4.2 (1999). A rating decision dated in January 1995 originally granted service connection for the residuals of a laceration to the left knee, assigning a noncompensable evaluation under Diagnostic Code 7805, based on the evidence then of record, which included service personal records and private medical records. These records showed that the veteran was in an automobile accident while on active service, in which he sustained laceration of his left knee into the joint, requiring surgical repair of the medial meniscus, anterior medial capsular ligament, joint capsule, and retinaculum with removal of chondral fragments apparently from the femur. Subsequent private medical records report the veteran underwent additional arthroscopy of the left knee in service, and that further arthroscopy was recommended. In December 1994, the veteran underwent VA examination. The report shows complaints of pain and swelling. The examiner observed no swelling or deformity in the left knee. Range of knee joint motion is reported from zero to 120 degrees, with limitation of motion on flexion only. The diagnosis was status post surgery for left knee reconstruction with limitation of motion up to 120 degrees in flexion only. In April 1997, the RO increased the evaluation for the veteran's service-connected left knee disability to 10 percent under Diagnostic Code 5299-5257, effective in September 1994, based on the report of a March 1997 VA examination. At this time, the veteran complained of sharp pain in the left knee and reported he had been told he needs another operation. The report reveals objective observations of considerable pain on flexion, and of tenderness at the medial part of the patella and deep into the scar, which the examiner opined are compatible with a neuroma of the proximal saphenous nerve or of the distal anterior femoral cutaneous nerve. The examiner further noted swelling in the left knee and secondary subluxation without loose motion or lateral instability. Range of motion was recorded at zero to 110 degrees. Results of X-rays evidence mild degenerative changes in the left knee joint, irregularity of the tibial spine, and a circular density in the area of the medial femoral condyle. The examiner diagnosed probable neuroma in the left knee due to prior surgery. This evaluation has been confirmed and continued to the present. As noted above, the Board remanded this claim to the RO for further development, including consideration of whether or not other of the manifestations of the veteran's left knee disability should be afforded separate, compensable evaluations in accordance with VAOPGCPREC 23-97. The RO was requested to obtain additional records of military and private medical treatment accorded the veteran for his left knee disability. However, also as noted above, the veteran did not respond to the RO's request for information it required in order to obtain these documents. Hence, the RO based its June 1999 rating decision on the medical evidence already of record. In this rating decision and effective in September 1994, the RO granted separate, 10 percent evaluations for left knee degenerative changes, under Diagnostic Code 5003; the residual scar, under Diagnostic Code 7804; and the tibial deformity, under Diagnostic Code 5262. The RO also granted separate, noncompensable evaluations for tenderness of the distal anterior femoral cutaneous nerve and tenderness of the neuroma proximal saphenous nerve of the left knee, under Diagnostic Codes 8527 and 8526, also effective in September 1994. Finally, the RO confirmed and continued the 10 percent evaluation previously granted under Diagnostic Code 5299-5257, for the symptoms of his left knee disability described as the residuals of the left knee laceration. These evaluations have also been confirmed and continued to the present. The veteran has appealed the assignment of the evaluations assigned his left knee disabilities. In particular, he testified before the undersigned member of the Board that he experiences pain, swelling, and weakness in his left knee, and that he must wear a knee brace. He also testified that he feels a looseness or lateral instability and that his physician has recommended that he have additional surgery. He stated that he experiences limitation of motion in the left knee joint which feels as though it is partially due to the scar tissue's inability to stretch when he bends the joint. Finally, he testified that his left knee has affected his employment. He is a police officer, but because of his knee, cannot work on the street and so must work at a desk. He testified that his inability to work as a patrolman has greatly reduced his earning potential. Service-connected disabilities are rated in accordance with the VA's Schedule for Rating Disabilities (Schedule). The ratings are based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § Part 4 (1999). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon a lack of usefulness of these systems in self- support. 38 C.F.R. § 4.10 (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 the higher rating. 38 C.F.R. § 4.7 (1999). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (1999). The current 10 percent evaluation assigned for the residuals of the left knee laceration was assigned under Diagnostic Code 5299-5257 for an unlisted residual condition of the left knee, evaluated under the criteria for other impairment of the knee involving recurrent subluxation or lateral instability. A 10 percent rating is assigned for mild disability and 20 percent rating, for moderate disability. See 38 C.F.R. §§ 4.27, 4.71a, Diagnostic Code 5257 (1999). The evidence does not show that the required manifestations of moderate subluxation or lateral instability are present. The veteran has testified that his left knee will buckle if he attempts to run, and that he feels lateral movement and a looseness in his left knee joint. Private medical records dated in December 1993 show findings of anterior lateral rotary instability, but no other gross instability. In addition, the March 1997 report shows clinical findings of subluxation, but no loose motion or lateral instability. The December 1994 report reveals no findings of instability. Rather, the examiner reported no other impairment of the left knee. Furthermore, the veteran had submitted no evidence that he has required treatment for impairment of the knee involving recurrent subluxation or lateral instability that is more than slight. After consideration of the evidence, the Board finds that an initial rating higher than 10 percent under Diagnostic Code 5299-5257 cannot be granted for the left knee disability. Specifically, the medical evidence simply does not show that the veteran's left knee disability is characterized by impairment of the knee involving subluxation or instability that is more than slight. The current 10 percent evaluation assigned for degenerative changes of the left knee was assigned under Diagnostic Code 5003. Diagnostic Code 5003 directs that 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 (Diagnostic Code 5200, etc.) or under the evaluations provided under Diagnostic Code 5003, which direct that arthritis established by X-ray findings and manifested by limitation of motion otherwise uncompensable under the appropriate diagnostic code for that specific joint will be rated 10 percent disabling for the involvement of each major joint or group of minor joints affected. Under Hicks v. Brown, 8 Vet. App. 417 (1995), limited motion includes painful motion. See also 38 C.F.R. § 4.59 (1999). In addition, weakness and swelling are also manifestations considered by the criteria as indicative of limitation of the normal excursion of joint movement in different planes. See 38 C.F.R. §§ 4.40, 4.45 (1999). A note following Diagnostic Code 5003 indicates that evaluations for that the 10 percent and 20 percent evaluations provided by the diagnostic code are not to be combined with ratings based on limitation of motion. In this case, the evidence shows that the veteran has limited range of left knee joint motion, with considerable pain upon flexion. In addition, he has testified, and the medical evidence establishes, that he experiences swelling and weakness. In March 1997, the examiner noted that the left knee was swollen and measured 1.5 centimeters greater in circumference than the right. Although the record does not contain consistent reported limitation of motion, the record clearly shows that the requirements for a higher rating under either Diagnostic Code 5260 or 5261 are not met. Under Diagnostic Code 5260, limitation of flexion of the leg is rated 0 percent when 60 degrees, 10 percent when 45 degrees, and 20 percent when 30 degrees. Under Diagnostic Code 5261, limitation of extension of the leg is rated 0 percent when 5 degrees, 10 percent when 10 degrees, and 20 percent when 15 degrees. In March 1997, his range of motion measured zero to 110 degrees. There are two reports, by the same examiner, for the December 1994 examination. In both, flexion was measured at 120 degrees. Although the general medical examination indicates that extension was 30 degrees, it also notes that he only had limitation of flexion. The joint examination did not list extension in degrees, but only diagnosed limitation of flexion of the left knee. In resolving the apparent contradiction in the December 1994 general medical examination report, the Board concludes that the preponderance of the evidence supports that conclusion that the extension of the knee was to 0 degrees, or normal. See 38 C.F.R. Part 4, Plate II. Significantly, no other reports show limitation of flexion approaching 30 degrees. After consideration of the evidence, the Board finds that an initial rating higher than 10 percent under Diagnostic Code 5260 or 5261 cannot be granted for the left knee disability. Specifically, the medical evidence simply does not show that the veteran's left knee disability is characterized by limitation of flexion to 45 degrees or less, as required for under Diagnostic Code 5260, or limitation of extension to 10 degrees or more as required under Diagnostic Code 5261. The current 10 percent evaluation assigned for the laceration scar, left knee, was assigned under Diagnostic Code 7804, for a scar that is tender and painful on objective observation. There is no higher rating under this Diagnostic Code. However, additional compensable evaluations could be afforded under Diagnostic Code 7803 for a scar that is poorly nourished with repeated ulceration, or under Diagnostic Code 7805 for a scar that limits the function of the joint so affected. In the present case, the medical evidence simply does not show that the scarring that is the residual of the inservice injury and resultant surgeries is poorly nourished with repeated ulceration. Rather, December 1994 report shows findings of a well healing scar. The March 1997 report notes no findings at the scar. Concerning limitation of motion, the veteran testified that he experiences limitation of motion and attributed that symptom to his scar. Yet, the medical evidence does not attribute that the limitation of left knee joint motion to the scar. In any event, the veteran is already compensated for his limitation of left knee joint motion, as described above, under Diagnostic Code 5003. Thus, further compensation for this manifestation is impermissible under 38 C.F.R. § 4.14 (1999). The Board finds that an initial rating higher than 10 percent under Diagnostic Code 7804 is not provided for by the rating criteria, and that additional compensable evaluations under Diagnostic Codes 7803 or 7805 are not warranted. Specifically, the medical evidence simply does not show that the residual scarring of the veteran's inservice left knee injury and surgeries is poorly nourished or ulcerated, or by limitation of function that is otherwise uncompensated. The current noncompensable evaluation assigned for deformity of the left tibia was assigned under Diagnostic Code 5262, for malunion of the tibia and fibula. A compensable evaluation is warranted for malunion of the tibia and fibula with slight knee or ankle disability. However, the medical evidence does not demonstrate that the required manifestations are present. The veteran testified that he wears a knee brace prescribed by a military physician before his separation from active service. Nonetheless, he has not testified, and the medical evidence does not reflect, that he experiences manifestations that may be attributed to the tibia. Rather, the veteran testified that the brace protects against pain to his nerve, for which compensation is granted under a separate diagnostic code, as discussed below. In addition, he is already receiving separate compensation for impairment of the knee involving subluxation and lateral instability; and for limitation of motion, which also contemplates symptoms of pain, weakness, and swelling, as discussed above. Compensation for these manifestations is thus impermissible under 38 C.F.R. § 4.14 (1999). After consideration of the evidence, the Board finds that an initial compensable evaluation under Diagnostic Code 5262 is not warranted. Specifically, the medical evidence simply does not establish that the veteran experiences manifestations of his left knee disability that are attributable to malunion or non-union of his tibia and fibula and are not compensated under other diagnostic codes. Noncompensable evaluations were assigned for tenderness of the distal anterior femoral cutaneous nerve, left knee, under Diagnostic Code 8526 and for tenderness of the tenderness of the neuroma in the proximal saphenous nerve, left knee, under Diagnostic Code 8527. Under Diagnostic Code 8526, incomplete paralysis of the anterior crural (femoral) nerve is rated 10 percent when mild, 20 percent when moderate, and 30 percent when severe. Under Diagnostic Code 8527, paralysis of the internal saphenous nerve is rated noncompensable when mild to moderate, and 20 percent when severe to complete. Although the RO granted service connection for disability of both nerves, the medical evidence presents some confusion as to which nerve is involved in the veteran's left knee disability. The medical evidence shows that the veteran has consistently exhibited pain attributable to a neurological defect in the left knee since December 1993. At that time, the veteran's private treating physician, Thomas R. Butaud, M.D., reported an impression of a neuroma of the infrapatellar branch of the saphenous nerve, which he described as exquisitely tender and observed to cause a great deal of pain upon touch. Similarly, in March 1997, the VA examiner noted point tenderness on touch at the medial part of the patella and deep into the scar, but opined that the manifestation was compatible with a neuroma of either the proximal saphenous nerve, or the distal anterior femoral cutaneous nerve. The examiner diagnosed a probable neuroma due to the prior surgery. The Board resolves the apparent conflict concerning which nerve involved by according more weight to the veteran's private treating physician. First, Dr. Butaud performed the original, post-injury, surgery in April 1991. Second, Dr. Butaud consistently treated the veteran following his surgery through December 1993. He does note in December 1993 that the veteran had an intervening arthroscopy, performed by a military physician; nonetheless, it is during this office visit and examination that he diagnosed the neuroma and opines that it is associated with the saphenous nerve. Third, Dr. Butaud uses very clear and precise language in describing his observations. In pertinent part, he states: On evaluation [the veteran] does have an obvious infrapatellar branch of the saphenous nerve that is exquisitely tender. I can even feel the neuroma coming out of the scar tissue. When tapping this, it causes a lot of discomfort. The only uncertainty presented in the medical evidence concerning which of the two nerves-saphenous or femoral cutaneous-is involved is in the March 1997 VA examination report, in which the examiner describes the point tenderness on touch at the medial part of the patella and deep to the scar as compatible with a neuroma of the proximal saphenous nerve or the distal anterior femoral cutaneous nerve. The VA examiner diagnosed a probable neuroma but did not identify the nerve involved. The RO has service-connected the neuroma as a manifestation of the saphenous nerve defect. Hence, considering the private examiner's involvement in the original surgery and treatment of the veteran's knee disability and his longstanding treatment thereafter, the Board resolves any ambiguity in favor of his diagnosis. Thus, while the medical evidence reflects that the veteran exhibits tenderness which may be attributable to either nerve and which the RO has specifically service-connected under both diagnostic codes, the Board will attribute other neurological symptomatology exhibited-such as pain and sensory deficit-to the veteran's saphenous nerve. A compensable, 10 percent, evaluation is warranted under Diagnostic Code 8527 for paralysis of the saphenous nerve manifested by severe, incomplete paralysis to complete paralysis. The Board finds that the required manifestations are present. The veteran has testified that he experiences constant and unbearable pain, and sensory deficit associated with the nerve. Specifically, he testified that his knee feels as though it has fallen asleep, at which time the nerve protrudes, and the side of his knee becomes extremely sensitive and painful. The pain travels to the back of his knee and, he testified, is fairly constant. The knee brace, he stated, protects his knee from touching or bumping into any other surfaces and helps to protect the nerve. The medical evidence contains objective findings that corroborate these statements. In December 1993, the neuroma found in the left knee is described as palpable, exquisitely tender, and productive of a great deal of discomfort. The March 1997 VA report findings concur, noting point tenderness on touch at the medial part of the patella and deep to the scar-which is the site of the neuroma. A higher evaluation under this diagnostic code is not available. A compensable, 10 percent, evaluation is warranted under Diagnostic Code 8526 for incomplete paralysis of the femoral nerve manifested by mild symptomatology. However, as discussed above, the Board has evaluated symptomatology such as pain and sensory deficit evidenced in the medical records under Diagnostic Code 8527. Compensation for the same symptomatology under Diagnostic Code 8526 is therefore impermissible under 38 C.F.R. § 4.14 (1999). Hence, the Board finds that the required manifestations for a compensable evaluation under Diagnostic Code 8526 are not present. The medical evidence simply does not establish that there are manifestations other than tenderness-such as pain, sensory deficit, or other neurological defects-that may be separately attributable to a femoral nerve defect, left knee. And, while tenderness is a symptom attributed to this defect, the medical evidence simply does not establish that tenderness, in and of itself, reaches the degree of severity equivalent to mild incomplete paralysis required by the criteria. After consideration of the evidence, the Board finds that an initial 10 percent evaluation, and no greater, under Diagnostic Code 8527 is warranted, but that an initial compensable evaluation under Diagnostic Code 8526 is not warranted. Specifically, the evidence establishes that the veteran exhibits manifestations of the service-connected tenderness and neuroma, proximal saphenous nerve, left knee, that are severe. In addition, the medical evidence simply does not establish that he experiences manifestations of the service connected tenderness, distal anterior femoral cutaneous nerve, left knee, that equate to mild incomplete paralysis. As noted above, in VAOPGCPREC 23-97 (July 1, 1997), it was held that where the manifestations of a condition create a separate disability, the symptomatology of which neither duplicates nor overlaps that of another condition, assigning a separate rating under the appropriate diagnostic code does not violate the provisions of 38 C.F.R. § 4.14, which prohibits evaluating the same manifestations of a condition, albeit diagnosed variously, under different ratings. The opinion held, for example, that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003, for arthritis, and 5257, for instability. See also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Thus, in addition to considering whether higher initial evaluations for the veteran's service-connected left knee laceration residuals under Diagnostic Code 5299-5257; degenerative changes under Diagnostic Code 5003; scar under Diagnostic Codes 7803, 7804, and 7805; tibial deformity under Diagnostic Code 5262; tenderness of the distal anterior femoral cutaneous nerve under Diagnostic Code 8526; and tenderness of the neuroma, proximal saphenous nerve, under Diagnostic Code 8527 are warranted, the Board will also analyze whether a compensable evaluation is warranted for other manifestations that may be rated under Diagnostic Codes 5258 and 5259. Diagnostic Codes 5258 and 5259 afford compensable evaluations for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; and for symptomatic removal of semilunar cartilage. However, the Board finds that the required manifestations are not met. Although the veteran testified that he experienced episodes of locking, the medical records - while indicating findings of meniscal pathology in December 1993 -- do not document instances of locking or clinical findings of effusion, nor establish that the veteran has undergone surgery to remove semilunar cartilage in his left knee. Rather, the April 1991 operation report shows that the lateral meniscus was found to be undamaged, and that the medical meniscus was repaired. Similarly, VA examination reports dated in December 1994 and March 1997 evidence no findings of locking, effusion, or other symptomatology association with the veteran's semilunar cartilage. After consideration of the evidence, the Board finds that the criteria for separate compensable evaluations under Diagnostic Codes 5262 or 5263 are not warranted. This does not, however, preclude the granting of a higher evaluation for the left knee disability than has been granted herein. In exceptional cases where schedular evaluations are found to be inadequate, consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities" is made. 38 C.F.R. § 3.321(b)(1) (1999). 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. Id. The Board first notes that the schedular evaluations in this case are not inadequate. As discussed above, higher and separate compensable evaluations are provided for greater disability under various diagnostic codes, but the required manifestations are not present. Second, the Board finds no evidence of an exceptional disability picture in this case. The record does not show that the veteran has required frequent hospitalization for his left knee disability. Moreover, the disabling manifestations of painful and somewhat limited motion of the left knee do not present an unusual or exceptional disability picture. Although the veteran has indicated that his left knee disability limits his job as a police officer by confining him to a desk job and thereby making it harder for him to qualifying for promotion, he has not presented any statements from his employer showing this, nor does the medical evidence of record present any medical findings of marked limitation of employability. Thus, the evidence cannot show that the impairment resulting from left knee disability markedly interferes with his employment. Thus, there is no evidence that the impairment resulting solely from the left knee disability warrants extra-schedular consideration. Rather, for the reasons noted above, the Board concludes that the impairment resulting from left knee laceration residuals, degenerative changes, scar, tibial deformity, tenderness of distal anterior femoral cutaneous nerve, and tenderness of neuroma, proximal saphenous nerve are adequately compensated by the ratings discussed above. Therefore, extraschedular consideration under 38 C.F.R. § 3.321(b) (1999) is not warranted. In rating this service-connected disability, the Board has considered the disabling effects of pain, as indicated in the above discussions. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Objective observations of limitation of movement and painful movement, tenderness, tenderness on palpation, swelling, instability, and pain attributable to the neuroma were noted by the examiners. No findings were made of abnormal movement, guarding of movement, muscle atrophy, or changes in condition of the skin indicative of disuse. In addition, the veteran complained of sensory deficit and weakness, which have been considered and compensated as discussed above. As the veteran's complaints of pain, weakness, and limitation of movement have been compensated, they do not, by themselves, support an assignment of a higher or separate, compensable evaluation other than that which is confirmed and awarded by this decision. As discussed above, the ratings now assigned for the left knee disability account for the painful and limited motion, swelling, instability, pain, and instability demonstrated. The presence of other factors listed in 38 C.F.R. § 4.45 is either not contended or not shown. ORDER Entitlement to initial evaluations greater than 10 percent for left knee laceration residuals, degenerative changes, and scar is denied. Entitlement to initial compensable evaluations for left knee tibial deformity and tenderness of the distal anterior femoral cutaneous nerve is denied. Entitlement to an initial evaluation of 10 percent, and no greater, for tenderness of the neuroma, proximal saphenous nerve, left knee, is granted subject to the laws and regulations governing the payment of monetary benefits. MARY GALLAGHER Member, Board of Veterans' Appeals