Citation Nr: 1222156 Decision Date: 06/25/12 Archive Date: 07/02/12 DOCKET NO. 07-02 873 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 30 percent for degenerative joint disease (DJD) of the right knee status post total knee arthroplasty with history of laxity, for the period since December 1, 2009. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from April 1983 to April 1987 and from March 1988 to April 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in December 2005 and September 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Subsequently, the Board remanded these issues for further development in a decision dated in August 2010. As explained in more detail below, the Veteran's original claim for a higher rating for his right knee disability was bifurcated at the time of the Board's August 2010 decision. His current claim for entitlement to a rating in excess of 30 percent for DJD of the right knee status post total knee arthroplasty with history of laxity since October 28, 2008 was remanded for further development. As the Veteran was awarded a temporary 100 percent rating from October 28, 2008 to November 30, 2009, the Board need only adjudicate the time period from December 1, 2009 to the present. Therefore, this claim is recharacterized as it appears on the title page. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. For the period since December 1, 2009, the Veteran's status post total right knee replacement surgery was manifested by limited range of motion with pain, but did not result in chronic residuals consisting of severe painful motion or weakness, ankylosis, limitation extension beyond 10 degrees, limitation of flexion beyond 90 degrees, malunion or non-union of the tibia and fibula, or instability. 2. The Veteran is in receipt of a combined schedular rating of 100 percent for multiple service connected disabilities, but with no single service connected disability rating as 100 percent disabling. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for DJD of the right knee status post total knee arthroplasty with history of laxity, since December 1, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5055, 5256-5262 (2011). 2. The criteria for assignment of a total disability rating based on individual unemployability are not met. 38 U.S.C.A. §§ 1114(s), 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.340, 3.350(i), 4.16 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the issues now on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letters dated in June 2005, July 2006, May 2008, and June 2009 of the criteria for establishing higher ratings for his right knee disability and his entitlement to a TDIU, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates. These letters, accordingly, addressed all notice elements. Nothing more was required. As indicated above, certain VCAA notice was provided after the initial unfavorable AOJ decision. However, the Federal Circuit Court and Veterans Claims Court have since further clarified that the VA can provide additional necessary notice subsequent to the initial AOJ adjudication, and then go back and readjudicate the claim, such that the essential fairness of the adjudication - as a whole, is unaffected because the appellant is still provided a meaningful opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (where the Federal Circuit Court held that a SOC or supplemental SOC (SSOC) can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC). As a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, after the notice letters were provided to the Veteran, the claim was readjudicated in a May 2012 SSOC. Next, VA has a duty to assist a veteran in the development of his claim. This duty includes assisting him in the procurement of pertinent records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159. The RO has obtained VA treatment records. The Veteran and his representative have submitted multiple written statements discussing his contentions and the Veteran testified at a hearing in front of the undersigned. Neither the Veteran nor his representative has identified any outstanding pertinent evidence related to his claims. Additionally, in June 2010, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the June 2010 hearing, the undersigned Veterans Law Judge identified the issues on appeal. Information was also solicited regarding the Veteran's claims for benefits and the need to show evidence of increased severity of his service-connected right knee disability. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor have they identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate these claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. His testimony, for example, triggered the Board's remand for a new VA examination to assign current symptomatology of the right knee. Such triggered the Remand for a VA examination to determine the current status of the Veteran's knee disability. Therefore, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate these claims based on the current record. As a result of the Board's August 2010 remand, the RO scheduled a VA joints examination of the Veteran's right knee in October 2010. The Board finds the above VA examination report for a right knee disorder otherwise to be thorough and adequate upon which to base a decision with regard to the Veteran's higher rating claim. The VA examiner personally interviewed and examined the Veteran, including eliciting a history from him, and provided the information necessary to evaluate his service-connected disability under the applicable rating criteria. Any deficiency or inadequacy in the October 2010 VA examination as related to his TDIU claim will not prejudice the Veteran in the adjudication of his higher rating claim. Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to the higher rating claim. The Board is aware of a potential Stegall violation in that the examiner provided an employability opinion limited to the Veteran's right knee disability on appeal while the remand had requested an opinion whether it was as likely as not that any of the Veteran's service-connected disabilities, alone or in combination, precluded him from engaging in substantially gainful employment. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Board confers on the claimant as a matter of law the right to compliance with remand directives). However, as discussed below, his TDIU claim must be denied for the reasons outlined below. There is, therefore, no need to remand for compliance with the Board's August 2010 directive. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of these claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Ratings - Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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 their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision, therefore, is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14. As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As a layperson the Veteran is only competent to report observable symptoms-not clinical findings which are applied to VA's Schedule for Rating Disabilities. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. Right Knee The Veteran was granted service connection for a right knee condition in an October 1989 rating decision. The history of his right knee claim was reviewed in detail in the Board's August 2010 decision and need not be repeated here, except to note that he underwent total right knee replacement surgery on October 28, 2008. Thus, in a November 2008 rating decision, VA combined previous ratings for DJD of the right knee and for slight laxity of the right knee into a recharacterized rating for DJD of the right knee status post total knee arthroplasty with history of laxity. A temporary total evaluation was assigned from October 28, 2008, under the provisions of 38 C.F.R. § 4.30, followed by the assignment of a 30 percent scheduler rating from December 1, 2009. As noted in the Introduction, in its August 2010 decision, the Board bifurcated the Veteran's claim for a higher rating for his right knee disability and remanded for further development his entitlement to a rating in excess of 30 percent for DJD of the right knee post total knee arthroplasty with history of laxity since October 28, 2008. As the Veteran was awarded a temporary 100 percent rating from October 28, 2008 to November 30, 2009, the Board now need only adjudicate the time period from December 1, 2009 to the present. The Veteran's right knee disability is currently rated under Diagnostic Code 5010-5055. DC 5010 indicates the presence of traumatic arthritis and DC 5055 is for rating total knee replacement with a prosthesis. Since the Veteran underwent a right knee total arthroplasty in October 2008, and the current VA examination fails to note any symptoms of arthritis in the joint, the appropriate diagnostic code for consideration is DC 5055. Under Diagnostic Code 5055, for one year following implantation, the knee joint warrants an evaluation of 100 percent. Thereafter, where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is warranted. Where there are intermediate degrees of residual weakness, pain or limitation of motion, the disability is rated by analogy to diagnostic codes 5256, 5261 or 5262. The minimum rating is 30 percent. 38 C.F.R. § 4.71a, DC 5055. Diagnostic Code 5256 provides for the assignment of a 30 percent rating when there is ankylosis in a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent rating is assigned when there is extremely unfavorable ankylosis in flexion between 10 and 20 degrees. A 50 percent rating is warranted when there is extremely unfavorable ankylosis in flexion between 20 and 45 degrees. A 60 percent rating is warranted when there is extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, DC 5256. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to 5 degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. 38 C.F.R. § 4.71a, DC 5261. Under Diagnostic Code 5262 a 40 percent rating requires nonunion of the tibia and fibula with loose motion, requiring use of a brace. Malunion of the tibia and fibula with marked knee or ankle disability allows for the assignment of a 30 percent rating; with moderate disability, 20 percent; and with slight disability, 10 percent. 38 C.F.R. § 4.71a, DC 5262. Standard range of knee motion is from 0 degrees (extension) to 140 degrees (flexion). 38 C.F.R. § 4.71, Plate II (2011). Additionally, under Diagnostic Code 5260 a zero percent rating is provided where flexion of the leg is limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under Diagnostic Code 5257, knee impairment with recurrent subluxation or lateral instability warrants a 10 percent rating if it is slight, a 20 percent rating if it is moderate, or a 30 percent rating if it is severe. 38 C.F.R. § 4.71a, DC 5257. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 examinations 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 enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by 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. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2011). An October 2008 private operative report describing the Veteran's total right knee replacement surgery on October 28, 2008 is associated with the claims file. As noted above, the Veteran's right knee disability is now rated under DC 5055 as 30 percent disabling since December 1, 2009. During his June 2010 Board hearing, the Veteran testified that he had experienced an even greater loss of range of motion and stability in his right knee following his October 2008 total right knee arthroplasty. He further testified that he did not feel that his VA examinations accurately reflected his right knee range of motion because in a normal context he would not have bent his knee to those extremes due to pain. He also testified that when he had his total right knee replacement in October 2008 the doctor had to leave a plate in his leg because of a tibial osteotomy done in 2004. He claimed this meant he could only get one instead of three revisions to his new right knee. The Veteran also commented that his left knee replacement disability, which is rated at 60 percent, was much worse that his right knee replacement disability. See transcript at pp. 4, 18-20. August 2010 VA treatment records noted chronic bilateral knee pain that was not controlled with current medications. It was also noted that the Veteran had been prescribed opioids for several years. A VA physician prescribed morphine tablets and later increased the dosage. The Veteran underwent a VA examination of his right knee in October 2010. He complained that his right knee had progressively worsened since his October 2008 total right knee replacement surgery. He said that he took medications, including morphine tablets, but had a poor response to treatment. He complained of pain, stiffness, weakness, incoordination, swelling, and effusions, but denied giving way or locking episodes. The examiner noted there were no constitutional symptoms of arthritis and that the Veteran was able to walk a quarter-mile. He had intermittent, but frequent use of a cane. The Veteran also complained of severe flare-ups for one to two days every one to two weeks after standing for more than 30 minutes or mowing the yard. On physical examination, an antalgic gait was noted and abnormal weight-bearing as well as tenderness, abnormal motion, and guarding of movement. There was no grinding, clicking, instability, or joint ankylosis. Examination of the right knee prosthesis showed no weakness. Range of motion of the right knee measured as follows: flexion to 90 degrees with facial grimacing with extension limited by 10 degrees. Objective evidence of pain was noted with active and repetitive motion of the right knee, but there was no additional limitation of motion after three repetitions of range of motion exercises. The examiner commented elsewhere in her report that she observed the Veteran sitting in a chair with his knees flexed at 90 degrees. X-ray studies showed postsurgical changes of the right knee arthroplasty and a small suprapatellar joint right effusion. Diagnosis was DJD of the right knee status post total knee replacement with residual of mild edema. While the examiner noted some severe effects on the Veteran's usual daily activities, she opined that his right knee disability did not preclude him from gainful employment as there was no evidence from the physical examination or X-ray studies that he was precluded from sedentary work. In considering the evidence of record under the laws and regulations set forth above, the Board concludes that the Veteran is not entitled to a rating in excess of 30 percent for his service-connected DJD of the right knee post total knee arthroplasty with history of laxity since December 1, 2009. As an initial matter, the Board has considered entitlement to a higher rating under Diagnostic Codes 5256, 5261, and 5262, as directed by Diagnostic Code 5055. The Board notes that while the record reflects that the Veteran frequently uses a cane, his residuals of a total right knee arthroplasty are not characterized by nonunion of the tibia and fibula with loose motion requiring a brace. Malunion or nonunion of the tibia and fibula was not shown. Indeed, reference is made to a post-surgical (October 2010) X-ray report that showed that the prosthesis was in satisfactory position, and that there were no osseous abnormalities. The Veteran, therefore, is not entitled to a compensable rating, much less a rating in excess of 30 percent, pursuant to Diagnostic Code 5262 for impairment of the tibia and fibula. There is also no evidence that the Veteran's right knee is ankylosed. A higher (or compensable) rating under Diagnostic Code 5256 is also not warranted. Ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). Here, as noted, the record shows that the Veteran retains an active although limited range of motion. In any event, a compensable rating under DC 5256 for ankylosis of the knee is not warranted. The Veteran's range of motion of the right knee measured flexion to 90 degrees, according to the October 2010 VA examination. Such does not warrant a compensable rating under DC 5260 for limitation of flexion. The Veteran's limitation of motion of the right knee does equate to 10 degrees, according to the October 2010 VA examination. VA records since May 2009 do not show the contrary. However, this limitation of extension only amounts to a 10 percent rating under DC 5261. When combined with the noncompensable flexion evaluation and the other noncompensable evaluations related to the pathology of the right knee noted above, the Veteran would only be entitled to a 10 percent rating for his right knee. At present, he is in receipt of the minimum 30 percent rating under DC 5055, so he is in a more favorable position currently than if he were rated by analogy to DC 5256, 5261, or 5262. The Board observes that the Veteran has complained of pain in the right knee as well as stiffness, weakness, incoordination, swelling, and effusions. He also reported he had difficulty walking more than a short distance. The VA examiner reported that the Veteran's right knee disability affected his activities of daily living. However, while the October 2010 VA examination report has shown objective evidence of pain with active and repetitive limited range of motion, there was no additional limitation of motion shown after repetitive use. Moreover, the examiner noted that she observed that the Veteran could sit in a chair with both knees flexed at 90 degrees. The examination report also noted that he does not require the use of an assistive device, although he frequently uses a cane. Even though the May 2010 examination showed a limitation of extension to 10 degrees, the Board does not believe this minimal functional impairment rises to the level of "chronic residuals consisting of severe painful motion or weakness in the knee" necessary to establish a higher rating under DC 5055. In consequence, a higher rating based on pain and the other DeLuca factors is not warranted in this appeal. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). As a higher rating is not otherwise available under Diagnostic Codes 5256, 5260, and 5262, the assignment of a rating in excess of 30 percent under Diagnostic Code 5055 is not warranted for the time period since December 1, 2009. The Board also finds that the assignment of a higher (60 percent) rating is not warranted under Diagnostic Code 5055 for severe, chronic residuals of his total knee replacement. Again, reference is made to the October 2010 VA examination report that described the Veteran as lacking signs of instability, ankylosis, giving way, grinding, clicking, or locking episodes. It is also noted that the Veteran's range of motion, while limited, would not support the assignment of a rating greater than 10 percent (loss of extension), even when considering his complaints of pain. Indeed, no additional loss of motion was shown with repetitions. The examiner also opined that the Veteran could resume sedentary work in spite of his complaints of functional impairment and the examiner's own findings of adverse effects on his activities of daily living. In rendering a decision on this appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report his increased right knee symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. However, the clinical evidence of record does not indicate that the assignment of any additional increased rating is warranted. As the Veteran's statements are somewhat inconsistent with the evidence of record, the Board does not find his assertions of increased right knee symptoms to be credible in this respect. See Caluza v. Brown, 7 Vet. App. 498 (1995) (in determining whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of a veteran); see also Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Thus, evidence of increased right knee symptomatology has not been established, either through medical or lay evidence. For all the foregoing reasons, the Veteran's claim for entitlement to a rating in excess of 30 percent for DJD of the right knee status post total knee arthroplasty with history of laxity, for the time period since December 1, 2009, must be denied. The Board has considered staged ratings, under Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted for this time period. Since the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board also has considered whether the Veteran is entitled to a referral for an extraschedular rating, which is a component of a claim for an increased rating under Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court recently clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made by the RO or Board. If the rating criteria are inadequate, the RO or Board must proceed to determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, there has been no showing that the Veteran's disability picture could not be contemplated adequately by the applicable schedular rating criteria discussed above. The Veteran's right knee disability, for the time period since December 1, 2009, was applied to the applicable rating criteria, general counsel opinions, and case law. Although the applicable criteria provide for higher ratings, the Board fully explained why a rating in excess of 30 percent is not warranted for this appeal. Given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's right knee disability includes exceptional factors. Referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340(a)(1), 4.15. However, the Court has also held that a TDIU is not available to a veteran who already has a 100 percent schedular disability. Green v. West, 11 Vet. App. 472 (1998); Vettese v. Brown, 7 Vet App. 31, 34-35 (1994); Holland v. Brown, 6 Vet. App. 443 (1994). Further, in Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011), the Federal Circuit recently affirmed a Court decision, which affirmed a December 3, 2007 Board decision, that among other things denied entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s) at the housebound rate. The Court rejected the argument that a veteran is entitled to benefits under subsection 1114(s) if the veteran suffers from several disabilities, where no one disability is rated at 100 percent, even if the veteran's combined disability rating is 100 percent. Such was in keeping with the Court's earlier decision in Bradley v. Peake, 22 Vet. App. 280, 294 (2008), in which it held that a veteran with a schedular rating of total disability must have a single disability rated at 100 percent in order to qualify for benefits under subsection 1114(s). To be sure, VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to special monthly compensation (SMC) under 38 U.S.C.A § 1114. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (finding that SMC "benefits are to be accorded when a veteran becomes eligible without need for a separate claim"). Indeed, as noted in Bradley, VA must consider a TDIU claim despite the existence of a schedular total rating and award SMC under 38 U.S.C.A. § 1114(s) if VA finds the separate disability supports a TDIU rating independent of the other 100 percent disability rating. See Bradley, 22 Vet. App. 280, 294 (2008); see also DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229 -04 (March 10, 2010) (withdrawing VAOPGCPREC 6-99, 64 Fed. Reg. 52375 (1999) (the logic of Bradley suggests that if a veteran has a schedular total rating for a particular service-connected disability and subsequently claims TDIU for a separate disability, VA must consider the TDIU claim despite the existence of the schedular total rating and award SMC under section 1114(s) if VA finds the separate disability(ies) support a TDIU rating independent of the other 100 percent disability rating). In the present case, the Veteran is evidently seeking entitlement to TDIU so that he may request benefits under subsection 1114(s). According to recent and up-to-date information found on the Virtual VA system, he is currently service connected for: depressive disorder (70 percent), left total knee replacement (60 percent), hiatal hernia (30 percent), degenerative joint disease of the right knee status post total knee arthroplasty with history of laxity (30 percent), hypertension (10 percent), right knee scars (10 percent), left knee scars (10 percent), and tinnitus (10 percent). His combined evaluation for all his service-connected disabilities is currently 100 percent. Significantly, the Veteran is not rated at 100 percent for any single service-connected disability; therefore, an award of TDIU is not warranted in this case. ORDER Entitlement to a rating in excess of 30 percent for DJD of the right knee post total knee arthroplasty with history of laxity since December 1, 2009, is denied. Entitlement to a total disability evaluation based on individual unemployability is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs