Citation Nr: 1301428 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 08-38 486 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for carpal tunnel syndrome of the right wrist. 2. Entitlement to an initial rating higher than 20 percent for service-connected low back strain with degenerative disc disease. 3. Entitlement to an initial rating higher than 20 percent for degenerative joint disease of the left knee with left femoral condyle disability. 4. Entitlement to an initial rating higher than 20 percent for degenerative joint disease of the right knee. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Edwards, Associate Counsel INTRODUCTION The Veteran had active service from March 1996 to April 2006. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In an October 2008 rating decision, the RO granted an increased initial evaluation of 20 percent for low back strain with degenerative disc disease, effective April 2006. Despite the grant of this increased initial evaluation, the Veteran has not been awarded the highest possible evaluation. As a result, he is presumed to be seeking the maximum possible evaluation. The issue remains on appeal, as the Veteran has not indicated satisfaction with the 20 percent rating. A.B. v. Brown, 6 Vet. App. 35 (1993). In January 2011, the Board remanded these claims for additional development. That development having been completed, the claims are now ready for appellate review. In May 2012, the Veteran was granted entitlement to service connection for DeQuervain's tenosynovitis of the right wrist. As such, this issue is no longer on appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU rating is part of an appeal for a higher initial rating claim when such claim is raised by the record. Here, the Board notes that the Veteran indicated his wrist disability affects his ability to use a computer; as such, the Board finds that the record reasonably raises a claim for TDIU. See March 2011 VA examination. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. There is no post-service diagnosis of carpal tunnel syndrome of the right wrist. 2. The Veteran's low back strain with degenerative disc disease is not manifested by a forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. 3. The Veteran's left knee disability is not manifested by ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage with locking, pain, and effusion, removal of semilunar cartilage, actual or function limitation of flexion to 15 degrees, actual or functional limitation of extension to 10 degrees, impairment of tibia and fibula or genu recurvatum. 4. The Veteran's right knee disability is not manifested by ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage with locking, pain, and effusion, removal of semilunar cartilage, actual or function limitation of flexion to 15 degrees, actual or functional limitation of extension to 10 degrees, impairment of tibia and fibula or genu recurvatum. CONCLUSIONS OF LAW 1. Service connection for carpal tunnel syndrome of the right wrist is not established. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for an initial rating higher than 20 percent for low back strain with degenerative disc disease are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). 3. The criteria for an initial rating higher than 20 percent for degenerative joint disease of the left knee with left femoral condyle disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5256 - 5263 (2012). 4. The criteria for an initial rating higher than 20 percent for degenerative joint disease of the right knee are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5256 - 5263 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As set forth in the Veterans Claims Assistance Act of 2000 (VCAA), the Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012). Under the VCAA, when VA receives a claim, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim; that VA will seeks to provide; and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. Concerning the Veteran's increased rating claims, the Board notes that the Veteran's disagreement is with the initial evaluations following the grant of service connection. It has been held that once service connection is granted, the claim is substantiated and additional notice is not required. Any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regarding the service connection claim, the VCAA duty to notify was satisfied by a letter sent to the Veteran in August 2006 that fully addressed the entire notice element. The letter informed him of what evidence was required to substantiate his claim and of his and the VA's respective duties for obtaining evidence. A letter fulfilling Dingess requirements was sent in August 2006. There is no allegation from the Veteran that he has any evidence in his possession that is needed for full and fair adjudication of this claim, and the Board finds that the notification requirements of the VCAA have been satisfied as to timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Additionally, VA has a duty to assist the Veteran in claim development. This includes assisting in the procurement of service treatment records and pertinent medical records, as well as providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA outpatient treatment records, private treatment records, service treatment records, and multiple VA medical opinions and examinations pertinent to the issue on appeal. Virtual VA records were reviewed. Therefore, the available medical evidence and records have been obtained in order to make an adequate determination. Neither the Veteran nor his representative has identified any additional existing evidence that has not been obtained or is necessary for a fair adjudication of the claim. The VA's duty to assist in the development of the claim is complete, and no further notice or assistance to the Veteran is required to fulfill the duty. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, Smith v. Principi, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Entitlement to Service Connection for Carpal Tunnel Syndrome of the Right Wrist The Veteran is claiming entitlement to service connection for carpal tunnel syndrome of the right wrist. He asserts that he currently suffers from chronic right wrist pain due to service. Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Generally, in order to prevail on the issue of service connection on the merits, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran's service treatment records were reviewed. In August 1996, the Veteran had a ganglion cyst in his right hand at the radiocarpal joint. In April 2000, the Veteran complained of right wrist pain. It was noted he had a history of a prior cyst. An x-ray was taken was normal. In May 2000, it was determined he had right DeQuervain's tenosynovitis. In May 2001, he had an operation involving the right DeQuervain's tenosynovitis release. Post-service treatment records were reviewed. In February 2011, the Veteran had an electromyography (EMG) nerve conduction study, which indicated his ulnar and median nerves were normal, bilaterally. The Veteran was afforded a VA examination in September 2006. The Veteran reported right wrist pain that started during service and has continued to present. The Veteran also reported experiencing numbness and tingling of the fingers, as well as weakness of the thumb and index finger. Examination of the right wrist revealed no edema, effusion, weakness, tenderness, redness, heat, or abnormal movement or guarding. An x-ray of the right wrist was normal. The examiner stated that there was no diagnosis of carpal tunnel syndrome because the condition was resolved. The Veteran was afforded a VA examination in March 2011. The Veteran reported he began having trouble with his right arm while in service, and he was told he had carpal tunnel syndrome. He reported that in 2002 or 2003, he was told he had tenosynovitis and underwent surgery; however, he stated he had no improvement from the surgery and continues to have numbness of the right fingers and wrist. He denied having numbness on the volar pads of any fingers of the right hand and denied having any symptoms at night or other symptoms typical of carpal tunnel syndrome. Examination revealed the Veteran had a normal range of motion of the right wrist, although he complained of pain with extension of the thumb against resistence. The Veteran was diagnosed with DeQuervain's tenosynovitis of the right wrist. The examiner stated that the Veteran did not give any history consistent with a diagnosis of carpal tunnel and the physical examination gave no indication of carpal tunnel. The examiner noted that an EMG from February 2011 indicated that both ulnar and median nerves bilaterally were normal. The Board notes that the Veteran is already service connected for DeQuervain's tenosynovitis. See May 2012 rating decision. However, the Veteran does not have a diagnosis of carpal tunnel syndrome of the right wrist. Where the evidence establishes that a Veteran does not currently have a disorder for which service connection is sought, service connection for that disorder is not authorized under the statues governing Veterans' benefits. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). In the instant case, there is no current diagnosis of carpal tunnel syndrome of the right wrist. The Board notes the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, and that a claimant may be granted service connection even though the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this case, however, there is no competent and probative evidence of carpal tunnel syndrome of the right wrist at any time during the period under appellate review. In the absence of a diagnosis, the other elements of service connection for this claim need not be addressed and the claim for service connection must be denied. In reaching such decision, the Board has considered the Veteran's lay statements that he currently has carpal tunnel syndrome of the right wrist. In this regard, the Board notes that he is competent to report pain and other symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. However, while the Veteran is competent to report his symptoms, the Board finds that he is not competent to diagnose carpal tunnel syndrome. In this regard, competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis or opinion. 38 C.F.R. § 3.159. The Court has held that, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the Veteran is not competent to provide evidence as to more complex medical questions. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, as diagnosing carpal tunnel syndrome is complex in nature, the Board finds that the Veteran is not competent to diagnose such disorder. Moreover, the Veteran's personal opinion on this matter is outweighed by the findings of VA examinations, which utilized clinical examinations to rule out the presence of carpal tunnel syndrome. Therefore, the Board finds that the competent and probative evidence fails to reveal a diagnosis of carpal tunnel syndrome of the right wrist. In the absence of proof of a present disability, there can be no valid claim for service connection. See Brammer, supra; Rabideau, supra; McClain, supra. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for carpal tunnel syndrome of the right wrist. As such, that doctrine is not applicable in the instant appeal, and the Veteran's claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. III. Increased Ratings The Veteran is seeking increased initial ratings for his service-connected low back strain, and degenerative joint disease of the bilateral knees. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the entire record, including the Veteran's VA clinical records and private treatment records. These show complaints and treatment, but will not be referenced in detail. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will discuss the evidence pertinent to the rating criteria and the current disability. A. Entitlement to an Initial Rating Higher Than 20 Percent for Service-Connected Low Back Strain with Degenerative Disc Disease The Veteran's low back disability is rated as 20 percent disabled under 38 C.F.R. §4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). He is seeking an increased rating. The Board notes that while the regulations pertaining to disabilities of the spine have undergone recent amendments, these changes do not affect the present claim, as the Veteran's claim was filed in March 2006, subsequent to the most recent regulation change. Thus, the rating criteria currently in effect, the General Rating Formula for Diseases and Injuries of the Spine, are the only rating criteria for current consideration. A rating of 20 percent is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm, or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). An increased rating of 40 percent is warranted when there is forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Id. A rating of 50 percent is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a rating of 100 percent is warranted for unfavorable ankylosis of the entire spine. Id. The Veteran was afforded a VA examination in September 2006. Examination revealed no evidence of radiating pain on movement and muscle spasm was absent. There was tenderness of the back. There was negative straight leg raising, bilaterally with no ankylosis of the lumbar spine. The Veteran's range of motion was 80 degrees of flexion, 20 degrees of extension, 20 degrees of right and left lateral flexion, and 20 degrees of right and left lateral rotation. The examiner noted that following repetitive range of motion the Veteran had additional limitation of motion and joint function secondary to pain, which additionally limited the joint functions by 10 degrees. There were no signs of intervertebral disc syndrome. The Veteran was afforded a VA examination in March 2011. He reported pain that is constant and that radiates down the right leg to the right foot. He also reported numbness that radiates down the leg in the same pattern as the pain. He reported he has flare-ups, occurring approximately two times a week that last for several hours. When he has a flare-up, he experiences spasms, weakness, discomfort, decreased motion, and numbness. He denied any bowel or bladder incontinence. Examination revealed his range of motion was 90 degrees of forward flexion with pain starting at 70 degrees, 30 degrees of extension with pain starting at 20 degrees, 15 degrees of left and right lateral flexion with pain starting at 10 degrees, and 15 degrees of left and right lateral rotation, with pain throughout the 15 degrees. The Board has considered all applicable statutory and regulatory provisions to include 38 C.F.R. §§ 4.40 and 4.59, as well as the holding in DeLuca v. Brown, 8 Vet. App. 202 (1995), regarding functional impairment attributable to pain, particularly in light of the fact that the Veteran contends his disability is essentially manifested by pain. Under 38 C.F.R. § 4.59, painful motion is considered limited motion even though a range of motion is possible beyond the point when pain sets in. Hicks v Brown, 8 Vet. App. 417, 421 (1995). VA 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 the 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). For a 40 percent evaluation, forward flexion of the thoracolumbar spine must be actually or functionally limited to 30 degrees or less or there must be favorable ankylosis of the entire thoracolumbar spine. The Board notes that during the September 2006 VA examination, the Veteran's forward flexion was limited to 80, and after repetition, was limited to 70 degrees. Similarly, during the March 2011 VA examination, the Veteran's flexion was limited to 90 degrees, with pain starting at 70 degrees. Thus, the Board finds that the current 20 percent evaluation, even considering the principles of 38 C.F.R. § 4.40 and 4.45, fully and appropriately contemplates the degree of limited flexion that exist during periods of exacerbation. Alternatively, the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes allows a rating of 40 percent where there is intervertebral disc syndrome with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. However, there has been no documentation of incapacitating episodes requiring bed rest prescribed by a physician in the post-service medical records. The current regulations also allow for separate neurological evaluations, but the evidence in this case does not allow for separate evaluations. During the VA examinations, the examiners noted intact motor strength and sensation in the lower extremities, and the neurological exams were normal. In addition, the Veteran reported no bowel or bladder dysfunction. The Board notes that during the March 2011 VA examination, the examiner noted there was a history of radicular type symptoms given by the Veteran; however, there were no objective findings of radiculopathy on physical exam. The examiner noted a treatment note from September 2005 indicated an electromyography (EMG) demonstrated right S1 radiculopathy, however, the Board notes that the Veteran is service connected for his low back effective April 2006. For these reasons, a higher rating is not warranted based on intervertebral disc syndrome and a separate rating is not warranted for any neurological symptomatology. Other medical evidence of record includes complaints and treatment of back pain at VA outpatient centers and private treatment centers. This evidence supports the diagnosis of low back strain with degenerative disc disease, but does not provide a basis to warrant a rating higher than 20 percent under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. B. Entitlement to an Initial Rating Higher Than 20 Percent for Degenerative Joint Disease of the Left Knee with Left Femoral Condyle Disability The Veteran's left knee is rated as 20 percent disabled under 38 C.F.R. § 4.71a, Diagnostic Code 5260. He is seeking an increased rating. Knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). VA's General Counsel has stated that when a knee disorder is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257 and a Veteran also has limitation of knee motion which at least meets the criteria for a noncompensable evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5260 or 5261, separate evaluations may be assigned for arthritis with limitation of motion and for instability. However, General Counsel stated that if a Veteran does not meet the criteria for a noncompensable rating under either Diagnostic Code 5260 or Diagnostic Code 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). If a rating is assigned under the provisions for other knee impairment (38 C.F.R. § 4.71a, Code 5257) a separate 10 percent rating may be assigned where some limitation of motion, albeit noncompensable, has been demonstrated. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). VA's General Counsel has also stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Rating the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran was afforded a VA examination in September 2006. The Veteran reported knee pain, weakness, stiffness, swelling, giving way, and locking. Examination revealed no signs of edema, effusion, weakness, tenderness, redness, heat, or abnormal movement or guarding of movement. Range of motion was 0 degrees extension to 120 degrees flexion, and was additionally limited by 20 degrees by pain, fatigue, weakness, and lack of endurance after repetition. The medial and lateral meniscus test, the medial and lateral collateral ligaments stability test, and anterior and posterior cruciate ligaments stability test were all within normal limits. X-rays demonstrated degenerative arthritic changes. The Veteran was afforded a VA examination in March 2011. The Veteran complained of pain in the knee but no locking, although the knee occasionally gave way on him. He did not report any dislocation or subluxation. It was noted the Veteran had a knee brace but did not use a cane or crutches. Examination revealed flexion was to 145 degrees, with pain starting at 115 degrees. Extension was to zero. The medial and lateral collateral ligaments were strong in both full extension and 30 degrees of extension. McMurray's testing did not indicate any significant problems with the medial meniscus or lateral meniscus and drawer testing revealed there was less than 5 millimeters of motion. As stated previously, knee disabilities are evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263, which rate disabilities of the knee and leg. Diagnostic Code 5256 is not applicable because there is no ankylosis, as evidenced in the range of motion exhibited in the September 2006 and March 2011 VA examinations. The Board finds that the Veteran is not entitled to a separate 10 percent rating under Diagnostic Code 5257. Although the Veteran indicated that his knee occasionally gives way, testing at both the September 2006 and March 2011 VA examinations indicated that his ligaments were strong and McMurray and drawer testing were negative. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain is inapplicable to ratings under Diagnostic Code 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Diagnostic Codes 5258 and 5259 are not applicable in this case. Although the Veteran reported episodes of locking, there has been no evidence of dislocated semilunar cartilage or removal of semilunar cartilage. Under Diagnostic Code 5260, to receive a rating of 30 percent, limitation of flexion of the leg must be actually or functionally limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent rating is warranted when limitation of extension is to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. During the September 2006 VA examination, the Veteran's extension was limited to 0 degrees and flexion was limited to 120 degrees with pain starting at 100 degrees. In March 2011, VA examination revealed flexion was limited to 145 degrees, with pain starting at 115 degrees and extension was limited to zero degrees. A higher rating under Diagnostic Code 5260 is not warranted, as there is no evidence that the Veteran's flexion has been limited to 30 degrees. Additionally, a separate rating of 10 percent for limitation of extension is not warranted, as the Veteran's extension is not limited to 10 degrees. In reaching these conclusions for Diagnostic Code 5260 and 5261, the Board has considered any additional functional limitation due to factors such as pain, weakness, incoordination, or fatigability. See 38 C.F.R. §§ 4.40 and 4.45; Deluca v. Brown. In considering additional limitation of function, the Board acknowledges the Veteran's complaints of knee pain and stiffness. These complaints are well documented in the Veteran's written statements and treatment records. The Board has considered the Veteran's functional limitation of flexion and extension based on pain and finds that the current rating adequately compensates the Veteran for his symptoms. Diagnostic Codes 5262 and 5263 are not applicable as there is no evidence that the Veteran suffers from impairment of the tibia and fibula or genu recurvatum. Additionally, a separate rating for arthritis is not assigned. As stated previously, General Counsel has stated that if a Veteran does not meet the criteria for a noncompensable rating under either Diagnostic Code 5260 or Diagnostic Code 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). The Board has also considered whether any additional Diagnostic Codes are applicable; however, the Board finds that the ratings for the knee and leg are the most appropriate. In summary, the Board finds that the currently assigned 20 percent rating is appropriate. C. Entitlement to an Initial Rating Higher Than 20 Percent for Degenerative Joint Disease of the Right Knee The Veteran's right knee is rated as 20 percent disabled under 38 C.F.R. § 4.71a, Diagnostic Code 5260. He is seeking an increased rating. The Veteran was afforded a VA examination in September 2006. The Veteran reported knee pain, weakness, stiffness, swelling, giving way, and locking. Examination revealed no signs of edema, effusion, weakness, tenderness, redness, heat, or abnormal movement or guarding of movement. Range of motion was 0 degrees extension to 120 degrees flexion, and was additionally limited by 20 degrees by pain, fatigue, weakness, and lack of endurance after repetition. The medial and lateral meniscus test, the medial and lateral collateral ligaments stability test, and anterior and posterior cruciate ligaments stability test were all within normal limits. X-rays demonstrated degenerative arthritic changes. The Veteran was afforded a VA examination in March 2011. The Veteran complained of pain in the knee but no locking. He did not report any dislocation or subluxation. It was noted the Veteran had a knee brace but did not use a cane or crutches. Examination revealed flexion was to 135 degrees, with pain starting at 105 degrees. Extension was to zero. The medial and lateral collateral ligaments were strong in both full extension and 30 degrees of extension. McMurray's testing did not indicate any significant problems with the medial meniscus or lateral meniscus and drawer testing revealed there was less than 5 millimeters of motion. As stated previously, knee disabilities are evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263, which rate disabilities of the knee and leg. Diagnostic Code 5256 is not applicable because there is no ankylosis, as evidenced in the range of motion exhibited in the September 2006 and March 2011 VA examinations. The Board finds that the Veteran is not entitled to a separate 10 percent rating under Diagnostic Code 5257. Testing at both the September 2006 and March 2011 VA examinations indicated that his ligaments were strong and McMurray and drawer testing were negative. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain is inapplicable to ratings under Diagnostic Code 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Diagnostic Codes 5258 and 5259 are not applicable in this case. There has been no evidence of dislocated semilunar cartilage or removal of semilunar cartilage. Under Diagnostic Code 5260, to receive a rating of 30 percent, limitation of flexion of the leg must be actually or functionally limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent rating is warranted when limitation of extension is to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. During the September 2006 VA examination, the Veteran's extension was limited to 0 degrees and flexion was limited to 120 degrees with pain starting at 100 degrees. In March 2011, VA examination revealed flexion was limited to 135 degrees, with pain starting at 105 degrees and extension was limited to zero degrees. A higher rating under Diagnostic Code 5260 is not warranted, as there is no evidence that the Veteran's flexion has been limited to 30 degrees. Additionally, a separate rating of 10 percent for limitation of extension is not warranted, as the Veteran's extension is not limited to 10 degrees. In reaching these conclusions for Diagnostic Code 5260 and 5261, the Board has considered any additional functional limitation due to factors such as pain, weakness, incoordination, or fatigability. See 38 C.F.R. §§ 4.40 and 4.45; Deluca v. Brown. In considering additional limitation of function, the Board acknowledges the Veteran's complaints of knee pain and stiffness. These complaints are well documented in the Veteran's written statements and treatment records. The Board has considered the Veteran's functional limitation of flexion and extension based on pain and finds that the current rating adequately compensates the Veteran for his symptoms. Diagnostic Codes 5262 and 5263 are not applicable as there is no evidence that the Veteran suffers from impairment of the tibia and fibula or genu recurvatum. Additionally, a separate rating for arthritis is not assigned. As stated previously, General Counsel has stated that if a Veteran does not meet the criteria for a noncompensable rating under either Diagnostic Code 5260 or Diagnostic Code 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). The Board has also considered whether any additional Diagnostic Codes are applicable; however, the Board finds that the ratings for the knee and leg are the most appropriate. In summary, the Board finds that the currently assigned 20 percent rating is appropriate. D. Extraschedular Evaluations The VA Schedule of Disability Ratings will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon 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 that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's lumbar and bilateral knee disabilities are inadequate. A comparison of the level of severity and symptomatology of the Veteran's disabilities with the established criteria found in the rating schedule shows that the rating criterion reasonably describes the Veteran's disability levels and symptomatology. The Board further observes that, even if the available schedular evaluations for the disabilities are inadequate (which they manifestly are not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for his disabilities. Additionally, there is no evidence in the medical records of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that the disabilities on appeal cause impairment with employment over and above that which is contemplated in the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to service connection for carpal tunnel syndrome of the right wrist is denied. Entitlement to an initial rating higher than 20 percent for service-connected low back strain with degenerative disc disease is denied. Entitlement to an initial rating higher than 20 percent for service-connected degenerative joint disease of the left knee with femoral condyle disability is denied. Entitlement to an initial rating higher than 20 percent for service-connected degenerative joint disease of the right knee is denied. REMAND As stated previously, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. The Veteran claims that he has difficulty working due to his service-connected disabilities. See March 2011 VA examination. The Board finds that the evidence raises a claim for a TDIU rating. The Board cannot adjudicate this issue in the first instance. Accordingly, the case is REMANDED for the following actions: 1. Provide the Veteran VCAA notice for entitlement to TDIU. 2. Obtain all current VA outpatient records and private records. If no further records are available, properly document a negative response in the file. 3. Ask the Veteran to provide documentation from his employer (including potential employers or former employers) that addresses his work performance, attendance, and whether his disabilities interfere with his employment or the performance of his job. Records showing missed time from work, release from employment based upon attendance or other reasons, and letters from employers and the like may be submitted by the Veteran and should be requested. 4. Afford the Veteran an examination to determine the effects of his service-connected disabilities (degenerative joint disease of the bilateral knees, degenerative disc disease of the lumbar spine with right lower extremity intervertebral disc syndrome, nerve root sciatic, bilateral tinnitus, and DeQuervain's tenosynovitis of the right wrist) on his ability to maintain employment consistent with his education and occupational experience. The claims file must be made available to the examiner for review in conjunction with the examination. All necessary special studies or tests are to be accomplished. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on a review of the case and the claims file, the examiner must provide an opinion as to whether it is at least as likely as not (i.e. at least 50 percent probability), more likely than not (i.e. more than 50 percent probability) or less likely than not (i.e. less than 50 percent probability) that the Veteran's service-connected disabilities alone preclude him from securing and following substantially gainful employment consistent with his education and occupational experience. All opinions provided must include an explanation of the bases for the opinion. If the requested opinion cannot be made without resort to speculation, the examiner must state this and specifically explain why an opinion cannot be provided without resort to speculation. 5. The Veteran is hereby notified that it is his responsibility to report for the examinations scheduled in connection with this REMAND and to cooperate in the development of his case. 6. After completion of the above and any additional development of the evidence that the RO may deem necessary, the RO should review the record and readjudicate the issue. If the claim remains denied, issue to the Veteran a supplemental statement of the case, and afford the appropriate period of time within which to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs