Citation Nr: 1303065 Decision Date: 01/30/13 Archive Date: 02/05/13 DOCKET NO. 09-49 554 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for internal derangement of the left knee with degenerative arthritis. 2. Entitlement to an evaluation in excess of 10 percent for left knee instability. 3. Entitlement to an evaluation in excess of 10 percent for coronary artery disease from September 1, 2007, to July 29, 2009. 4. Entitlement to an evaluation in excess of 10 percent for coronary artery disease subsequent to November 1, 2009. 5. Entitlement to an initial disability evaluation in excess of 10 percent for iliotibial band syndrome with bursitis of the left hip. 6. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression. 7. Entitlement to service connection for purpose of establishing eligibility to treatment. REPRESENTATION Appellant represented by: David L. Huffman, Attorney-at-Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran (the appellant) had active service from October 1984 to November 1990 and service in the National Guard from May 5, 2007, to May 9, 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from various rating determinations of the Department of Veterans Affairs (VA) Regional Office (RO) located in Huntington, West Virginia. In a February 2009 rating determination, the RO granted service connection for iliotibial band syndrome with bursitis of the left hip and assigned a 10 percent disability evaluation. The RO also continued a 10 percent disability evaluation for internal derangement of the left knee with degenerative arthritis and denied service connection for a heart condition. In a February 2009 rating determination, the RO granted service connection for coronary artery disease and assigned a 100 percent disability evaluation from May 10, 2007, to September 1, 2007, and a 10 percent disability evaluation thereafter. In an August 2010 rating determination, the RO granted service connection for instability of the left knee and assigned a 10 percent disability evaluation effective April 8, 2010. In a November 2011 rating determination, the RO denied service connection for an acquired psychiatric disorder, to include depression, as well as service connection for the purpose of establishing eligibility for treatment. In a May 2012 rating determination, the RO assigned a 100 percent disability evaluation for coronary artery disease from July 27, 2009, to November 1, 2009, and a 10 percent disability evaluation thereafter. With regard to the 10 percent disability assigned for instability of the left knee, the Board notes that while the RO classified this as a grant of service connection, the issue of instability is subsumed within the Veteran's claim for an increased evaluation for his left knee disorder, received in November 2007. Moreover, the Board observes that the RO provided the Veteran with necessary laws and regulations with regard to instability/subluxation (Diagnostic Code 5257) in the November 2009 statement of the case and discussed the Veteran's instability, or lack thereof, in the reasons and bases portion of the decision. As such, the Board will address this issue as part and parcel of the Veteran's claim for an increased evaluation in November 2007, to include by way of staged ratings, if necessary. As to the November 2011 rating determination, the Veteran filed a notice of disagreement with the denial of service connection for a psychiatric disorder and the denial of entitlement to service connection for the purposes of establishing treatment. To date, there has been no statement of the case issued on these issues. The Veteran appeared at a Travel Board hearing before the undersigned Veterans Law Judge in October 2012. A transcript of the hearing is of record. Based upon the above actions, the Board has listed the issues as such on the title page of this decision. The issues of entitlement to an initial disability evaluation in excess of 10 percent for iliotibial band syndrome with bursitis of the left hip and entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression as well as entitlement to service connection for the purpose of establishing treatment are remanded to the RO. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. Flexion of the left knee has been shown to be no less than 115 degrees, with extension to no less than 0 degrees. 2. Objective findings of subluxation or lateral instability of the left knee were not demonstrated prior to April 8, 2010. 3. No more than mild subluxation/lateral instability of the left knee has been shown since April 8, 2010. 4. The preponderance of the evidence of record indicates that, prior to July 29, 2009, and subsequent to November 1, 2009, the Veteran's heart disease was not productive of: a workload less than 5 METs but not greater than 7 METs; cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray; or left ventricular dysfunction with an ejection fraction at or below 50 percent. CONCLUSIONS OF LAW 1. The criteria for a separate 10 percent disability evaluation for left knee arthritis, based upon limitation of flexion, have been met throughout the course of the appeal. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260 (2012). 2. The criteria for a separate compensable disability evaluation for left knee arthritis based upon subluxation/lateral instability were not met prior to April 8, 2010. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.71a, Diagnostic Code 5257 (2012). 3. The criteria for a 10 percent disability evaluation, and no more, for left knee arthritis based upon subluxation/lateral instability have been met since April 8, 2010. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(b)(1), 4.71a, Diagnostic Code 5257. 4. The criteria for a rating in excess of 10 percent for the Veteran's service-connected heart disease were not met for the time period prior to July 29, 2009, or subsequent to November 1, 2009. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.104, Diagnostic Code 7006 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 has been amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). The Court has also held that that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As to the issues for higher evaluations for a left knee disorder and heart disease, a VCAA notice letter sent in February 2008 satisfied the provisions of 38 U.S.C.A. § 5103(a). In this letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information on disability ratings and effective dates required by Dingess. With regard to the heart disease claim, because the Veteran's appeal arises from his disagreement with the initial rating following the grant of service connection no additional notice is required. The Court and the United States Court of Appeals for the Federal Circuit (Federal Circuit) have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As to both issues, the Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA and private treatment records, VA and private examination reports, and lay evidence. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c). No additional pertinent evidence has been identified by the claimant. The Board further notes that as it relates to the left knee disorder, the Veteran was afforded VA examinations in January 2008 and April 2010. As to whether an additional VA examination may be warranted, the Veteran specifically testified that his knee problems had essentially remained the same from the time of the last VA examination. As to the heart disease claim, the Board notes that the Veteran was afforded VA examinations in September 2008 and May 2011. The Veteran did not indicate that there had been an increase in his heart symptomatology at the October 2012 hearing. Information obtained from both the heart and knee examinations is sufficient in order to properly address the issues on appeal. As such, the Board finds that additional VA examinations are not warranted as there is otherwise sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments presented by his representative. He also appeared at a Travel Board hearing before the undersigned Veterans Law Judge in October 2012. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. Evaluations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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). In Fenderson, the Court noted an important distinction between an appeal involving a Veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Left Knee Diagnostic Code 5003 provides 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 (DC 5200 etc.). When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assigned where x-ray evidence shows involvement of two or more major joints or 2 or more minor joint groups. Where there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent evaluation is assigned. Note (1) to Diagnostic Code 5003 states that the 20 and 10 percent ratings based on x-ray findings, above, will not be combined with ratings based on limitation of motion. Id. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees; 10 percent rating where flexion is limited to 45 degrees; 20 percent rating where flexion is limited to 30 degrees; and 30 percent rating where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to 5 degrees; 10 percent rating where extension is limited to 10 degrees; 20 percent rating where extension is limited to 15 degrees; a 30 percent rating where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel further held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Under Diagnostic Code 5259, a 10 percent disability rating is warranted for symptomatic removal of the semilunar cartilage. In addition, General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by X-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate disability rating must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). In this case, the Veteran is currently assigned a 10 percent rating for his service-connected internal derangement of the left knee pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5259 which is the maximum rating allowed under that diagnostic code, and a 10 percent disability evaluation for instability under Diagnostic Code 5257. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59 (2012). In November 2007, the Veteran requested an increased disability evaluation for his left knee. In connection with his claim, treatment records were obtained from Parkersburg Orthopedics Associates. At the time of a March 2007 visit, the Veteran complained of pain in his left knee, more on the lateral aspect of the knee. The Veteran noted that the knee pain was worse with exercise or when he drove a truck at work. He reported that the left knee felt like it was popping, locking, and catching at times. Physical examination of the knee revealed that there was no obvious effusion. There were old scars from a previous arthroscopy. The Veteran had no obvious joint line tenderness. He had full range of motion for flexion and extension. The knee was ligamentously stable to valgus and varus stress. Lachman's was positive as he did not have solid endpoint compared to the right knee. McMurray's testing was negative. X-rays revealed medial compartment narrowing consistent with osteoarthritis. It was the examiner's assessment that the Veteran had left knee pain, left knee osteoarthritis, and an old cruciate ligament tear. Additional treatment records obtained from Parkersburg Orthopedics reveal that the Veteran was given cortisone injections into the knee. The Veteran was afforded a VA examination in January 2008. He was noted to have pain in the knee and to be receiving cortisone injections in the knee. The Veteran described the pain as a sharp type of pain on the outside of the knee. He denied any locking and reported that the knee held him upright. He had a lack of endurance and could only walk 200 feet. He was unable to squat. Flare-ups were caused by his job. He had a hard time pushing the clutch with his left leg. Exacerbations were caused by driving a clutch truck with there being no alleviating factors. There was no additional loss of motion during flare-ups. The Veteran did not use crutches, braces, or canes. There were no dislocations or subluxations. He was able to do his job quite well with the condition as it existed and the knee did not affect his activities of daily living. Physical examination revealed he walked without a limp and that there was no atrophy in the left thigh. He had full range of motion for extension and flexion to 135 degrees in both knees. There was no loss of motion with repetition, both active and passive, and no pain on motion. There was no crepitation and the left knee was not swollen. The collateral ligaments were tight on both the medial and lateral side in full extension and in 30 degrees of flexion. Lachman's sign was 1+ on the left and 1/2 to 1 on the right. Pivot shifting and McMurray's tests were negative. The left knee had a large cystic swelling on the lateral side at the joint line level which was not present on the right knee. The large cystic swelling appeared to be full of joint fluid because it was compressible. It was also very tender and the lateral joint line itself was quite tender. X-rays showed a mild amount of medial joint space narrowing on the left side. The examiner indicated that the Veteran had early medial compartment osteoarthritis of the left knee as well as a torn lateral meniscus. He stated that the torn lateral meniscus was the cause of the cystic swelling on the joint and the cystic swelling was diagnostic of a torn lateral meniscus. The Veteran was afforded an additional VA examination in April 2010. At the time of the examination, the Veteran reported that his left knee pain had become progressively worse. He was taking NSAIDS and aspirin as needed. His response to treatment had been fair. The Veteran was noted to have undergone a left knee meniscectomy in 1992. The Veteran reported having no deformity, giving way, instability, incoordination, episodes of dislocation or subluxation, locking, effusion or symptoms of inflammation. He did have stiffness, weakness, decreased speed of joint motion, limitation of motion, and flare-ups of joint disease. The flare-ups were moderate in nature and occurred every two to three weeks depending on activity. Precipitating factors were cold weather and prolonged standing. Alleviating factors were changing positions. The Veteran reported having to sit during a flare and having difficulty ambulating. He was able to stand for 15-30 minutes and had no limitations with walking. He had increased wear outside the heel on the left and right shoes. Physical examination of the left knee revealed crepitus, abnormal motion, and guarding of movement. Grinding was present as was instability. The Veteran had mild medial/lateral instability. Anterior instability was also noted. He also had subpatellar tenderness and the meniscus was noted to be surgically absent. Range of motion was from 0 to 115 degrees on the left as compared to 0 to 130 on the right. There was objective evidence of pain following repetitive motion but no additional limitation of motion. X-rays revealed very minimal degenerative changes involving the medial compartment of the left knee. The Veteran was not working as he had been laid off in December 2009. The examiner rendered a diagnosis of left knee degenerative joint disease with internal derangement. The service-connected left knee and hip problems were noted to have a significant effect on the Veteran's occupation in that they caused decreased mobility, problems with lifting and carrying, decreased strength, and lower extremity pain. With regard to activities of daily living, there was moderate impact on chores, exercise, and recreation. There was severe impact on traveling and driving, and no impact on bathing, dressing, toileting, and grooming. In a December 2010 statement, the Veteran reported that his symptoms were more consistent with a 20 percent disability evaluation for instability. At the time of his October 2012 hearing, the Veteran noted having problems moving sideways. He indicated that as long as he stood straight he was fine but that if someone pushed him or he was knocked to the left, his knee would go out on him. The Veteran stated that his knee problem had remained the same over the past several years. With regard to the left knee, the Veteran has been found to have full extension at the time of each VA examination and outpatient visit, with no additional limitation of motion being found after repetitive use. As such, an increased or separate evaluation is not warranted under Diagnostic Code 5261. As it relates to flexion of the left knee, the Veteran has not been shown to have flexion to less than 115 degrees at the time of any VA examination or outpatient visit during the time period in question. As the Veteran has been shown to have limitation of motion, although it be noncompensable for rating purposes, in conjunction with his arthritis, a 10 percent disability evaluation would be warranted under 5260. See also VAOPGCPREC 9-98; VAOPGCPREC 9-2004; As to instability/subluxation, the Board notes that prior to the April 2010 VA examination, performed on April 8, 2010, the Veteran was not shown to have either instability or subluxation on objective testing. At the time of his March 2007 private examination, the Veteran's knee was noted to be ligamentously stable to valgus and varus stress and McMurray's testing was negative. Moreover, at the time of the January 2008 VA examination, the Veteran's knee collateral ligaments were tight on both the medial and lateral side in full extension and in 30 degrees of flexion and pivot shifting and McMurray testing were negative. Furthermore, the examiner noted at that time that the Veteran had no history of dislocations or subluxations. Thus, while the Board has considered the Veteran's subjective reports, the objective medical evidence simply does not reveal clinical support for his contentions and the Board therefore cannot assign a compensable disability evaluation under 5257 for the left knee prior to April 8, 2010. The clinical presence of instability or subluxation is a medical finding which the Veteran is not competent to relate. The criteria for a 10 percent disability evaluation for lateral instability under DC 5257 were met as of April 8, 2010. At that time, the Veteran was noted to have grinding and instability. The medial/lateral/anterior instability was described as mild. As such, a 10 percent disability evaluation, contemplating mild instability/subluxation, is warranted under DC 5257. The Board notes that the Veteran has expressed his opinion that the symptomatology associated with the instability warrants at least a moderate disability evaluation and observes that lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, a lay person, such as the Veteran, lack the medical training and expertise to be able to provide a complex medical opinion. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Moreover, in adjudicating this claim, the Board must assess not only competency of the Veteran's statements, but also their credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, the Board concludes that the objective evidence derived from the examinations by medical professionals to be more probative than the Veteran's assertions. Moreover, an additional VA examination is not warranted to determine the current severity of any subluxation, as the Veteran, at the time of his October 2012 hearing, indicated that his left knee problems were the same as they were at the time of the April 2010 examination. With regard to consideration under DC 5259, the Veteran has been assigned the highest possibility disability evaluation under this code. Coronary Artery Disease A 10 percent evaluation is warranted for arteriosclerotic heart disease (coronary artery disease) with a documented history of coronary artery disease where a workload of greater than 7 metabolic equivalents (METs) but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, continuous medication is required. A 30 percent evaluation is warranted for arteriosclerotic heart disease (coronary artery disease) with a documented history of coronary artery disease where a workload of greater than 5 metabolic equivalents (METs) but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or, there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted where there is more than one episode of acute congestive heart failure in the past year; or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent evaluation is warranted with chronic congestive heart failure; or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7006. The provisions of 38 C.F.R. § 4.104 define one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. On May 5, 2007, the Veteran suffered a myocardial infarction. Surgery performed at that time included cardiac catheterization and stenting. In conjunction with his claim, the Veteran was afforded a VA examination in September 2008. His course since onset was noted to be stable. The Veteran was noted to be on Metoprolol, Plavix, Nitroglycerin, and Zocor. The myocardial infarction was noted to have been mild in nature. The examiner indicated that the Veteran had an angioplasty and thrombectomy to left anterior descending (LAD) artery with 2 stents being placed in the LAD. An echocardiogram performed prior to the surgery revealed an ejection fraction of 40 percent. An echocardiogram performed following the surgery revealed an ejection fraction of 55 percent. Physical examination revealed that heart sounds were present in S1, S2. Rhythm was regular and there was no murmur, click, or pericardial rub. Chest shape was normal and breath sounds were clear. The examiner noted that stress tests were not performed as the Veteran reported that he had had a stress test in early 2008 at Holzer Medical Center and the Veteran stated that his symptoms/condition had not changed since that time. The examiner rendered a diagnosis of coronary artery disease. Impact on occupational activities included lack of stamina, weakness, or fatigue and increased absenteeism. It had a moderate impact on chores and a mild impact on recreation, with no effect on bathing, dressing, or grooming. Treatment records submitted by the Veteran from the Holzer Clinic in conjunction with his claim include a January 2008 outpatient visit, at which time the Veteran was found to have a normal rate and rhythm, normal heart sounds, and no murmurs. Edema was not found to be present. The Veteran was found to be status post stress test and to be doing very well. He was noted to be tolerating his medications well. A January 2009 VA examination report noted that he Veteran was scheduled for a VA stress test examination in February 2009 and did not report. It was noted that an EKG performed in conjunction with his January 2009 hip examination revealed marked sinus bradycardia and an anteroseptal infarct. In a March 2009 letter, the Veteran indicated that he had not been informed about the February 2009 examination and was willing to report for an additional VA examination. On July 27, 2009, the Veteran was admitted and hospitalized at St. Joseph's Hospital for a period of two days for stent thrombosis. The Veteran was afforded a VA examination in May 2011. At the time of the examination, the Veteran stated he was first diagnosed with heart problems in 2007. He had had two stents placed in his LAD at that time. The Veteran noted that two years later he had another heart attack and that prior to the second incident VA had stopped his Plavix. He was treated at St. Joseph's Hospital for the second incident. The Veteran stated that he had chest pain at night or when driving. He noted that he had not sought medical care for these chest pain episodes and that the chest pain was not activity related. The examiner stated that there was no evidence of functional limitations due to heart disease. An exercise test was not conducted as the Veteran denied experiencing symptoms with any level of physical activity. The examiner stated that there was no evidence of cardiac hypertrophy or dilatation and that the Veteran had a left ventricular ejection fraction of 60 percent and moderate distal septal and apical hypokinesis on echocardiogram testing. The examiner opined that the Veteran's heart disease did not have any impact on his ability to work. At his October 2012 hearing, the Veteran testified as to the two prior hospitalizations and indicated that his most recent testing was performed in May 2011. He stated that his blood pressure was usually 110/60 and that he would have dizzy spells every now and then. He noted that if he sat for a long time and then stood up he would have dizzy spells. The Veteran reported that he had cut back his activities as a result of his heart problems. He noted that he was not taking his blood thinner medication as he was not working and had no insurance. He stated that he was not working as there was no work available at this time. Records obtained from Virtual VA reveal that at a June 2009 myocardial perfusion study revealed a left ventricular ejection fraction of 53 percent with normal left ventricular wall motion and thickening with no evidence of myocardial ischemia. October 2009 chest x-rays revealed no evidence of acute pulmonary process. In sum, none of the evidence above demonstrates that the Veteran had congestive heart failure, a workload of greater than 5 METs but not greater than 7 METs, or cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. While the Veteran was noted to have an ejection fraction of less than 50 percent at the time of his March 2007 hospitalization, this was encompassed in the time period where he was rated as 100 percent disabled; subsequent ejection fraction testing did not reveal a reading of 50 or below. Therefore, an evaluation is excess of 10 percent is not warranted for the pertinent time periods. The Board notes that the Veteran has expressed his opinion that the symptomatology associated with his heart disease warrants a higher evaluation and that lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. However, the Veteran, lacks the medical training and expertise to be able to provide a complex medical opinion. Here, the Board concludes that the objective evidence derived from the examinations by medical professionals to be more probative than the Veteran's assertions. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for the Veteran's left knee disorder and heart disease. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2011). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's left knee disorder, rated as part of arthritis, directly corresponds to the schedular criteria for the assigned disability evaluations, which also incorporates various orthopedic factors that limit motion or function of the knee. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. As it relates to the Veteran's heart disease, comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, there is a higher rating available under the code - under DC 7006- addressed in this decision. But the Veteran's disorder is not productive of the manifestations that would warrant the higher rating. As such, the available schedular evaluations for the service-connected heart disease at issue here are adequate. For this reason, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's left knee disorder and heart disease and no referral for an extraschedular rating is required. Finally, while the Veteran indicated that his left knee interfered with his employment, he reported having been laid off as a result of no work as opposed to a disability. Moreover, the most recent VA examiner found that the Veteran's heart disease had no effect on his employability. Consequently, the matter of entitlement to a total disability rating based on individual unemployability is not raised by the Veteran or the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A separate 10 percent disability evaluation for left knee arthritis, based upon limitation of flexion, from December 5, 2007, is granted. A separate compensable disability evaluation for left knee arthritis based upon subluxation/lateral instability prior to April 8, 2010, is denied. A 10 percent disability evaluation, and no more, for left knee arthritis based upon subluxation/lateral instability from April 8, 2010, is granted. An evaluation in excess of 10 percent for coronary artery disease prior to July 29, 2009, and subsequent to November 1, 2009, is denied. REMAND With regard to his claim for a higher disability evaluation for iliotibial band syndrome with bursitis of the left hip, the Board notes that at the time of his October 2012 hearing, the Veteran testified that the symptomatology associated with his left hip disorder had increased in severity since the time of the last VA examination. He indicated, however, that he was not receiving any ongoing treatment for the hip condition. VA is obliged to afford a veteran a contemporaneous examination where there is evidence of an increase in the severity of the disability. VAOPGCPREC 11-95 (1995). The veteran is competent to provide an opinion that his disability has worsened. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). As such, an additional VA examination to determine the severity of the service-connected left hip disorder is warranted. With regard to the claims of service connection for an acquired psychiatric disorder and entitlement to service connection for purposes of establishing treatment, the Board notes that following the denial of service connection for these claims in November 2011, the Veteran filed a notice of disagreement in June 2012. To date, a statement of the case has not been issued as it relates to these issues. The Board is required to remand the case for issuance of the statement of the case. Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the severity of his service-connected iliotibial band syndrome with bursitis of the left hip. The claims folder, and a copy of this remand, must be reviewed by the examiner in conjunction with the examination, and the examiner must acknowledge this review in any report generated as a result of this remand. All indicated tests and studies must be performed and all findings must be reported in detail. (i) The examiner must report the Veteran's ranges of motion for left hip/left thigh in terms of degrees. The examiner should determine whether the iliotibial band syndrome with bursitis of the left hip is manifested by weakened movement, excess fatigability, or incoordination. These determinations should be expressed in terms of the additional degree of range of motion loss due to any pain, weakened movement, excess fatigability, incoordination, or flare-ups. The examiner should also note any nerves affected by paralysis, partial paralysis, neuralgia, or neuritis, and, for affected nerves, express an opinion as to the severity of such symptoms in terms of being slight, moderate, moderately severe, severe, or complete. (ii). The examiner is specifically requested to indicate the absence/presence of the following: flexion in the thigh limited to 45 degrees; flexion in the thigh limited to 30 degrees; flexion in the thigh limited to 20 degrees; flexion in the thigh limited to 10 degrees; extension limited to 5 degrees; limitation of rotation of the thigh with an inability to toe-out more than 15 degrees on the affected leg; limitation of adduction of the thigh with an inability to cross legs; limitation of abduction of the thigh with motion lost beyond 10 degrees. 2. The RO must ensure the required actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, corrective action must be undertaken before the claims file is returned to the Board. See Stegall v. West, 11 Vet. App. 268 (1998). 3. If any benefit sought on appeal is not granted, the Veteran's attorney should be issued a Supplemental Statement of the Case, which should include all pertinent laws and regulations, and be afforded a reasonable opportunity to reply. 4. Issue a statement of the case on the issues of entitlement to service connection for an acquired psychiatric disorder and entitlement to service connection for purposes of establishing treatment. The issues should be certified to the Board only if a timely substantive appeal is received. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs