Citation Nr: 1306044 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 07-11 408 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased evaluation in excess of 30 percent for residuals, left knee injury, postoperative with surgical scar. 2. Entitlement to an increased evaluation in excess of 10 percent for left knee medial compartment degenerative joint disease (DJD), based on range of motion. 3. Entitlement to an initial evaluation in excess of 10 percent for a 14 centimeter (cm) scar extending from the right cheek to the lateral aspect of the right eyebrow. 4. Entitlement to an increased evaluation in excess of 30 percent prior to July 23, 2010, and 50 percent thereafter for posttraumatic stress disorder (PTSD). 5. Entitlement to service connection for a right ankle disorder, to include as secondary to the service-connected left knee disability. 6. Entitlement to service connection for a left ankle disorder, to include as secondary to the service-connected left knee disability. 7. Entitlement to service connection for a right shoulder disorder, to include as secondary to the service-connected left knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran, S.K., and G.S. ATTORNEY FOR THE BOARD Kristi L. Gunn, Counsel INTRODUCTION The Veteran served on active duty from November 1978 to July 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal from June 2006 and April 2007 rating decisions of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO). In August 2009, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. In June 2010, the Board remanded the claims for additional development and adjudicative action. The case was returned to the Board for further appellate review. The Board has reviewed the contents of the Veteran's Virtual VA file and found no medical or other evidence pertinent to this appeal that is not in her claims file. The issues of entitlement to an increased evaluation in excess of 30 percent prior to July 23, 2010, and 50 percent thereafter for PTSD, entitlement to an initial evaluation in excess of 10 percent for a 14 centimeter scar extending from the right cheek to the lateral aspect of the right eyebrow, and entitlement to service connection for a right ankle disorder, left ankle disorder, and right shoulder disorder, all to include as secondary to service-connected left knee disability, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected residuals, left knee injury, postoperative with surgical scar is manifested by recurrent subluxation with no evidence of anklyosis or impairment of the tibia and fibula. 2. The Veteran's service-connected left knee medial compartment DJD is manifested by arthritis with painful motion. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent for residuals, left knee injury, postoperative with surgical scar, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.71a, Diagnostic Code (DC) 5257 (2012). 2. The criteria for an evaluation in excess of 10 percent for left knee medial compartment DJD based on range of motion have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.71a, Diagnostic Codes (DCs) 5003, 5010, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States 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, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board notes that, with regard to the Veteran's increased rating claims, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of her claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir. 2004). In this regard, the Board notes that an RO letter dated in October 2005 informed the Veteran of all the elements required by 38 C.F.R. § 3.159(b), as stated above, with regard to establishing entitlement to an increased rating. A July 2006 letter also provided the Veteran with information on how VA determines and assigns effective dates. As such, the October 2005 and July 2006 letters satisfied VA's duty to notify. The Board highlights that, although the notice regarding effective dates was not provided prior to the first adjudication of the Veteran's increased rating claims, the Veteran has not been prejudiced. Furthermore, the Board notes that, after all notice requirements were met, the Veteran's claims were readjudicated in a statement of the case (SOC) dated in January 2007. Therefore, the purpose of VCAA notice was not frustrated. See Mayfield v. Nicholson, 19 Vet. App. 103, 121 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); see also Medrano v. Nicholson, 21 Vet. App. 165, 170 (2007). Regarding the duty to assist, the RO has obtained the Veteran's service treatment records, VA outpatient treatment records, private treatment records, and records from the Social Security Administration (SSA). The RO also provided the Veteran with VA examinations for her increased rating claims. Moreover, the Board is satisfied that the RO has substantially complied with the Board's June 2010 remand directives as they pertain to the increased rating claims. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating her claim. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. II. Decision 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. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Although the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. However, as discussed below, in this case, the record reflects that the Veteran's disabilities have remained constant with respect to the applicable schedular criteria. The Veteran bears the burden of presenting and supporting her claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. The Court held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When all the evidence is assembled, 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. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran was originally granted service connection for a left knee disability in an October 1984 rating decision and was assigned a 20 percent disability evaluation, effective February 24, 1983, pursuant to 38 C.F.R. § 4.71a, DC 5257. The disability evaluation was increased to 30 percent disabling under 38 C.F.R. § 4.71a, DC 5257, effective September 23, 1992, in a February 1993 rating decision. In a December 2000 rating decision, the RO granted a separate 10 percent disability evaluation, effective November 1, 2000, pursuant to 38 C.F.R. § 4.71a, DC 5010. Thereafter, in July 2005, the Veteran submitted claims for increased ratings for her service-connected left knee disabilities. In the June 2006 rating decision, the RO continued the 30 percent disability evaluation for the service-connected residuals, left knee injury, postoperative with surgical scar under DC 5257 and the 10 percent disability evaluation for the service-connected left medial compartment degenerative joint disease, based on range of motion under DCs 5010-5260. At the August 2009 Board hearing, the Veteran testified that her service-connected left knee disabilities cause throbbing, aching, and stabbing pain. The Veteran testified that range of motion in the left knee is limited, and she has experienced cracking, popping, burning, giving way, and falling due to her service-connected left knee disabilities. She asserts that increased ratings are warranted for her service-connected left knee disabilities. As noted, the Veteran's service-connected left knee disabilities are currently rated under DCs 5257 and 5010-5260. Under Diagnostic Code 5257, recurrent subluxation or lateral instability warrants a 10 percent rating if slight, a 20 percent rating if moderate, and a 30 percent rating if severe. The Board observes that the words "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just," under 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Under DC 5010, arthritis due to trauma, which is substantiated by X-ray findings, will be rated as degenerative arthritis under DC 5003. Under DC 5003, degenerative arthritis, when substantiated by X-rays, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, 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 DC 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 20 percent disability rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent disability rating is warranted with x-ray evidence of involvement of two or more major joints or two or more minor joint groups. Note 1 accompanying DC 5003 states that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based upon limitation of motion. Note 2 states that the 20 percent and 10 percent ratings based on X-ray findings will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024. 38 C.F.R. § 4.71a, DC 5003. Under DC 5260, a noncompensable rating is warranted for flexion limited to 60 degrees, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. Under DC 5261, a noncompensable rating is warranted for extension limited to five degrees, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. Normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). Separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee joint. See VAOPGCPREC 9-2004 (Sept. 17, 2004). When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2011); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 592. Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. In May 2006, the Veteran was afforded a VA examination for her service-connected left knee disabilities. She reported daily pain, stiffness, swelling, and redness in the left knee. She rated the pain between a 3 and 4 out of 10 in terms of severity, at its best and 10 out of 10 in terms of severity, at its worse. She also reported daily stiffness, significant weakness, and giving way of her left knee, which has resulted in falls on numerous occasions. The Veteran admitted to having recurrent subluxation of her patella and flare-ups after standing for long periods of time or with any wrong movement. She stated that the flare-ups were not medically incapacitating, but require her to stay off her feet as much as possible for a day or so. The Veteran informed the VA examiner that she takes morphine sulfate daily and Percocet on an as needed basis (PRN) for the pain associated with the service-connected left knee pain. Physical examination testing revealed mild swelling of the left knee with surgical scars over the anterior aspect of the left knee. Palpation revealed significant tenderness at the medial tibiofemoral joint line with excessive mobility of the patellar tendon and tenderness in grinding with moving of the patella. Range of motion testing of the left knee revealed extension to 0 degrees and flexion to 125 degrees without significant limitation. Repetitive testing elicited increased stiffness of the left knee. During McMurray's testing, the VA examiner noted grinding and clicking, but no impediment of movement, and there was excessive ligamentous laxity with Lachman's testing. Valgus and varus testing revealed excessive ligamentous laxity and some moderate amount of increased laxity. The VA examiner noted a positive grind test for patella discomfort. Magnetic resonance imaging (MRI) testing conducted in July 2005 showed a chronic anterior cruciate ligament (ACL) tear, as well as postoperative changes in the posterior horn over medial meniscus area. The VA examiner diagnosed the Veteran with chronic patella instability and subluxation, chronic ACL tear, and degenerative joint disease of the left knee. In August 2008, a second VA examination was afforded to the Veteran in order to determine the severity of her service-connected left knee disabilities. The Veteran explained that her service-connected disabilities have progressively worsened and while the medicine she takes alleviates her pain, she still requires the use of a left knee brace and walker. The Veteran also admitted to functional limitations when standing and walking due to her service-connected left knee disabilities. She admitted to deformity, giving way, instability, pain, stiffness, and weakness associated with her service-connected left knee disabilities. She reported constant effusion and swelling, but denied episodes of dislocation or subluxation and locking. Physical examination testing revealed an antalgic gait with no evidence of abnormal weight bearing. Range of motion testing revealed extension to 0 degrees and flexion to 120 degrees, with pain beginning at 110 degrees. There was no additional limitation of motion on repetitive use with no reported pain, fatigue, weakness, or incoordination. There was no loss of a bone or part of a bone, joint ankylosis, or inflammatory arthritis. However, the examiner noted the presence of painful movement and grinding. The VA examiner diagnosed the Veteran with residuals, left knee injury post operative with surgical scar and left medial compartment degenerative joint disease. The VA examiner noted that the Veteran's service-connected left knee disabilities have significant effects on her occupation and severe effects on chores, shopping, exercise, recreation, traveling, bathing, dressing, toileting, and grooming. The VA examiner determined that the Veteran's service-connected left knee disabilities prevented sports and caused no problems with feeding. In July 2010, the Veteran underwent a third VA examination for her service-connected left knee disabilities. The Veteran complained of constant pain involving the left knee and rated it at 6 out of 10 in terms of severity and at 8 out of 10 with flare-ups. She admitted to stiffness, weakness, instability, giving way, subluxation of the left knee, as well as anterior dislocation of the left tibia. She denied experiencing locking, heat, and redness associated with the left knee. Upon physical examination of the Veteran, the VA examiner noted an obvious deformity of the left knee with anterior displacement of the tibia. There was tenderness to palpation of the left knee, along with extensive scars of the left knee from multiple surgical procedures. Left anterior drawer sign was positive and most likely due to meniscus deficiency rather than cruciate ligament dysfunction. Bilateral posterior drawer sign was negative, Lachman's testing was negative, and McMurray's sign was negative. Range of motion testing reflected extension to 25 degrees and flexion to 120 degrees actively and passively with pain flaring to 8 out of 10 at both extremes of range of motion. The VA examiner noted that the Veteran was unable to perform any repetitive motion exercises due to pain on extension and flexion. The VA examiner stated that the pain would have likely increased with repetitive motion. X-ray testing conducted in November 2009 revealed bilateral degenerative joint disease of the knees with a bone infarct of the metaphyseal region of the left tibia adjacent to the tibial tuberosity likely representing postsurgical change. The VA examiner diagnosed the Veteran with traumatic arthritis of the left knee caused by military service. The Veteran was afforded a fourth VA examination for her service-connected left knee disabilities in April 2012. The Veteran admitted to having flare-ups, as well as constant pain since the last VA examination in July 2010, but not falling as much since she has had a ramp installed since that time. Range of motion testing revealed extension to 5 degrees and flexion to 125 degrees with no objective evidence of painful motion. The VA examiner noted that the Veteran was able to perform repetitive-use testing with three repetitions with no additional limitation in range of motion of the knee and lower leg following repetitive-use testing. However, the VA examiner indicated that the Veteran has functional loss and/or functional impairment of the knee and lower leg with less movement than normal, pain on movement, deformity, and disturbance of locomotion being the contributing factors. The VA examiner also reported that the Veteran has tenderness or pain to palpation for the joint line or soft tissues of the left knee with normal muscle strength testing for the Veteran's left knee flexion and extension. Lachman's testing was 2+, with normal results for the Posterior drawer test and valgus/varus testing. The VA examiner noted the evidence of recurrent patellar subluxation/dislocation of the left knee and indicated that it was moderate in severity. The VA examiner diagnosed the Veteran with degenerative joint disease of the left knee, patella alta of the left knee, and patellofemoral pain syndrome (PFPS) of the left knee. VA outpatient treatment records, private treatment records, and SSA records note the presence of chronic pain and chronic instability associated with the Veteran's service-connected left knee, and a history of frequent falls secondary to dislocating the left knee. Based on a thorough review of all the evidence of record, the Board finds that the Veteran's service-connected left knee disability does not warrant an increased rating in excess of 30 percent under 38 C.F.R. § 4.71a, DC 5257. The Veteran is presently receiving the maximum available rating under DC 5257; therefore, DC 5257 does not assist her in obtaining a higher evaluation. The Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, Diagnostic Code 5257 provides for evaluation of instability of the knee without reference to limitation of motion. Therefore, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not apply to evaluations under Diagnostic Code 5257. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). The Board must consider evaluation of the Veteran's service-connected left knee disability under all potentially appropriate codes pertaining to the knee and leg. In this case, the available diagnostic codes that could provide a higher rating in excess of 30 percent are DC 5256, knee, ankylosis of; and DC 5262, impairment of the tibia and fibula. To that end, there is no evidence of ankylosis of the left knee, which is immobility and consolidation of a joint. See Dorland's Illustrated Medical Dictionary 86 (28th ed., 1994). The Veteran demonstrated extension and flexion of the left knee at all four VA examinations, and the August 2008 VA examiner specifically found no evidence of ankylosis of the service-connected left knee. Additionally, there is no nonunion of the tibia and fibula, with loose motion requiring brace. In June 2010, the VA examiner noted anterior displacement of the tibia, but there was no indication of nonunion. Therefore, a higher rating is not warranted for the Veteran's service-connected residuals, left knee injury, postoperative with surgical scar, under DC 5256 or DC 5262. The current 10 percent rating is assigned under Diagnostic Codes 5003 and 5010 for painful motion of the left knee with some limitation of flexion. At no time during the rating period on appeal does the evidence suggest that the Veteran had flexion limited to approximately 60 or 45 degrees. At worst, flexion was to 120 degrees with pain starting at 110 degrees, which does not meet even the criteria for a 0 percent rating under DC 5260. Thus, a rating in excess of 10 percent is not warranted under DC 5260. The current 10 percent rating under DC 5010-5260 appears to be based upon painful motion and functional loss. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). The Board has also considered whether a separate rating is warranted for limitation of extension of the left knee under DC 5261. Extension was to 0 degrees in May 2006 and August 2008. There was a single finding of extension limited to 25 degrees in July 2010; however, extension was subsequently limited to only 5 degrees in April 2012. Although there was a single finding indicative of a 30 percent rating in July 2010 under DC 5261, this was an isolated incident and not sustained. Flexion was limited to only 5 degrees on examination in April 2012. This is so even with consideration of painful motion and other factors. Thus, a separate, compensable rating under DC 5261 is not warranted. To assign two, separate compensable ratings based on painful motion under two separate diagnostic codes (i.e., under Diagnostic Codes 5260 and 5261) would be in violation of the rule of pyramiding. See 38 C.F.R. § 4.14; VAOPGCPREC 9-04. The Board notes that the VA examiners identified endpoint pain during range of motion testing, but did not indicate that there was additional decreased motion of the left knee based on the painful motion. Specifically, at the July 2010 VA examination, the VA examiner noted that the Veteran was unable to perform any repetitive motion exercises due to pain on extension and flexion. The VA examiner stated that the pain would have likely increased with repetitive motion. Similarly, in April 2012, the VA examiner indicated that the Veteran has functional loss and/or functional impairment of the knee and lower leg with less movement than normal, pain on movement, deformity, and disturbance of locomotion being the contributing factors. The evidence does not suggest that the Veteran has flexion limited to 45 degrees, or extension limited to 10 degrees (other than the isolated incident in July 2010). This is so even with consideration of painful motion. The evidence does show that the Veteran experiences painful motion (and other symptoms such as weakness); however, it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. The Board further finds that a rating higher than 10 percent is not warranted under DC 5010, as there is no x-ray evidence showing that the Veteran's service-connected left knee disability involves two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Indeed, the service-connected left knee disability only involves one major joint, i.e., the knee joint. See 38 C.F.R. § 4.45(f). In addition, the Board notes that the Veteran has been shown to have a chronic ACL tear of the left knee. However, there has been no evidence of effusion into the joint and the Veteran has denied any locking. Thus, a separate rating under DC 5258 is not warranted. See 38 C.F.R. § 4.71a, DC 5258. The Board has also considered whether the Veteran is entitled to a separate rating for her left knee scar. However, there is no indication of record that the knee scar(s) are painful or cause any functional impairment. The VA examiner in April 2012 found that the scars were not painful or unstable. Thus, a separate rating is not warranted. See 38 C.F.R. § 4.118, DC 7804, 7805. The Veteran is competent to report her symptoms, and the Board does not doubt the sincerity of the Veteran's belief that her service-connected left knee disabilities have worsened. However, the objective clinical findings do not support her assertions for the reasons stated above. As the preponderance of the evidence is against the Veteran's claims for an increased rating for her service-connected left knee disabilities, the benefit-of-the-doubt doctrine is not for application, and an increased rating must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. The Board has also considered whether referral for an extraschedular rating is appropriate. In this regard, the Board notes that ratings are generally based on average impairment, and that the rating schedule represents, as far as is practicable, the average impairment of earning capacity. See 38 C.F.R. § 3.321(a), (b) (2012). However, to afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.3211 (b) (2012). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. at 115-16. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, and is therefore found to be 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.' Id. 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. Id. As noted above, the Veteran's left knee symptoms primarily involve pain, instability/subluxation, limited motion, stiffness, swelling, weakness, giving way, and grinding. Such impairment is specifically contemplated by the rating criteria. See 38 C.F.R. § 4.40, 4.45, 4.71a, DC 5257, 5261, 5262. Accordingly, the Board finds that the Veteran does not present such an exceptional or unusual disability picture that the available schedular evaluations for her left knee are inadequate. Therefore, the Board concludes that referral for consideration of an extraschedular rating is not warranted in this case. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). ORDER Entitlement to an increased evaluation in excess of 30 percent for residuals, left knee injury, postoperative with surgical scar, is denied. Entitlement to an increased evaluation in excess of 10 percent for left knee medial compartment degenerative joint disease (DJD) based on range of motion is denied. REMAND Although the Board sincerely regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. The Board finds that this appeal must be remanded to obtain an adequate examination that complies with the directives of the June 2010 remand. A Court or Board remand confers upon the appellant the right to compliance with that order. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). Additionally, where VA provides the Veteran an examination in a service connection claim the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). An adequate examination and medical opinion addresses the appropriate theories of entitlement and provides a supporting rationale for any medical opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 123-25 (2007). When the matter was before the Board in June 2010, a remand was ordered. The remand directed that an examination of the Veteran be conducted to determine the etiology of her current right ankle, left ankle, and right shoulder disabilities. Specifically, it was requested that the VA examiner provide an opinion as to whether it is at least as likely as not that any disorder of the right ankle, left ankle, and right shoulder was caused by the Veteran's service-connected left knee disability, to include as a result of falls caused by the Veteran's left knee disability in 2003, 2006, or on other occasions. However, the Board finds that the examination report does not comply with the specific directives mentioned above. Upon review of the claims file, the Veteran was afforded a VA examination in July 2010. The VA examiner indicated that to resolve the question of the right shoulder and ankle disabilities being caused by the service-connected left knee disability would require resorting to speculation. The VA examiner explained that there was no objective documentation that the ankles and right shoulder were caused by giving way of the left knee, though these injuries "may have occurred and not been objectively documented." As such, the VA examiner indicated that the VA examination scheduled would be only confined to the knees. The VA examiner failed to conduct an actual physical examination of the right shoulder and ankles. With regard to the Veteran's increased rating claim for her service-connected PTSD, the Board notes that the Veteran was afforded a PTSD examination in July 2010. See the May 2012 rating decision. However, the July 2010 PTSD examination report is not within the claims file. On remand, the July 2010 VA examination report should be associated with the Veteran's claims file. Further, the Board notes that the July 2010 VA examination report is almost three years old. As such, once the foregoing development has been accomplished, the Veteran should be provided a contemporaneous VA examination to assess the current nature, extent, and severity of her PTSD. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Finally, with regards to the Veteran's service-connected 14 cm scar extending from the right cheek to the lateral aspect of the right eyebrow, the Veteran was afforded several VA examinations to determine the current severity of the service-connected disability. According to a January 2007 VA examination report, the VA examiner noted on physical examination testing that the service-connected scar measured 14 cm linear by 0.25 cm in width. Again, at a July 2010 VA examination, the service-connected scar measured 14 cm. However, more recently at a third VA examination in April 2012, the VA examiner measured the scar at 10.5 cm in length and 0.20 cm in width. The VA examiner described the location of the scar as being on the right cheek extending to the lateral aspect of the right eyebrow. However, the Board notes that the Veteran has a 10 cm scar on the right cheek with a 2 cm branch angling down distally, for which service connection has been granted separately. See the July 2012 rating decision. As noted in the June 2010 remand, the Board requested that a VA examiner describe in detail the 14 cm scar extending from the right cheek to the lateral aspect of the right eyebrow. See the June 2010 remand. Since it is unclear as to which scar was examined at the time of the most recent VA examination in April 2012 (i.e., the 10 cm scar or the 14 cm scar), the Veteran must be afforded an additional VA examination. As such, because of the aforementioned procedural deficiencies, the Board's remand instructions were not complied with, and another remand is needed in order to ensure compliance. If any action required by a remand is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. While the Board regrets the delay, another remand is required. See Stegall v. West, 11 Vet. App. 268 (1998). As the case must be remanded for the foregoing reasons, any recent VA treatment records should be obtained. To ensure that VA has met its duty to assist the Veteran in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is again REMANDED for the following action: 1. Make arrangement to obtain a copy of the Veteran's treatment records from the Gainesville VA Medical Center, dated from May 2012 forward. 2. Associate with the claims file the July 2010 VA examination report for the Veteran's service-connected PTSD. 3. Thereafter, schedule the Veteran for VA orthopedic and scar examination(s). The Veteran's claims file and a copy of this remand should be made available to and reviewed by the examiner(s) in conjunction with the examination(s). All indicated studies should be conducted, and all findings reported in detail. The orthopedic examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any disorder of the left ankle, right ankle, and/or right shoulder was caused by the Veteran's service-connected left knee disorder, to include as a result of falls caused by the Veteran's left knee disability in 2003, 2006, or on other occasions. If the answer to the above question is negative, the orthopedic examiner should provide an opinion as to whether it is at least as likely as not that any disorder of the left ankle, right ankle, and/or right shoulder was aggravated beyond its normal progress as a result of the Veteran's service-connected left knee disorder. The scar examiner should describe, in detail, the scar on the Veteran's face - the 14 cm scar extending from the right cheek to the lateral aspect of the right eyebrow. The Board points out that the Veteran also has a separate, 10 cm scar on the right cheek with a 2 cm branch angling down distally. Specific findings should be reported as to the 14 cm scar extending from the right cheek to the lateral aspect of the right eyebrow. The 10 cm scar is not at issue. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 4. Schedule the Veteran for a VA psychiatric examination. The claims folder should be provided to the examiner for review. All indicated tests, studies and interviews should be conducted. Following examination of the Veteran, the examiner should identify what symptoms, if any, the Veteran currently manifests or has manifested in the recent past that are attributable to her service-connected PTSD. The examiner must conduct a detailed mental status examination. The examiner must also discuss the effect, if any, of the Veteran's PTSD on her social and industrial adaptability. The examiner should assign a Global Assessment of Functioning (GAF) score for the veteran's PTSD consistent with the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM- IV) and explain the significance of the score. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 5. Read all medical opinions obtained to ensure that the remand directives have been accomplished, and return the case to the examiner if all questions posed are not answered. 6. Finally, readjudicate the issues on appeal. If the benefits sought on appeal are not granted, issue a supplemental statement of the case, and give the Veteran an appropriate amount of time to respond. The appellant 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. 2012). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs