Citation Nr: 1312415 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 09-16 071 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to a rating in excess of 30 percent prior to June 13, 2012, for tricompartmental osteoarthritis, status post total right knee arthroplasty. 2. Entitlement to a rating in excess of 60 percent on and after June 13, 2012, for tricompartmental osteoarthritis, status post total right knee arthroplasty. 3. Entitlement to a total rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from September 1990 to January 1991. These matters come to the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office in Louisville, Kentucky (RO). During the pendency of this appeal, the evidence of record reasonably raised the issues of entitlement to service connection for a right hip disorder and a low back disorder, to include as secondary to the Veteran's service-connected right and/or left knee disabilities. As the RO has not addressed these claims, the Board does not have jurisdiction to address these claims on their merits herein. As such, the Board is referring these claims to the RO for the appropriate action. Evidence associated with the Veteran's claims file during the pendency of this appeal reasonably raised the issue of entitlement to a total disability evaluation for compensation purposes based on individual unemployability (TDIU). As such, this claim is properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009); see also VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996). The issue of entitlement to a TDIU is addressed in the remand portion of the decision below, and is remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. Prior to June 13, 2012, the Veteran's tricompartmental osteoarthritis, status post total right knee arthroplasty, was manifested by pain, weakness, stiffness, and tenderness, with limitation of flexion at 75 degrees without pain. 2. From June 13, 2012, the Veteran's tricompartmental osteoarthritis, status post total right knee arthroplasty, is assigned the maximum schedular rating. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent prior to June 13, 2012, for tricompartmental osteoarthritis, status post total right knee arthroplasty, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Code 5055, 5256, 5260, 5261 (2012). 2. A schedular rating in excess of 60 percent on and after June 13, 2012, for tricompartmental osteoarthritis, status post total right knee arthroplasty, is not available. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Code 5055, 5256, 5260, 5261 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 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 notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. 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); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO's March 2008 and March 2009 letters to the Veteran satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the March 2009 letter notified the Veteran that she must submit, or request that VA obtain, evidence of the worsening of her disability, the different types of evidence available to substantiate her claim for a higher rating, the need to submit evidence of how such worsening effected her employment, and the requirements to obtain a higher rating. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1275-82 (2009). After the March 2009 letter was sent, the Veteran's claim was re-adjudicated in a March 2009 statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006)(noting that a notice defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of her claim, including the opportunity to present pertinent evidence. As such, the Board finds that the content requirements of the notice VA is to provide have been met and no further development is required regarding the duty to notify. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, her VA and private treatment records, and the records associated with her application for disability benefits from the Social Security Administration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Further, there is no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. Additionally, the Veteran underwent an adequate VA examination in March 2008 and in August 2012 in order to ascertain the severity of her service-connected right knee disability. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examiners reviewed the Veteran's claims file, treatment records, and administered a thorough examination, which allowed for fully-informed evaluation of the claimed disability. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of her claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Shinseki v. Sanders, 129 S. Ct. 1696 (2009)(reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Historically, the Veteran served on active duty from September 1990 to January 1991. In February 2008, she submitted a claim of entitlement to a rating in excess of 30 percent for her service-connected right knee disability. In a May 2008 rating decision, and again in a July 2008 rating decision, the Veteran's claim was denied. Subsequently, the Veteran perfected an appeal. During the pendency of this appeal, specifically in an August 2012 rating decision, the rating assigned to the Veteran's service-connected right knee disability was increased to 60 percent, effective June 13, 2012. The RO then certified the Veteran's claim to the Board for appellate review. In October 2012, the Board remanded the Veteran's claim in order to afford the Veteran the opportunity to provide testimony at a Board hearing. This hearing was conducted in January 2013 with the undersigned Veterans Law Judge. The matter has been returned to the Board for appellate consideration. Given that the Veteran was afforded the January 2013 hearing, the Board finds that the RO complied with the directives of the October 2012 remand and, thus, a remand for corrective active is not warranted. See Stegall v. West, 11 Vet. App. 268 (1998). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the Board January 2013 hearing, the undersigned Veterans Law Judge noted the elements of the claim that were lacking to substantiate entitlement to an increased rating. The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The representative and the Veterans Law Judge asked questions to ascertain the course and severity of the Veteran's disability. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or the representative. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate his claim for service connection. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). 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. This involves a factual determination of the current severity of the disability. Staged ratings are appropriate whenever the factual findings show distinct periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2012). Therefore, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Under Diagnostic Code 5055, the minimum 30 percent evaluation is warranted when the medical evidence of record shows a history of prosthetic knee replacement. 38 C.F.R. § 4.71a, Diagnostic Code 5055. A maximum 60 percent evaluation is warranted when there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. Although Diagnostic Code 5055 provides for a 100 percent rating, this is only assigned for one year following implantation of the prosthesis. Id. Additionally, Diagnostic Code 5055 instructs VA to rate by analogy when there are intermediate degrees of residual weakness, pain, or limitation of motion, using Diagnostic Codes 5256, 5261, or 5262. Id.; see 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, 5262 (2012). Normal knee range of motion is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2012). Diagnostic Code 5256 concerns knee ankylosis. Knee ankylosis at a favorable angle in full extension, or in slight flexion between 0 and 10 degrees, warrants a 30 percent rating. For knee ankylosis in flexion between 10 and 20 degrees, a 40 percent rating is assigned, while in flexion between 20 and 45 degrees warrants a 50 percent rating. Extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more, warrants a 60 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Under Diagnostic Code 5261, a noncompensable rating is warranted if knee extension is limited to five degrees. A 10 percent rating is assigned if knee extension is limited to 10 degrees. A 20 percent rating is warranted if knee extension is limited to 15 degrees. A 30 percent rating if knee extension limited to 20 degrees. A 40 percent rating if knee extension is limited to 30 degrees. A maximum 50 percent rating if knee extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. According to Diagnostic Code 5262, a 10 percent rated is assigned upon demonstration of malunion of the tibia and fibula with a slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with a moderate knee or ankle disability. Malunion of the tibia and fibula with a marked knee or ankle disability warrants a 30 percent rating. For nonunion of the tibia and fibula with loose motion that requires a brace a 40 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The Board acknowledges that neither the Rating Schedule nor the regulations provide definitions for words such as "severe," "intermediate," "slight," "moderate," or "marked." Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). Given that the Veteran's claim of entitlement to an increased rating was received on February 25, 2008, the Board will consider the evidence of record dated on and after February 25, 2007. A. Prior to June 13, 2012 According to an April 2007 VA history and physical report, the Veteran underwent total right knee arthroplasty in 2006, after which she reported "complete relief from pain and resolution of her symptoms." According to a September 2007 VA orthopedic clinic note, the Veteran's recovery post right knee replacement was deemed "slow." Further, she complained of discomfort, localizing the pain over the medical aspect of her right knee. She stated that he experienced constant pain, but that the pain was stable. She denied that her knee buckled or gave out; she also denied a history of rigor, chills, or fever. Upon physical examination, showed tenderness along the pes anserinus tendon; no effusion; and no elevated temperature. Range of motion testing demonstrated that the Veteran was able to stably extend to zero degrees and flex to 90 degrees with valgus and varus stress. A radiological examination demonstrated that the Veteran's right knee was "reasonably aligned and well fixed." Ultimately, the assessment was that the Veteran had "not done well" since the right knee replacement and continued to experience symptoms. The doctor did not have a "good explanation" for the presence of these continued symptoms, but wanted to rule out infection. A follow-up appointment was scheduled. An October 2007 VA orthopedic clinic note demonstrated that the Veteran had not experienced the type of recovery following right knee replacement that she had expected. Specifically, she complained of continued pain. Upon examination, there was no detectable effusion. After consultation with another doctor, it was concluded that nothing more should be done with respect to treatment at that time. A December 2007 VA rheumatology report demonstrated that the Veteran was being assessed for fibromyalgia. During a review of her systems, the Veteran reported that her "knees" hurt "about as bad after the surgery as they did before." A physical examination did not result in and findings specific to her right knee disability; however, the examiner observed that the Veteran ambulated "very slowly," but with a normal gait that was "quite antalgic." The impression was that the "active majority" of the Veteran's pain was related to the heightened pain and sensitivity associated with fibromyalgia and chronic pain syndrome. With respect to her right knee, the physician stated there was inflammation in the Veteran's system and "some hints" of inflammatory arthritis. Further, the physician noted that the Veteran's right knee "replacement" was still bothering her. In her February 2008 claim, the Veteran asserted that she experience increased pain since the last VA examination. Moreover, she described the pain as constant and severe, and endorsed weakness and loss of motion. Additionally, she stated that she was experiencing difficulty walking, standing, and sitting. According to a March 2008 VA treatment report, a physical examination demonstrated no local elevation of temperature, no knee effusion, and no instability. The doctor was unsure about the source of the Veteran's claimed discomfort, but postulated that it was possibly her fibromyalgia. In March 2008, the Veteran underwent a VA examination to ascertain the severity of her right knee disability. The examiner indicated that the "problem" was arthritis, and that the course since onset was "stable." The examiner then indicated that the Veteran was taking a non-steroidal anti-inflammatory and hydrocodone, without side effects. The examiner indicated that the Veteran required the use of a cane during ambulation; that she was able to stand for 15 to 30 minutes; and that she was able to walk 250 yards. Joint symptoms included the following: pain and stiffness, but did not include deformity; giving way; instability; weakness; episodes of dislocation, subluxation, or locking; effusion; flare-ups; or inflammation, and did not affect the range of motion one or more joints. Upon physical examination, the examiner described the Veteran's gait as "normal," and found no evidence of abnormal weight bearing. Range of motion testing demonstrated that the Veteran was able to extend to zero degrees and flex to 90 degrees, both during passive and active motion. The examiner determined that there was no additional limitation of motion after repetitive use. Further, the examiner found that the Veteran's right knee disability was not manifested by loss of bone or part of bone; no inflammatory arthritis; and no ankylosis. Additionally, there was no crepitation, no click or snaps, no grinding, no instability, and no patellar or meniscus abnormality. The examiner opined that the Veteran's right knee disability resulted in mild impairment of the Veteran's ability to shop, participate in recreation, travel, bathe, and dress; moderate impairment of her ability to perform chores; and prevented her from exercising and participate in sports, but did not impair her ability to eat, toilet, or groom. In June 2008, the Veteran underwent a VA examination to ascertain the severity of her left knee disability. However, because the Veteran reported that her service-connected left knee disorder was not "bothersome," and that "all of her problems" came from her right knee disability, both knees were assessed. The examiner noted that the Veteran required the use of a cane during ambulation. With respect to functional limitations on standing, the examiner indicated that the Veteran was only able to stand for 15 to 30 minutes. With respect to functional limitations on walking, the examiner indicated that the Veteran was able to walk more than 1/4 mile, but less than one mile. The examiner observed that the Veteran's right knee was not productive of deformity; instability; episodes of dislocation, subluxation, or locking; effusion; or flare-ups. Further, the examiner found that the Veteran's right knee did not affect the motion of one or more joints. The examiner determined that the Veteran's right knee was manifested by giving way; pain; and stiffness, and caused the Veteran problems sleeping. Upon physical examination, the examiner described the Veteran's gait as antalgic and that she moved with poor propulsion, but that there was no evidence of abnormal weight bearing. Range of motion testing showed that the Veteran was able to extend to zero degrees, which was not further limited after repetitive use. Right knee flexion was to 85 degrees on active motion and to 90 degree on passive motion, with pain beginning at 75 degrees during both motions. The examiner found that right knee flexion was additionally limited to 80 degrees due to pain following repetitive use. The examiner found that the Veteran's right knee disability was not manifested by ankylosis; loss of bone or part of bone; or inflammatory arthritis. A general summary of the Veteran's right knee disability was as follows: bony joint enlargement, tenderness, painful movement, and abnormal motion. Specifically, the examiner found no crepitation, clicks or snaps, grinding, instability, effusion, dislocation, or locking, but that there was subpatellar tenderness, both medially and laterally, and mild weakness. The examiner opined that the Veteran's right knee disability resulted in mild impairment of the Veteran's ability to bathe and dress; moderate impairment of the Veteran's ability to shop, participate in recreation, travel, and toilet; severe impairment of the Veteran's ability to perform chores; and prevented the Veteran from exercising and participating in sports, but no impairment of the Veteran's ability to eat or groom. An April 2008 VA psychiatric treatment report showed that the Veteran complained that her knees "really" hurt at times and that the pain woke her up at night, which had been better since switched to a new medication. A separate April 2008 VA treatment report demonstrated that the Veteran appeared for a routine appointment for her "medical problems." During a review of her systems, the Veteran denied joint effusion, and during a physical examination, she denied tenderness and swelling. With respect to her right knee, the assessment indicated that the Veteran was then taking hydrocodone twice each day for "break through pains." According to a July 2008 VA pain clinic note, the Veteran reported right leg pain that she rated as 5 on a 10-point scale when sitting and 8 on a 10-point scale during ambulation. It is unclear from the Veteran's report whether her pain was limited to her right knee, or included pain associated with other disorders. In July and August 2008 letters, the Veteran stated that her right knee was "doing pretty good" until she underwent a total left knee arthroplasty. After the left knee operation, she said she needed to put more pressure on her right knee, which caused her right knee to hurt "more and more." She asserted that the pain was so great that her right knee would "buckle" during ambulation. She also asserted that her right knee would "lock up." She endorsed difficulty falling and staying asleep, and stated that it was difficult for her to walk, stand, or drive. She said that, even though doctors have informed her that radiological examination results did not demonstrate an issue, she was experiencing right knee pain nonetheless. In an April 2009 letter, the Veteran provided details as to her inservice right knee injury and the course of her symptoms and treatment thereafter. Relevant to her appeal, the Veteran stated that her right knee felt "pretty good" until she underwent a total left knee arthroplasty in 2007. After this operation, the Veteran stated that she was forced to rely more on her right knee, and that this reliance caused a worsening of her right knee symptoms. She state that her right knee hurt all the time, describing the pain as being "like a toothache." In April 2011, the Veteran underwent a private neurological examination that was primarily administered for purposes of assessing the severity of cervical and lumbosacral spine disorders. In relevant part, a physical examination demonstrated that the Veteran's right lower extremity exhibited normal bulk, tone, and power. Further, deep tendon reflex was +2 at her right knee. No diagnosis was provided with respect to the Veteran's right knee. In a May 2011 statement, the Veteran complained that her right knee range of motion was "lacking" and that she was experiencing "a lot" of pain. She expressed concern that her right knee was "in trouble." Specifically, she claimed that she was notified by a medical professional that her right knee was not "set right" and that she had arthritis. In a November 2011 statement, the Veteran asserted that her right knee gave out on her "some time[s]," and that she was not always able to catch herself. She asserted that she had fallen on her right knee "one to[o] many times." The Veteran also reported that her right knee had stiffened. Although occurring after June 13, 2012, the Veteran provided testimony during a January 2013 hearing concerning the claimed severity of her service-connected right knee disability. As such, to the extent that this testimony applies to her symptoms prior to June 13, 2012, it will be considered here. The Veteran testified that she experienced "a lot" of pain in 2007, but that doctors were unable to "see anything" and that "everything looked fine." She asserted that her right knee pain was getting "worse and worse" leading up to her 2008 claim. She described her pain as constant, and that it increased during ambulation, after prolonged sitting, and during driving. She also asserted that it interfered with her ability to sleep. The Veteran characterized the pain as "aching" and "throbbing" in nature, and that it rated an 8 out 10, with exacerbations to 10. The remainder of the Veteran's testimony concerned her then present symptoms. The Veteran's service-connected right knee disability has already been assigned a 30 percent rating prior to June 13, 2012, pursuant to Diagnostic Code 5055. In order for the maximum 60 percent rating to be warranted prior to June 13, 2012, the evidence relevant to his period must demonstrate, or more nearly approximate, chronic residuals consisting of severe painful motion or weakness. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5055 (2012). Alternatively, if chronic residuals consisting of severe painful motion or weakness are not demonstrated a rating in excess of 30 percent may be warranted pursuant to Diagnostic Codes 5256, 5261, or 5262. Id. Based on a review of the evidence relevant to the period prior to June 13, 2012, the Board finds that the Veteran's service-connected right knee disability was manifested by the following: a "slow" recovery post right knee replacement; stable, constant, pain; weakness; stiffness; and tenderness. Range of motion testing showed that the Veteran was able to extend to zero degrees throughout the period, which was not further limited after repetitive use. Right knee flexion was to 85 degrees on active motion and to 90 degree on passive motion, with pain beginning at 75 degrees during both motions. Right knee flexion was additionally limited to 80 degrees due to pain following repetitive use. The examiner's use of the word "beginning" demonstrated that, although the Veteran complained of "constant" right knee pain, she also endorsed the ability to flex her right knee from zero degrees to 75 degrees without pain. In other words, pain during motion did not begin until she flexed to 75 degrees. The Board finds that this disability picture did not represent, or more nearly approximate, severe painful motion or weakness. 38 C.F.R. §§ 4.6, 4.7, 4.71a, Diagnostic Code 5055. Consequently, the Board finds that a rating in excess of 30 percent prior to June 13, 2012, is not warranted for the Veteran's service-connected tricompartmental osteoarthritis, status post total right knee arthroplasty, under Diagnostic Code 5055. In making this determination, the Board observed that, in the beginning of this period, the Veteran denied that her right knee buckled or gave out. As time progressed, the Veteran eventually asserted that her pain was so great that her right knee would buckle during ambulation. She also asserted that her right knee would lock up. However, the evidence of record during this period demonstrated that the "active majority" of the Veteran's pain was related to the heightened pain and sensitivity associated with fibromyalgia and chronic pain syndrome, neither of which are service-connected disabilities. See Mitleider v. Brown, 11 Vet App 181 (1998) (standing for the proposition that where non-service symptoms cannot be separated from service connected symptoms, all of the symptoms are treated as service connected). Additionally, the March 2008 and June 2008 VA examiner found that the Veteran's service-connected right knee disability was not manifested by locking or episodes of giving way. The evidence of record did not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent opinions associating pain with one disability in the presence of other, over-lapping disorders (such as fibromyalgia), or attributing falls or episodes of giving way to one disability versus another. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Board finds that the VA examiners' opinions are more probative than the Veteran's assertions with respect to episodes of giving way, locking, and the extent of pain associated with her service-connected right knee disorder. Despite the above, the Board finds that the Veteran's service-connected right knee disorder more nearly approximated intermediate degrees of residual weakness, pain, or limitation of motion prior to June 13, 2012. As such, the Board will address whether a rating in excess of 30 percent is warranted under Diagnostic Codes 5256, 5260, 5261, or 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055; see also Schafrath, 1 Vet. App. at 594. The evidence of record, dated prior to June 13, 2012, consistently demonstrated that the Veteran's service-connected right knee disorder was not manifested by ankylosis. Further, range of motion testing demonstrated that the Veteran was able to extend to zero degrees and flex to between 85 and 90, with pain beginning at 75. The Board finds that this disability picture did not represent, or more nearly approximate, ankylosis. As such, a rating in excess of 30 percent is not warranted pursuant to Diagnostic Code 5256, 5260, or 5261, even when rating by analogy. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5256, 5260, or 5261. As discussed above, the Veteran's service-connected right knee disability was manifested by extension to zero degrees, and flexion beyond 60 degrees, throughout the period prior to June 13, 2012. Further, with respect to right knee extension and flexion, there was no additional function limitation following repetitive use. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); Mitchell v. Shinseki, 25 Vet. App. 32, 37-44 (2011)(holding that pain itself is not functional loss, but can cause functional loss to the extent that it affects the normal working movements of the body such as excursion, strength, speed, coordination, or endurance); DeLuca v. Brown, 8 Vet. App. 202 (1995). In order for a rating in excess of 30 percent to be warranted, extension must be limited to, or more nearly approximate limitation to at least 30 degrees. The Board finds that the Veteran's right knee extension to zero degrees does not represent or more nearly approximate the requisite criteria for an increased rating and, thus, a rating in excess of 30 percent is not warranted under Diagnostic Code 5261. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5261. A 30 percent rating is the maximum rating assignable under Diagnostic Code 5260. The Board also finds that that the Veteran's disability picture did not represent, or more nearly approximate, nonunion of the tibia and fibula with loose motion that requires a brace. The evidence of record relevant to the period prior to June 13, 2012, demonstrated that the Veteran's right knee had been replaced, and that radiological evaluation of her right knee demonstrated that it was "reasonably aligned and well fixed." As such, rating in excess of 30 percent for tricompartmental osteoarthritis, status post total right knee arthroplasty, is not warranted pursuant to Diagnostic Code 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5262. B. On and After June 13, 2012 In a claim for an increased disability rating, a veteran will generally be presumed to be seeking the maximum benefit allowed by law and regulation and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran's service-connected tricompartmental osteoarthritis, status post total right knee arthroplasty, has been assigned the maximum available rating (60 percent) pursuant to Diagnostic Code 5055 on and after June 13, 2012. 38 C.F.R. § 4.71a, Diagnostic Code 5055. While the Board acknowledges that a 100 percent rating is assignable under Diagnostic Code 5055, this total rating is only available for one year after the implantation of the prosthesis. In the Veteran's case, the 100 percent rating was assigned and was effective from June 1, 2006 to June 1, 2007. Accordingly, the maximum available rating for the Veteran's service-connected disability under Diagnostic Code 5055 is 60 percent, which has already been assigned on after June 13, 2012. Ratings in excess of 60 percent are not available under the other relevant diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5260, 5261, 5262; see also Schafrath, 1 Vet. App. at 594. As a higher schedular rating is not available, no further consideration will be undertaken as to the Veteran's entitlement to a higher schedular rating on and after June 13, 2012. AB, 6 Vet. App. at 38. C. Extraschedular Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates the Veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture, in both of the periods outlined above, is not so unusual or exceptional in nature as to render the assigned ratings inadequate. The Veteran's service-connected tricompartmental osteoarthritis, status post total right knee arthroplasty, is evaluated as an impairment of the musculoskeletal system under 38 C.F.R. § 4.71a, Diagnostic Code 5055, 5256, 5260, 5261, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by her disability. Id. Prior to June 13, 2012, the Veteran's tricompartmental osteoarthritis, status post total right knee arthroplasty, was characterized by stable, constant, pain; weakness; stiffness; and tenderness. Range of motion from zero degrees extension to 75 degrees flexion without pain. This disability picture resulted in varying degrees of impairment to the Veteran's ability to perform activities of daily living, including preventing her from participating in exercise and sports, and made difficult standing, walking, sitting, and driving. She required the use of a cane for ambulation throughout this period. On and after June 13, 2012, the Veteran's tricompartmental osteoarthritis, status post total right knee arthroplasty, was characterized by severe pain; extension to zero degrees and flexion to 20 degrees, with no additional functional limitation following repetitive use; weakened movement; excess fatigability; pain upon movement; swelling; interference with sitting, standing, and weight-bearing; muscle strength of 4/5; and tenderness to palpation. The Veteran required the regular use of a cane and a brace throughout this period. Prior to June 13, 2012, a rating in excess of 30 percent is available for certain manifestations of a right knee disability, but the evidence demonstrates that those manifestations were not then present. See Lendenmann, 3 Vet. App. at 349. With respect to the period on and after June 13, 2012, a schedular rating in excess of 60 percent is not available. When comparing the disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability pictures represented by the already assigned disability ratings. The criteria for the already assigned ratings reasonably described the Veteran's disability level and symptomatology. Consequently, the Board concludes that schedular evaluations are adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. §§ 4.71a, Diagnostic Code 5055, 5256, 5260, 5261; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against evaluations in excess of those already assigned to the Veteran's tricompartmental osteoarthritis, status post total right knee arthroplasty, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 30 percent prior to June 13, 2012, for tricompartmental osteoarthritis, status post total right knee arthroplasty, is denied. A rating in excess of 60 percent on and after June 13, 2012, for tricompartmental osteoarthritis, status post total right knee arthroplasty, is denied. REMAND On several occasions throughout the pendency of this appeal, the Veteran indicated that she experienced great difficulty working or was unable to work due to symptoms associated with her service-connected knee disabilities. As such, the Board finds that the evidence of record reasonably raised the issue of entitlement to TDIU. The determination of whether the Veteran is entitled to TDIU is part and parcel of the determination of the appropriate rating for tricompartmental osteoarthritis, status post total right knee arthroplasty. Rice, 22 Vet. App. at 453; see also VAOGCPREC 06-96, 61 Fed. Reg. 66749. Generally, all issues "inextricably intertwined" with the issue certified for appeal, are to be identified and developed prior to appellate review. Harris v. Derwinski, 1 Vet. App. 180 (1991). As the issue of TDIU is "intertwined" with the issue of entitlement to an increased rating for tricompartmental osteoarthritis, status post total right knee arthroplasty, but was not addressed by the RO, the claim is remanded to the RO in accordance with the holding in Harris for development. Accordingly, the case is remanded for the following action: 1. The RO must provide the Veteran a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for her to complete, with instructions to return the form to the RO, for the purpose of obtaining a detailed, post-service educational and occupational history. 2. The RO must then make arrangements with the appropriate VA medical facility for the Veteran to undergo an examination. After a review of the entire evidence of record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to obtain and retain employment consistent with her education and occupational experience due to all of her service-connected disabilities, irrespective of age and any nonservice-connected disorders. At present service-connection is in effect for tricompartmental osteoarthritis, status post total right knee arthroplasty, rated as 30 percent disabling prior to June 13, 2012, and 60 percent disabling on and after June 13, 2012. Service connection is also in effect for status post total left knee arthroplasty, which has been assigned a 30 percent rating prior to June 13, 2012, and a 60 percent rating on and after June 13, 2012. A complete rationale for any opinion must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. The RO must notify the Veteran that it is her responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation must be obtained that shows that notice scheduling the examination was sent to the Veteran's last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. The RO must review the resulting examination report to ensure that it is in compliance with the directives of this remand. If the RO determines that the report is deficit in any way, corrective actions must be undertaken prior to returning the Veteran's claim to the Board for appellate review. 5. Once the above action has been completed, the RO must adjudicate the Veteran's claim of entitlement to a TDIU, taking into consideration all relevant evidence of record throughout the rating period on appeal from February 2007. If the benefit sought remains denied, a supplemental statement of the case must be provided to the Veteran and her representative. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until she receives further notice; however, the Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs