Citation Nr: 1314130 Decision Date: 04/29/13 Archive Date: 05/15/13 DOCKET NO. 05-13 375 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to increases in the "staged" ratings (30 percent prior to September 16, 2011 and a combined 50 percent from that date) assigned for a left knee disability. 2. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from December 1978 to December 1981. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2004 rating decision by the Roanoke, Virginia Department of Veterans Affairs (VA) Regional Office (RO). An interim (January 2005) rating decision replaced a 30 percent rating under Diagnostic Code (Code) 5257 with a combined 30 percent rating (based on a formulation of 10 percent for arthritis and 20 percent for instability) effective August 8, 2003. A Travel Board hearing was held before the undersigned in June 2006; a transcript of the hearing is associated with the claims file. These matters were before the Board in November 2006, June 2008, July 2009, and August 2011, when they were remanded for additional development. An interim (January 2013) rating decision increased the rating for the left knee disability to 50 percent (based on a formulation of 40 percent for limitation of motion and 20 percent for instability) from September 16, 2011. The Veteran has continued to express dissatisfaction with the ratings. The issue pertaining to the rating for the left knee disability is recharacterized to reflect that staged ratings are assigned, and that both "stages" of the rating are on appeal. The matter of entitlement to a TDIU rating (on a schedular basis) is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action on his part is required. FINDINGS OF FACT 1. Prior to September 16, 2011 the Veteran's service connected left knee disability (postoperative arthritis with chondromalacia and instability) was manifested by X-ray confirmed arthritis, instability and some limitation of motion; limitation of flexion to less than 90 degrees, limitation of extension at more than 10 degrees, more than moderate instability, ankylosis or additional limitations due to pain, weakened movement, excessive fatigability with use, or incoordination are not shown. 2. From September 16, 2011 the Veteran's service connected left knee disability is not shown to have been manifested by limitation of flexion to 45 degrees or less, limitation of extension at more than 30 degrees, and/or more than moderate instability; ankylosis or additional limitations due to pain, weakened movement, excessive fatigability with use, or incoordination are not shown. CONCLUSION OF LAW Ratings for the Veteran's left knee disability in excess of 30 percent prior to September 16, 2011 and/or in excess of 50 percent (combined) from that date are not warranted. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. § 4.40, 4.45, 4.59, 4.71a, Codes 5003, 5010, 5257, 5260, 5261, (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 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 of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Letters in March 2003 and June 2003 advised the Veteran of VA's duties to notify and assist in the development of the claim prior to the initial (March 2004) adjudication of her claim. A January 2007 letter provided additional notice and explained the evidence necessary to substantiate her claim, the evidence VA is responsible for providing, and the evidence she is responsible for providing. This letter (as well as letters dated in March 2006, April 2006, and January 2008) also informed the Veteran of rating and effective date criteria, and the January 2008 letter provided the specific criteria for rating knee disability. The January 2008 letter provided notice that is Vazquez-Flores-compliant. Supplemental statements of the case in August 2008, October 2010, and January 2013 readjudicated the matter. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The appellant has had ample opportunity to respond/supplement the record, and has not alleged that notice in this case was less than adequate. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. The RO arranged for VA examinations in August 2003, September 2007 (with addendum in October 2007), July 2008, December 2009, September 2011, and September 2012. The Board finds that those examinations cumulatively are adequate for rating purposes, as the examiners expressed familiarity with the history of the disability and conducted thorough examinations, noting all necessary findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The RO's actions have substantially complied with the November 2006, June 2008, July 2009, and August 2011 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In January 2011, the Director, Compensation and Pension Service, issued a memorandum regarding entitlement to extra-schedular ratings under 38 C.F.R. § 3.321(b)(1) and 4.16(b). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claim. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that all of the evidence in the Veteran's claims file and in "Virtual VA" has been reviewed. [At present there are no additional documents pertinent to this appeal in Virtual VA.] Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In a claim for increase the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating the level of disability of an increased rating claim begins one year before the claim was filed. As the instant claim for an increased rating was received in October 2002, the period for consideration will include evidence one year prior to the receipt of claim. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a [maximum] 10 percent rating 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. 38 C.F.R. § 4.71a, Code 5003. The Veteran's statements describing her symptoms and condition are competent evidence to the extent that she can describe what she experiences. See Barr v. Nicholson, 21 Vet. App. 303 (2007). However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Code 5257. Flexion of the leg limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Code 5260. Extension limited at 10 degrees warrants a 10 percent rating, extension limited at 15 degrees warrants a 20 percent rating, extension limited at 20 degrees warrants a 30 percent rating, extension limited at 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Code 5261. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate II. The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August, 1998). Moreover, the General Counsel has also held that separate ratings under 38 C.F.R. § 4.71a, Code 5260 (limitation of flexion of the leg) and under Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 2004). The instant claim for increase was received in October 2002; the March 2004 rating decision continued a 30 percent rating that was assigned for the Veteran's postoperative left knee osteoarthritis with chondromalacia patella based on severe recurrent subluxation or lateral instability of the knee under Codes 5010-5257. [Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27.] Reports of ongoing VA and private treatment during the appeal period show that the Veteran sought treatment for various illnesses, including orthopedic complaints; however, these records do not provide medical evidence relevant to her left knee increased rating claim. An April 2003 X-ray examination report of the knees shows bilateral osteoarthritic changes of the knee joints. There were no features to suggest knee joint effusion and no fractures or dislocations were seen. An August 8, 2003 VA examination report notes the Veteran's complaints of fairly severe anterior knee pain while going up and down stairs, squatting and with sitting for prolonged periods with bent knee. She was able to ambulate without any walking aids. She reported that she had to quit her job working in the prison system and with the handicapped because both jobs required standing. On examination of the knees there was no effusion. There was marked retropatellar tenderness and medial joint line tenderness to palpation. There was no laxity with varus or valgus strain. The left knee range of motion was 0 to 110 degrees with pain at the extreme of flexion. She also had some pain on McMurray's testing bilaterally but there was no palpable click, slight patellar grind, normal Lachman, and negative anterior and posterior drawer and pivot shift. The Veteran was demonstrating pain and walked with an antalgic gait, lifting the left hip slightly with each movement. The diagnosis was bilateral knee osteoarthritis with left knee chondromalacia status post surgery with chronic pain requiring narcotics, Tylenol #3 tabs, four per day, and with significant impairment in her employment abilities. At the June 2006 Travel Board hearing, the Veteran testified regarding her left knee that she is unable to work in her yard, exercise, or climb a flight of stairs. She reported that there are days when she is unable to drive because her joints lock or stiffen when she sits a lot. On September 2007 VA examination, the Veteran reported symptoms of left knee weakness with increasing loss of stability and support, stiffness with increasing loss of flexibility, swelling with daily activity, periodic heat due to inflammation, giving way, lack of endurance, intermittent fatigability depending on usage, and numbness during periods of stiffness/swelling. She complained of constant left knee pain characterized as "crushing, aching, sticking, oppressing and sharp in nature." She rated the pain as 6 (on a scale of 10), reported that it was elicited by activity and relieved by rest, medication and heating pads/ice/soaking (she could function with medication). Her treatment consisted of physical therapy, use of assistive devices to ambulate, and pain medications. The left knee disability resulted in limited ability to perform routine activities and limited mobility. Examination of the left knee showed weakness, tenderness and guarding of movement. There was no edema, effusion, redness, heat, or subluxation. Left knee range of motion was 110 degrees of flexion and 10 degrees of extension with pain occuring at 110 degrees. The left knee joint function was additionally limited (by 0 degrees) after repetitive use with pain, fatigue, weakness, lack of endurance (pain having the major functional impact). The left knee joint was not additionally limited by incoordination after repetitive use. Left knee anterior and posterior cruciate ligaments stability, medial and lateral collateral ligaments stability and medial and lateral meniscus tests were within normal limits. Motor and sensory function of the lower extremities was normal and knee and ankle jerks were 2+ on neurological examination. The diagnosis was left knee instability and osteoarthritis with chondromalacia patella, post operative with scar. On July 2008 VA examination, the examiner reviewed the Veteran's claims file and noted that her current treatment consisted of medication, physical therapy, bracing, activity limitation, an exercise program, and steroid injections. There were no constitutional symptoms. She was unable to stand for more than a few minutes or walk for more than a few yards. Left knee symptoms included giving way, instability, pain, stiffness, weakness, locking several times per week, constant effusion, inflamation (warmth and redness) and severe weekly flare-ups resulting in 90 percent loss of function (she sat in a recliner until the flare resolved). There was no left knee deformity and there were no episodes of dislocation or subluxation. On examination, the Veteran had an antalgic gait and there was evidence of abnormal weight bearing (increased wear on the outside edge of heel of left shoe). Left knee active and passive range of motion was 0 to 90 degrees of flexion (with pain beginning at 0 degrees and ending at 90 degrees) and -5 degrees of extension with pain beginning and ending at -5 degrees. There was no additional loss of motion on repetitive use. There was no inflammatory arthritis or joint ankylosis. Findings included crepitus, effusion, heat, tenderness, painful movement, weakness, guarding of movement, and Baker's cyst. There were no clicks or snaps, grinding, instability, locking, dislocation, or patellar abnormality. The meniscus was surgically absent and McMurray's test was positive. X-rays of the left knee showed a very mild varus deformity with slight lateral subluxation of the tibia, mild narrowing of the medial tibiofemoral compartment, and small suprapatellar effusion. The diagnosis was left knee degenerative joint disease and chondromalacia. There was a severe impact on her daily activities other than feeding (none) and dressing, toilet and grooming (moderate). A December 2009 VA examination report was essentially identical to the July 2008 VA examination report (both examinations were by the same examiner); there were no additional findings regarding the left knee disability. A September 16, 2011 VA examination report notes the Veteran's claims file was reviewed and also notes her complaints of left knee flare-ups (increasing left knee pain and swelling) when she goes up stairs. On range of motion testing, flexion was to 100 degrees (with objective evidence of painful motion beginning at 100 degrees); she was unable to fully extend her left knee (extension ended at 30 degrees). She was unable to perform repetitive-use testing with 3 repetitions and stated that "she has pain and thus can not repeat the motion." The examiner noted that the Veteran has additional limitation in left knee range of motion following repetitive-use testing as well as functional loss and/or functional impairment of the knee and lower leg. Contributing factors in such functional loss/impairment are less movement than normal, weakened movement, excess fatigability, incoordination (impaired ability to execute skilled movements smoothly), pain on movement, swelling, deformity, disturbance of locomotion, and interference with sitting, standing and weight-bearing. She also had tenderness or pain on palpation for joint line or soft tissues of the left knee. Left knee muscle strength was 4/5 on flexion and extension. Joint line stability test of the left knee was 1+ (0-5 millimeters) for anterior instability (Lachman test) and medial-lateral instability, the examiner was unable to perform posterior instability test. There was moderate patellar subluxation/dislocation. The examiner noted that the Veteran regularly uses a brace and occasionally uses a cane to assist with locomotion. The examiner noted that imaging studies of the left knee documented degenerative or traumatic arthritis and patellar subluxation. The diagnosis was left knee degenerative joint disease and chondromalacia patella. On September 2012 VA left knee examination, the Veteran stated "it's like a lazy leg" and complained of "no strength in her left knee." She also reported left knee swelling, pain, stiffness, instability and Baker's cyst. The Veteran reported using a brace (which does not always help) and trying to exercise with stationery bicycle. She reported she had left knee flareups with changes in weather and "being up weightbearing for prolonged periods." Left knee range of motion was flexion to 120 degrees with pain at 100 degrees and 0 degrees of extension with no objective evidence of painful motion. After repetitive-use testing with 3 repetitions, left knee range of motion was 110 degrees of flexion and the Veteran was unable to fully extend, with extension ending at 5 degrees. The examiner noted that the Veteran has additional limitation in left knee range of motion following repetitive-use testing as well as functional loss and/or functional impairment of the knee and lower leg. Contributing factors in such functional loss/impairment are less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, and deformity. She also had tenderness or pain on palpation for joint line or soft tissues of the left knee, left knee muscle strength was 5/5 on flexion and extension, and joint stability tests were normal. There was moderate patellar subluxation. The Veteran regularly used a brace for the left knee and a cane for the right hip and both knees. The examiner noted there was X-ray evidence of degenerative or traumatic arthritis and patellar subluxation. The diagnosis was osteoarthritis, chondromalacia, and subjective instability of the left knee. A January 2013 rating decision assigned an increased combined rating of 50 percent from September 16, 2011 based on a formulation of 40 percent for arthritis with limitation of extension under Codes 5010-5261 and 20 percent for instability under Code 5257. The Veteran's left knee disability is manifested by X-ray-confirmed arthritis and may be rated under Codes 5257 (for recurrent subluxation or lateral instability), 5010-5003 (for arthritis with less than compensable limitation of motion), 5260 (for limitation of flexion), 5261 (for limitation of extension) or for combinations of Code 5257 and 5010-5003 or 5257 and 5260 and/or 5261. Prior to September 16, 2011 Prior to September 16, 2011, the Veteran's left knee disability was rated 30 percent. To warrant a higher rating for her left knee disability for this period, she would have to show, in addition to X-ray confirmed arthritis, there was instability and limitations of flexion and/or extension; ratings for which (under the criteria outlined above) combined to exceed 30 percent. At no time prior to Septmeber 16, 2011 was there competent evidence (even with consideration of pain) that the Veteran's left knee flexion was limited to 45 degrees or less, that extension was limited at more than 10 degrees, or that there was more than moderate instability. Consequently, the Board finds that a rating in excess of 30 percent for the left knee disability under any combination of ratings for the impairment demonstrated prior September 16, 2011 is not warranted. From September 16, 2011 From September 16, 2011 the Veteran's service connected left knee disability was assigned an increased combined rating of 50 percent based on the September 16, 2011 VA examination which showed limitation of extension at 30 degrees and patellar subluxation/dislocation described as moderate. Thus, she was assigned an increased 40 percent rating under Codes 5010-5261 for arthritis with extension limited to 30 degrees. Accordingly, the focus is on criteria that would provide for (at least) the next higher combined rating. As there is no competent medical evidence (even with consideration of pain) of limitation of flexion to 45 degrees or less, limitation of extension at more than 30 degrees, more than moderate instability or subluxation, or ankylosis, an increase in either the rating for limitation of motion or the rating for instability (so as to warrant an increase in the combined rating) is not warranted. The Board has considered whether any other diagnostic codes apply, and would afford the Veteran an increased rating for her left knee disability (either as alternate ratings or in combination with those currently assigned). Rating under Codes 5258 and 5259 would be of no benefit to the Veteran, as 20 percent is the maximum under Code 5258, and 10 percent is the maximum under Code 5259. Further, as there is no evidence of tibia and fibula involvement at any time during the appeal period, rating under Code 5262 is not warranted. The Board notes the lay statements submitted by the Veteran in support of this claim. Those statements detail the types of problems (additional limitations due to pain, weakened movement, excessive fatigability with use, and incoordination) that result from her service-connected left knee disability. The levels of functioning impairment described by the Veteran are encompassed by the criteria for the schedular ratings assigned; thus the lay statements do not support the assignment of higher schedular ratings. Extraschedular Evaluation The Board has also considered whether the Veteran is entitled to an extraschedular increased rating for her left knee disability. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) ; see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court articulated a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, 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. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms". Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. In January 2011, pursuant to an October 2010 referral of the Veteran's claim by the RO for consideration of entitlement to an extra-schedular evaluation, the Director, Compensation and Pension Service, determined that an extra-schedular evaluation for the serivce-connected left knee disability under the provisions of § 3.321(b)(1) and a TDIU rating on an extra-schedular basis under 38 C.F.R. § 4.16(b) were not warranted. Citing to Thun v. Peake, 22 Vet. App. 111 (2008), the Director found that an unusual or exceptional disability pattern had not been demonstrated that would render application of the regular rating criteria as impractical. The Director also found that the Veteran's symptomatology - pain, weakness, loss of motion - associated with the service-connected left knee disability are contemplated by and considered in the regular rating criteria. The medical evidence does not reflect any symptoms not contemplated by the schedular criteria, and the Veteran has not alleged/identified any such symptoms. Therefore, the schedular criteria are not inadequate, and an extraschedular rating is not warranted. In essence, the arguments presented in this matter pertain to the impact the disability has on the Veteran's employment (and do not challenge the adequacy of the schedular criteria to reflect the symptoms and level of disability shown). ORDER Ratings for the Veteran's left knee disability in excess of 30 percent prior to September 16, 2011 and (a combined) 50 percent from that date are denied. REMAND From September 16, 2011, the Veteran's left knee disability is rated 50 percent combined, her service-connected lumbar degenerative disc disease is rated 10 percent, and the combined rating for her service-connected disabilities is 60 percent. As the service-connected disabilities affect a single body system (orthopedic), the schedular criteria for TDIU are met from the September 16, 2011 date. 38 C.F.R. § 4.16(a). The analysis therefore progresses to whether the Veteran's service-connected disabilities are of such nature and severity and their associated disability picture so distinct from the average veteran rated 60 percent disabled as to preclude her from participating in any regular substantially gainful employment, and render her individually unemployable. It is alleged (and the competent medical evidence shows) that the Veteran's service-connected left knee and lumbar spine disabilities are of such nature and severity as to preclude other than sedentary employment. VA examiners have found her physically capable of sedentary employment. She alleges that she lacks the education and training to engage in sedentary employment. Notably, in her August 2003 (and March 2007) claim for TDIU (VA Form 21-8940), the Veteran reported employment as a Juvenile Correctional Officer and an adult handicapped care provider. Her listed education and training included a leadership development course, computer keyboarding and "various/basic college studies" at a community college. The Veteran's DD Form 214 shows that her military occupational specialty (MOS) was military police. However, the nature of her duties with the military police is unclear. Her service personnel (201) file has not been previously sought, likely contains information regarding her formal education and occupational duties in service (bearing on her capabilities for employment), and must be secured. The record also shows that the Veteran entered a VA Vocational Rehabilitation program. Pursuant to the August 2011 Board remand, AMC requested her Vocational Rehabilitation folder (the best identified source for information regarding the Veteran's training and experience for sedentary employment). However, it has been certified that after the folder was received at AMC, it was lost and is unavailable for review. In light of the foregoing (and the resulting heightened duty to assist), and given the Veteran's allegations and the sparse information in the record regarding her education and training; the record is inadequate to assess her capability to engage in sedentary employment. Accordingly, the case is REMANDED for the following: 1. The RO should secure for association with the record copies of the Veteran's complete service personnel records (201 file). 2. The RO should then arrange for an evaluation of the Veteran by a VA Counselor/Vocational Rehabilitation Specialist to ascertain whether or not (in light of her education/training and experience) she has skills/aptitude to participate in sedentary employment. Specifically, the examiner should ascertain: * The extent of the Veteran's formal education and any training she has completed (other than what is shown by the current record). * The nature of her duties in service, i.e., did they include any desk/sedentary work. * The extent of her computer training (the record shows she has taken computer keyboarding). * Whether her employment as a Juvenile Correctional Officer and/or an adult handicapped care provider included any sedentary duties. The examiner should summarize the findings in a report that includes a professional opinion regarding whether or not the Veteran has sufficient education and/or work experience to participate in any form of substantial gainful sedentary employment, and if so, cite examples of the types of sedentary employment that would be feasible considering her education/experience. 3. The RO should then review the record and readjudicate the claim for TDIU. If TDIU is not granted, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and her representative the opportunity to respond. The case should then be returned to the Board for further appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter 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 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). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs