Citation Nr: 1321276 Decision Date: 07/02/13 Archive Date: 07/12/13 DOCKET NO. 09-26 721 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. 2. Entitlement to service connection for a right knee disability. 3. Entitlement to an increased evaluation for left knee tendonitis, evaluated as noncompensably disabling from November 16, 2007 to March 27, 2012, and as 10 percent disabling since March 28, 2012. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel INTRODUCTION The Veteran served on active military duty from January to June 1981, and from July 1985 to July 2005. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision by the Waco, Texas Regional Office (RO) of the Department of Veterans Affairs (VA) and an October 2011 Board remand. The Veteran's claims file is currently in the jurisdiction of the Nashville, Tennessee RO. In February 2012, the Veteran testified at a Board video hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims file. In the April 2012 decision, the Board reopened the Veteran's claim for service connection for a right knee disorder and remanded the underlying claim for additional evidentiary development. The Board also remanded the claims seeking service connection for hypertension, and a higher rating for the left knee disability. Specifically, the Board instructed the Agency of Original Jurisdiction (AOJ) to schedule the Veteran for VA examinations to determine the nature and etiology of her hypertension and right knee disorder, and to determine the extent and severity of her service-connected left knee disorder. These examinations were conducted in April 2012, and additional addendum opinions were issued in May 2012 and March 2013, the reports of which have since been obtained and associated with the claims file. Although the Board finds the opinions concerning the Veteran's claims seeking service connection of the right knee disability and a higher rating for her service-connected left knee disability to be adequate, the Board does not find the May 2012 medical opinion in connection to her claim for service connection for hypertension to be adequate. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance.) After additional evidentiary development had been undertaken, and by way of the November 2012 rating action, the Appeals Management Center (AMC) increased the disability evaluation for the service-connected left knee tendonitis to 10 percent disabling, effective from March 28, 2012. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (where evidence indicates that the degree of disability increased or decreased during appeal period following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found). Although the Board sincerely regrets further delay, another remand with regard to the Veteran's claim seeking service connection for hypertension is essential to ensure that the Board remand instructions are complied with and carried out prior to a final adjudication of the claim. As such, the issue of entitlement to service connection for hypertension, to include as secondary to a service-connected disability, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. The Veteran does not have a diagnosed disease of the right knee. 2. For the period from November 16, 2007 to March 27, 2012, the Veteran's left knee tendonitis has been manifested by normal extension and flexion, even taking into account her complaints of pain; nor has she been shown to have any ankylosis; slight recurrent subluxation or lateral instability; dislocated semilunar cartilage; and/or impairment of the tibia and fibula with slight left knee or ankle disability. 3. From March 28, 2012, the Veteran's left knee tendonitis has been manifested by normal extension, limitation of flexion no worse than 130 degrees, even taking into account her complaints of pain; nor has she been shown to have any ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage; and/or impairment of the tibia and fibula with moderate left knee or ankle disability. CONCLUSIONS OF LAW 1. The Veteran does not have a right knee disability that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The criteria for a compensable rating for left knee tendonitis for the period from November 16, 2007 to March 27, 2012 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5256 to 5262 (2012). 3. The criteria for a schedular rating in excess of 10 percent for left knee tendonitis on and after March 28, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5256 to 5262 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board notes the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of this law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, a duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to arrive at a decision on the claims on appeal has been accomplished. Through the June 2007 notice letter, the RO notified the Veteran of the information and evidence needed to substantiate her claims. Thereafter, the Veteran was afforded the opportunity to respond. In addition, the Veteran was provided notice concerning the assignment of rating criteria and effective dates via the June 2007 letter. Hence, the Board finds that the Veteran has received notice of the information and evidence needed to substantiate her claims, and has been afforded ample opportunity to submit such information and evidence. The Board also finds that the June 2007 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letter, the RO notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom she wanted the RO to obtain and consider evidence. Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (to be codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned notice letter. The Board thus finds that "the appellant [was] provided the content-complying notice to which he [was] entitled." Pelegrini, 18 Vet. App. at 122. In this regard, the more detailed notice requirements set forth in 38 U.S.C.A. §§ 7105(d) and 5103A have been met. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Nothing about the evidence or any response to the RO's notification suggests that the rating issue must be re-adjudicated ab initio to satisfy the requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims on appeal. The Veteran's service treatment records as well as her post-service VA medical records are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. Significantly, neither the Veteran, nor her representative, has otherwise alleged that there are any outstanding medical records probative of her claim on appeal that need to be obtained. In addition, the Veteran testified before the Board in February 2012. The duty to assist also includes obtaining a medical examination/opinion when such is necessary to make a decision on the claim, as defined by law. VA examinations in connection to the service connected left knee disorder were performed November 2007 and April 2012, and a VA examination in connection to the claimed right knee disorder was also performed in April 2012. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate, as they were predicated on a review of the Veteran's medical records, an interview of the Veteran and a discussion of her medical history, and the examinations fully addressed the rating criteria that are relevant to rating the left knee disability at issue. With respect to the claimed right knee disorder, the Board finds that the April 2012 examination report, combined with the March 2013 medical opinion, addresses all the necessary directives listed in the April 2012 Board remand. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination has been met. 38 C.F.R. § 3.159(c)(4). Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Analysis Service Connection for a Right Knee Disorder Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to establish direct service connection for a disorder, there must be (1) evidence of the current disability; (2) evidence of the in-service incurrence of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a). Subsection (a) also refers to "each disabling condition . . . for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases, including arthritis, may be presumed to have been incurred during service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provisions, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In the present appeal, the Veteran contends that she developed a right knee disability as result of her years in the military. During the February 2012 hearing, the Veteran testified that she developed knee problems after participating in numerous physical training exercises which included running 10 to 12 miles on concrete five days a week. See Hearing Transcript, p. 7. The Veteran's service treatment records reflect that she presented at various military health care facilities on a number of occasions with complaints of on-going pain in her right lower extremity. However, a majority of these records appear to attribute the Veteran's right leg symptoms to her low back disorder. During an August 2003 visit at the pain management clinic, she reported that her low back pain began radiating down her right lower extremity two years prior. She was assessed with L5 radiculopathy in the right lower extremity. Indeed, records dated from June 2004 to October 2004 reflect that the Veteran presented at the military on a regular basis with complaints of right leg pain. A majority of these records indicate that the Veteran's right leg pain was radicular in nature, and are clear for any signs of a right knee condition. However, at the March 2004 Medical Board examination, the Veteran reported a history of knee trouble and in the Summary of Defects and Diagnoses section, it was noted that the Veteran had been experiencing chronic right knee pain. While the evidence shows the Veteran's complaints of right knee pain in service, the weight of the evidence demonstrates that during the Veteran's service there was no combination of manifestations sufficient to identify a right ankle disability so as to establish chronicity of such claimed disorder during service. 38 C.F.R. § 3.303(b). Service treatment records reflect complaints of pain in the right leg and knee; however there was no actual clinical finding of chronic right knee disability. Thus, while the Veteran reported chronic right knee pain during her period of active duty, the service treatment records do not reflect a chronic right ankle disability. Turning to the post-service treatment records, the Board notes that the Veteran first reported to experience knee pain during an October 2007 VA treatment visit at the VAMC in Temple, Texas. During this visit, the Veteran stated that her knees were "so bad" that it hurt to climb stairs. She further stated that she would like to have a cane. On physical examination, the Veteran exhibited full flexibility in both knees with no signs of swelling or tenderness to motion. Based on the Veteran's complaints as well as her evaluation of the Veteran, the treatment provider assessed her with knee arthralgia and noted that she may need knee braces. The Veteran was afforded a VA orthopedic examination in April 2012, at which time, she reported to experience anterior knee pain and denied any instances of locking or instability in the knees. Based on his discussion with, and evaluation of the Veteran, as well as his review of the claims file and imaging studies, the VA examiner did not diagnose the Veteran as having a right knee disability. In a March 2013 addendum, a VA examiner explained that the Veteran has idiopathic anterior knee pain. According to the VA examiner, review of the claims file and service treatment records was negative for a history of a knee injury, or anything to suggest that the Veteran's current knee condition was related to her service. The VA examiner further explained that this condition was a common complaint in the general population and typically managed with conservative treatment. According to the VA examiner, it was less likely than not that the Veteran's current knee pain was related to any activity or injury. Upon consideration of the above evidence, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a right knee disability. With regard to this claim, the Board notes that the existence of a current diagnosed disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, the greater weight of the evidence points to the Veteran not having any chronic right knee disability. The Board notes that neither VA examiner (to include the April 2012 and March 2013 examiners) has identified a current disease, and a review of the entire medical evidence of record is completely absent for a clear and definitive diagnosis pertaining to the right knee joint. Although the October 2007 VA treatment provider (M.D.) assessed the Veteran with knee arthralgia, she did not discuss whether this diagnosis applied to both knees. As such, the Board is unclear as to whether the Veteran was in fact diagnosed with right knee arthralgia Moreover, it is unclear from the opinion provided, whether M.D. reviewed the Veteran's service treatment records and medical records in their entirety prior to issuing her opinion. Indeed, M.D. failed to address the service treatment reports which were clear for any signs of an in-service injury. Thus, the Board finds the October 2007 treatment report to be of little probative value because (1) the treatment provider did not provide a definitive diagnosis of a right knee disability, and (2) the report was not predicated on a thorough review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (which stipulates that it is what an examiner learns from the claims file for use in forming the expert opinion that matters. When the Board uses facts obtained from one opinion over another, it is incumbent upon the Board to point out those facts and explain why they were necessary or important in forming the appropriate medical judgment.) Conversely, the April 2012 examination report, in conjunction with the March 2013 VA medical opinion, includes a physical examination of the Veteran, a review of the Veteran's claims file, and a concrete opinion concerning whether the Veteran had a current right knee disability. The March 2013 VA examiner noted that service treatment records were clear for a history of a knee injury, and based on his review of the service and post-service treatment record, he found no evidence of a chronic condition following her service. In reaching this conclusion, the VA examiner relied on the service treatment records and the April 2012 examination findings, which, other than revealing signs of patellofemoral crepitus in both knees, were absent any clinical findings that would establish a diagnosis of a right knee disability. Based on his review of these findings, and his review of the post-service records on appeal, the March 2013 VA examiner assessed the Veteran with idiopathic anterior knee pain, a condition he described as common in the general population, and less likely than not related to an in-service event or injury. The Board is more persuaded by the evaluations in which it was concluded that there was no right knee pathology because of the more thorough approach taken. Moreover, the assessment of a idiopathic anterior knee pain does not equate to underlying disease. In other words, pain itself is not a disease. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The Board has considered the Veteran's assertions that she has a right knee disorder related to her time in service. However, as a layperson, the Veteran is not competent to give a medical opinion on the diagnosis of this claimed disorder. She is competent to report on symptoms she experienced either during or following service, but not to say what any diagnosis is. Thus, while the Veteran is competent to report symptoms observable to a layperson, such as pain in the right knee area, a diagnosis that is later confirmed by clinical findings, or a contemporary diagnosis, she is not competent to independently provide a medical diagnosis or opine as to the specific etiology of a condition. See Davidson v. Shinseki, 581 F.3d 1313 (2009). Further, the April 2012 and March 2013 VA examiners considered the Veteran's report of in-service and post-service symptoms in reaching their medical conclusions. Consequently, in this case, lay assertions of medical diagnosis or etiology cannot constitute evidence upon which to grant a claim for service connection. Lathan v. Brown, 7 Vet. App. 359, 365 (1995). Because the medical evidence in the current appeal does not establish that the Veteran has any current right knee pathology, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a right knee disability. The benefit-of-the-doubt provisions do not apply. Service connection for a right knee disability is not warranted. Entitlement to an Increased Rating for Left Knee Tendonitis Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings will be applied, the higher rating will be assigned if the disability picture more closely approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2 (2012). As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. As is the case here, where entitlement to compensation 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). It should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. For purposes of this decision, the Board notes that normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA General Counsel has stated that compensating a claimant for separate functional impairment under DC 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 (July 1, 1997). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under DC 5257, the Veteran must also have limitation of motion under DC 5260 or 5261 in order to obtain a separate rating for arthritis. If the Veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also held that, if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under DC 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under DCs 5260 and 5261. Painful motion may add to the actual limitation of motion so as to warrant a rating under DCs 5260 or 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under DCs 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under DC 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). The Veteran's left knee disability has been rated pursuant to Diagnostic Codes 5299-5024. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the 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 (2012). Diagnostic Code 5024, for tenosynovitis, rates the left knee disability based on limitation of motion of the affected part, as arthritis, degenerative. (Although the Veteran has not been diagnosed with tenosynovitis, the RO found that the condition was sufficiently analogous to her currently diagnosed tendonitis). Limitation of motion is in turn rated under the appropriate diagnostic codes. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When limitation of motion is noncompensable under the diagnostic codes, a rating of 10 percent is for application under each major joint or group of major joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, a 10 percent rating is assigned. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 60 degrees warrants a noncompensable evaluation; flexion limited to 45 degrees warrants a 10 percent evaluation; flexion limited to 30 degrees warrants a 20 percent evaluation; and flexion limited to 15 degrees warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 5 degrees warrants a noncompensable evaluation; extension limited to 10 degrees warrants a 10 percent evaluation; extension limited to 15 degrees warrants a 20 percent evaluation; extension limited to 20 degrees warrants a 30 percent evaluation; extension limited to 30 degrees warrants a 40 percent evaluation; and extension limited to 45 degrees warrants a 50 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5262, pertaining to "impairment of tibia and fibula," a 10 percent rating is warranted for malunion with slight knee or ankle disability. A 20 percent rating contemplates malunion with moderate knee or ankle disability, and a 30 percent rating is warranted for malunion with marked knee or ankle disability. A 40 percent rating is warranted for nonunion with loose motion, requiring brace. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability, 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, Diagnostic Code 5257. Normal range of motion for the knee is defined as follows: flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. (2009). A. From November 16, 2007 to March 27, 2012 The Veteran was originally granted service connection for her left knee disability in the August 2005 rating decision. A disability evaluation of 10 percent was assigned for the left knee tendonitis under Diagnostic Code 5099-5024, effective as of August 1, 2005. In June 2007, VA received a claim from the Veteran seeking a higher disability evaluation. Medical records during this time period reflect that the Veteran presented at the Temple VAMC in October 2007, seeking treatment for a painful rash on her hands. During this visit, the Veteran described her knee pain as "bad" and stated that it hurt to climb stairs. On examination, it was noted that the bilateral knees exhibited full flexibility and were negative for signs of tenderness to motion or swelling. She was assessed with knee arthralgia and it was noted that she might have to get knee braces. The Veteran was afforded a VA examination in November 2007, at which time, she reported a history of pain, residual crepitance and aching in her left knee since service. She denied any periods of gait instability, but noted that she had been prescribed a brace for her left knee. She further denied experiencing any acute flare-ups, but added that her left knee pain had been incapacitating during the last twelve months. On physical examination, the Veteran was shown to have flexion to 140 degrees and extension to 0 degrees, with no objective evidence of painful motion. The examiner did not observe additional limitation of motion during repetitive movement, and further noted no objective evidence of painful motion, heat, redness, swelling or tenderness of the left knee. Other than a diagnosis of left knee tendonitis, the Veteran's examination findings were otherwise normal. In the December 2007 rating decision, the RO determined that the Veteran's left knee tendonitis was noncompensably disabling, effective November 16, 2007. The remaining VA treatment records are clear for any discussion of the left knee. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that a compensable evaluation for the service-connected left knee disorder for the period from November 16, 2007 to March 27, 2012, is not warranted. In this regard, under Diagnostic Code 5260, the Veteran has not been shown to have limitation of flexion to 45 degrees to warrant a compensable disability rating for this period. Additionally, the Veteran is not entitled to a separate compensable rating under Diagnostic Code 5261, which governs limitation of extension in the leg. The Board notes that the Veteran has not been shown to have limitation of extension to 10 degrees. Report of the November 2007 VA examination showed the Veteran's range of motion in her left knee to be 0 to 140 degrees, with no limitation or reduction of range of motion upon repetition. Accordingly, a compensable rating is not warranted under Diagnostic Code 5260 or 5261. See 38 C.F.R. § 4.71a, Diagnostic codes 5260-5261. Moreover, there was no objective evidence of pain found during the November 2007 examination. As such, there was no painful limitation of motion shown and a compensable rating is not warranted under Diagnostic Codes 5003 and 5024. In addition, the Board has considered whether the Veteran is entitled to a compensable evaluation under Diagnostic Code 5257. As previously noted, the Veteran exhibited fully flexibility in the left knee during the October 2007 VA treatment visit. In addition, the Veteran denied any episodes of dislocation or recurrent subluxation in the left knee at the November 2007 VA examination. Moreover, upon physical examination, the examiner described the Veteran's left knee stability as intact and noted that the Lachman and McMurray tests both produced negative results. Further, when asked to describe any gait and functional limitations in the knee joint when standing and walking, the examiner observed none. As such, a compensable rating for instability of the right knee cannot be granted. The Board has also considered a functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, a compensable evaluation for the Veteran's service-connected left knee disorder is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are contemplated by the noncompensable disability rating already assigned. In this regard, the Board observes that the Veteran has complained of pain, crepitance and aching in her knee. However, she reported no difficulty conducting her activities of daily living and noted that had not taken any time off from school as a result of her left knee pain. In addition, the November 2007 examiner noted that there was no objective evidence of limited or reduced range of motion following repetitive motion. Furthermore, the examiner observed no gait or functional limitations upon standing or walking as a result of the left knee condition. Thus, the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. The Board finds that the effect of this symptomatology is contemplated in the currently assigned noncompensable disability evaluation. Additionally, the Board has also considered whether an increased evaluation would be in order under other relevant diagnostic codes for the knee. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." 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. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In this regard, Diagnostic Code 5256 is not for application as ankylosis was not shown. Diagnostic Codes 5258-5259 are not for application as dislocated or removed cartilage was not indicated. Diagnostic Code 5262 is not for application as impairment of the tibia and fibula was not shown and Diagnostic Code 5263 is not for application as recurvatum was not shown. Thus, as the criteria for a compensable evaluation for the Veteran's service-connected left knee disorder for the period from November 16, 2007 to March 27, 2012 have not been met, this portion of the Veteran's appeal is denied. In essence, the preponderance of the evidence is against a compensable disability evaluation for the Veteran's left knee disorder from November 16, 2007 to March 27, 2012. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. As such, entitlement to a compensable evaluation for service-connected left knee tendonitis from November 16, 2007 to March 27, 2012 must be denied. B. On or after March 28, 2012 Following a review of the relevant evidence, the Board finds that the record does not contain evidence showing that the Veteran is entitled to an evaluation in excess of 10 percent as of March 28, 2012. The Veteran was afforded another VA examination in April 2012, at which time, she complained of anterior knee pain, and denied any episodes of locking or instability. According to the Veteran, her knee pain flares up when climbing a staircase, rising from a seated position, or during prolonged walking. On physical examination, the Veteran was shown to have flexion to 130 degrees and extension to 0 degrees with no objective evidence of painful motion. The VA examiner indicated that the Veteran was able to perform repetitive use testing with three repetitions, and her range of motion measurements post repetitive testing was shown to be 0 to 130 degrees. While the examiner did not observe additional limitation of motion upon repetitive movement, he did note that the Veteran had functional loss in her knees due to pain on movement. In addition, the examiner noted signs of tenderness or pain to palpation on the joint line or soft tissues of both knees. The Lachman and Posterior drawer tests were both shown to be normal, and the Veteran displayed normal strength to valgus and varus pressure. When asked whether the Veteran had any other pertinent physical findings, complications or symptoms related to her left knee, the examiner marked yes and noted that the Veteran had patellofemoral crepitus in the left knee and exhibited tenderness to palpation over the lateral patellar facet. The examiner further noted that the Veteran does not use any assistive device as a mode of locomotion. Additionally, the examiner reviewed the left knee diagnostic studies and observed no x-ray evidence of degenerative or traumatic arthritis in the left knee. As previously discussed above, the Veteran was granted a 10 percent disability evaluation for her service-connected left knee tendonitis based on painful motion of the knee, effective March 28, 2012. See November 2012 rating decision. She now seeks entitlement to an evaluation greater than 10 percent for her left knee disorder for the period on and after March 28, 2012. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an increased rating in excess of 10 percent for her service-connected left knee tendonitis for the period from March 28, 2012. In this regard, from March 28, 2012, limitation of flexion or extension of the left knee was not shown to be compensable under the corresponding diagnostic codes. As previously discussed above, the April 2012 VA examiner noted that the Veteran had flexion to 130 degrees and extension to 0 degrees with no limitation or reduction of range of motion upon repetition. Moreover, a review of the record throughout this period of the appeal is absent any findings indicating that flexion of the left knee was limited to 45 degrees or less or that extension of either knee was limited to 10 degrees or more. Accordingly, a compensable rating is not warranted under Diagnostic Codes 5260 or 5261. See 38 C.F.R. § 4.71a. Diagnostic Codes 5260-5261. Also, from March 28, 2012, instability or subluxation was not shown in the left knee. The April 2012 VA examiner noted there to be no evidence or history of patellar subluxation or dislocation in the left knee, the Lachman and Posterior drawer tests were both shown to be normal, and the Veteran displayed normal strength to valgus and varus pressure. Moreover, the Veteran denied any episodes of locking or instability in the left knee, and there were no objective findings during this time frame indicative of instability or subluxation in the left knee. Results from muscle strength testing were shown to be normal during left knee flexion and extension and x-ray reports were clear for any findings of patellar subluxation. As such, a separate compensable rating under Diagnostic Code 5257 is not warranted. Further, as the Veteran has already received a 10 percent rating under Diagnostic Code 5299-5024 and this is the highest rating available for noncompensable painful limitation of motion of one joint (i.e. the knee), a rating in excess of 10 percent is not warranted for the left knee under these codes. See 38 C.F.R. § 4.71a. The Board has also considered a functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, an increased evaluation for the Veteran's service-connected left knee disorder is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are contemplated by the10 percent disability rating already assigned. In this regard, the Board observes that the Veteran has complained of ongoing pain in her left knee. The Board also acknowledges findings of patellofemoral crepitus in the left knee. However, the April 2012 examiner noted that there was no objective evidence of limited range of motion following repetitive motion. Thus, the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. The Board finds that the effect of this symptomatology is contemplated in the currently assigned 10 percent disability evaluation. Additionally, the Board has also considered whether an increased evaluation would be in order under other relevant diagnostic codes for the knee. In this regard, Diagnostic Code 5256 is not for application as ankylosis was not shown. Furthermore, the Veteran may not be rated by analogy to this code as she has not suffered functional immobility of the knees. Likewise, Diagnostic Code 5259 does not provide for higher disability ratings, and is inapplicable. Diagnostic Code 5258 is not for application as dislocated or removed cartilage was not indicated. Additionally, there are no objective findings of impairment of the tibia and fibula, thus there is no basis for disability ratings under Diagnostic Code 5262. Finally, Diagnostic Code 5263 is not for application as recurvatum was not shown. In reaching this conclusion, the Board has also considered the testimony and assertions by the Veteran pertaining to her knees. She is competent and credible to attest to the exhibited symptoms in her left knee. However, the objective evidence of record is more probative and persuasive than the descriptions of her symptoms. The objective findings do not support higher ratings based on the schedular criteria. The Veteran's symptoms do not more nearly approximate the criteria for the assignment of higher ratings in any regard. Therefore, to the extent that a disability evaluation in excess of 10 percent for the Veteran's service-connected left knee disability is warranted on and after February March 28, 2012, the appeal is denied. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulations, an extraschedular disability rating is warranted 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 scheduler standards. 38 C.F.R. § 3.321(b)(1) (2012); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-116 (2008), the Court set forth a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the Veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the Veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is, whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA 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. Here, the evidence of record does not reflect that the Veteran's left knee disability is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for this disability contemplate her symptoms, including pain and restricted movement, and there are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. As such, the threshold issue under Thun is not met, and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the service-connected left knee disability does not present such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. Lastly, the Board has considered whether a claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) should be considered. However, the evidence of record does not show, and the Veteran has not contended, that she is unable to maintain gainful employment as a result of her service-connected right knee disability. At the November 2007 VA examination, the Veteran reported that she was a full-time student, and denied having to take any time off from school due to her left knee pain. Although the April 2012 VA examiner noted that the Veteran's left knee symptomatology, which includes pain with excessive standing, walking and climbing a staircase, impacts her ability to work, there is nothing in the record to indicate that the Veteran is unable to work as a result of her left knee disability. Indeed, at the February 2012 hearing, the Veteran testified that she had received her degree in education and was currently looking for full-time work. See Hearing Transcript (T.) pp12-13. Therefore, no further discussion of entitlement to a TDIU is warranted at this time. ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to a compensable evaluation for left knee tendonitis, from November 16, 2007 to March 27, 2012, is denied. Entitlement to an evaluation in excess of 10 percent for left knee tendonitis, on and after March 28, 2012, is denied. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Veteran contends that her hypertension arose during her years of active service and/or was caused or aggravated by her service-connected interstitial cystitis. Specifically, the Veteran contends that her elevated blood pressure readings in service were early manifestations of her current hypertension. See December 2008 Statement of the Veteran, December 2008 notice of disagreement (NOD); and February 2012 Hearing Transcript, (T.) pp. 3-4. As a preliminary matter, the Board observes that the evidence of record at present is sufficient to decide the Veteran's claim under the theory of direct service connection. However, the Veteran also asserts her claim under the theory of secondary service connection. While the theory of entitlement regarding whether the Veteran's hypertension is directly related to service is thoroughly addressed during the May 2012 VA examination, the theory of entitlement with regard to whether the Veteran's hypertension is secondary to her service-connected interstitial cystitis still requires further evidentiary development for proper adjudication of the Veteran's claim. Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. Secondary service connection is also available for chronic aggravation of a nonservice-connected disorder. In reaching the determination as to aggravation of a nonservice-connected disability, the baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular nonservice-connected disorder. 38 C.F.R. § 3.310. A review of the post-service treatment records reflects that the Veteran was first diagnosed with hypertension in September 2006. She was afforded a VA examination in connection to her hypertension claim in November 2007, at which time the examiner determined that it was less likely than not that the Veteran's hypertension is secondary to her interstitial cystitis. Pursuant to the April 2012 Board remand, the Veteran was afforded another VA examination in May 2012, and the VA examiner was asked to discuss whether the Veteran's hypertension was aggravated by her interstitial cystitis. In addressing this question, the VA examiner indicated that there were multiple notes related to interstitial cystitis, but unfortunately, all notes did not contain "VS's" (the Board assumes this refers to vital signs), and the ones that did have "VS's" did not support the claim that interstitial cystitis aggravated hypertension or hypertension aggravated interstitial cystitis. If the VA undertakes the effort to provide a veteran with a medical examination, it must ensure that such examination is an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). While the examiner provided a recitation of the Veteran's post-service medical history, to include a list of her blood pressure readings during a number of post-service treatment visits, she did not provide an explanation as to the relevance of these findings, and she failed to discuss how these findings influenced her ultimate conclusion. A medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions," see Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007), and the "examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two," Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). As it remains unclear whether the Veteran's hypertension is in fact secondary to her service-connected interstitial cystitis, another remand is necessary for a clarifying VA medical opinion. Also, as this matter is being remanded for further development, the RO should also attempt to obtain any ongoing medical records pertinent to the Veteran's claim. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (noting that VA medical records are in constructive possession of the agency and must be obtained if pertinent). Accordingly, the case is REMANDED for the following action: 1. Request records of treatment that the Veteran may have received for her hypertension at the VAMC in Temple, Texas since June 2008. Copies of such records which are available should be associated with the claims folder. 2. Then, once these records have been obtained, refer the claims file the same VA examiner who conducted the May 2012 examination, or a VA cardiologist if that examiner is unavailable. The claims folder and all records on Virtual VA must be made available to the examiner in conjunction with the examination. A notation that this review has taken place should be made in the evaluation report. The examiner should specifically take note of the May 2012 VA medical opinion. Following a review of the record, the examiner should express an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's hypertension was caused or aggravated (permanently worsened beyond normal progression) by her service-connected interstitial cystitis. If the examiner finds that the Veteran's interstitial cystitis aggravated her hypertension, she or must discuss the baseline level of disability prior to aggravation and what permanent measurable degree of the hypertension is due to interstitial cystitis? All opinions expressed must be supported by a rationale for why the examiner arrived at the opinion. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). 3. After completing the above, and undertaking any additional evidentiary development deemed necessary, readjudicate the remaining issue on appeal. If any benefit sought is not granted, the Veteran and her representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. No action is required of the Veteran until she is notified; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). 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). This case must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the Court 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). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs