Citation Nr: 1323636 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 01-05 574 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent prior to January 20, 2011, and in excess of 30 percent as of March 1, 2012, for a right knee disability. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1969 to March 1978 and from October 1979 to December 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2000 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, that continued a 10 percent disability rating for the Veteran's right knee disability. This case has previously been before the Board on a number of occasions. In November 2003, March 2009, October 2010, and March 2012, the Board remanded the Veteran's claim for additional development. This case was most recently before the Board in March 2013, when the Board remanded the Veteran's claim in order to obtain outstanding treatment records and provide the Veteran with an additional examination. Additional treatment records were obtained, and the Veteran received an additional VA examination in April 2013. The Board finds that there has been substantial compliance with the remand instructions. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). In April 2009, the Veteran raised a claim of entitlement to an increased rating for a bilateral ankle disability. As that claim has not been developed for appellate review, the Board refers it to the RO for appropriate action. The issue of entitlement to a TDIU is REMANDED to the RO via the Appeals Management Center, in Washington, D.C. FINDINGS OF FACT 1. Prior to January 20, 2011, the Veteran's right knee disability was manifested by a range of motion limited by pain and weakness to no worse than 75 degrees of flexion and 10 degrees of extension, x-ray evidence of arthritis, but no clinical evidence showing at least a mild level instability. 2. From March 1, 2012, the Veteran's right knee disability is manifested by a range of motion limited by pain and weakness to no worse than 110 degrees of flexion and 15 degrees of extension, x-ray evidence of arthritis, but no clinical evidence showing mild instability. 3. The evidence does not show such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. CONCLUSIONS OF LAW 1. Prior to January 20, 2011, the criteria for a rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261, 5262 (2012). 2. From March 1, 2012, the criteria for a rating in excess of 30 percent for a right knee disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5055, 5256, 5257, 5261, 5262 (2012). 3. The criteria for referral of the Veteran's disability for consideration of an extraschedular rating are not met. 38 C.F.R. § 3.321(b)(1) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty notify a Veteran of the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). VA also has a duty to assist Veterans in the development of their claims. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2011); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Correspondence dated in September 2007 provided the Veteran notice with respect to all required elements. While the Board acknowledges that the notice was provided to the Veteran before the initial adjudication of his claim in May 2000, the Veteran filed his claim prior to both the enactment of the statutory provisions regarding notice. Additionally, since the time of the September 2007 notice, the Veteran has been provided with several readjudications of his claim, and the Board finds that there has been no prejudice to the Veteran requiring additional notice. The Board finds that the notice provisions have been fulfilled, and that no further notice is necessary. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). The Veteran's service medical records have been associated with the claims file. All identified and available treatment records have been secured, which includes VA examinations, VA health records, and private health records. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not show the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran has been provided with a number of VA examinations. The examination reports indicate that the examiners reviewed the Veteran's claim file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board concludes that the examination reports are adequate for the purpose of making a decision in this appeal. 38 C.F.R. § 4.2 (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). Neither the Veteran nor his representative has argued otherwise. In March 2002, the Veteran presented testimony before a Veterans Law Judge (VLJ), and a transcript of that hearing has been associated with the record. In April 2003, the Board informed the Veteran that the VLJ who conducted his March 2002 hearing was no longer employed by the Board. The April 2003 letter advised the Veteran that he had the option to testify at a hearing before another VLJ. 38 C.F.R. § 20.707, 20.717 (2012). The letter informed the Veteran that he had 30 days from the date of the letter to respond, and that if no response was received, the Board would assume that he did not want another hearing. To date, no response has been received from the Veteran or his representative. Accordingly, the Board finds that all due process concerns have been satisfied. 38 C.F.R. § 3.103 (2012). Accordingly, the Board will proceed to a decision. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular Diagnostic Code is completely dependent on the facts of a particular case. Butts v. Brown, 5 Vet. App. 532 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2012); Esteban v. Brown, 6 Vet. App. 259 (1994). However, pyramiding, or rating of the same disability or the same manifestation of a disability under different Diagnostic Codes, is to be avoided when rating service-connected disabilities. 38 C.F.R. § 4.14 (2012). The Veteran's right knee disability was initially rated 10 percent under Diagnostic Code 5010, applicable to traumatic arthritis. A January 2005 rating decision appeared to award the Veteran with a separate, additional 10 percent disability rating effective April 11, 2000 under Diagnostic Code 5261, applicable to limitation of extension. In March 2009, the Board remanded the Veteran's claim for clarification of the currently-assigned disability rating for the Veteran's right knee. In May 2010, the RO clarified that the Veteran was in receipt of a single 10 percent disability rating for his right knee under Diagnostic Code 5261 effective April 11, 2000. The Veteran underwent a total right knee replacement on January 20, 2011, and the right knee was rated 100 percent under Diagnostic Code 5055, applicable to knee prosthesis. 38 C.F.R. § 4.71a (2012). Under that Diagnostic Code, a 100 percent rating applies during the one-year period following the implantation of a knee prosthesis. Accordingly, the Veteran received a 100 percent rating for his right knee from January 20, 2011, to March 1, 2012. Thereafter, the minimum disability rating following a knee replacement is 30 percent, and the Veteran received that minimum 30 percent rating effective March 1, 2012. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). Under Diagnostic Code 5055, a 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain, or limitation of motion, adjudicators should rate Diagnostic Code 5055 by analogy to Diagnostic Codes 5256 (knee ankylosis), 5261 (limitation of leg extension), or 5262 (impairment of the tibia and fibula). 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2012). The rating schedule does not define the terms intermediate or severe as used in Diagnostic Code 5055. Instead, adjudicators must evaluate all of the evidence and render a decision that is equitable and just. 38 C.F.R. § 4.6 (2012). Clinicians' use of terminology such as severe, although an element that the Board will consider, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2012). When making a rating determination, VA must consider whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. 38 C.F.R. § 4.45 (2012); Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). Diagnostic codes pertaining to limitation of motion and the diagnostic code pertaining to instability of a knee may be rated separately and rating a knee disability under those codes does not amount to pyramiding, where a compensable level of disability is shown under each diagnostic code. Separate ratings can be awarded for limitation of flexion and limitation of extension where the criteria for a compensable rating are met for each limitation. 38 C.F.R. §§ 4.14, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2012); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998). Although Diagnostic Code 5055 covers a range of symptoms and manifestations of knee disability, it does not appear to contemplate subluxation or instability. Therefore, consideration of a separate rating under Diagnostic Code 5257 does not violate the rule against pyramiding set forth in 38 C.F.R. § 4.14. With regard to knee instability, recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). Prior to January 20, 2011 An April 1999 radiographic report showed tri-compartmental degenerative changes in the right knee. A July 1999 radiographic report showed degenerative joint disease in the right knee. In April 2000, a VA examiner noted the Veteran's complaints of worsening pain. The Veteran specifically complained of pain with walking or standing, and he had difficulty ascending and descending stairs. The Veteran avoided sports and other activities that required him to squat. Medications provided the Veteran with good relief. The Veteran had a range of motion from 0 degrees to 130 degrees. The examiner noted medial joint line tenderness. The Veteran had crepitus with active flexion and extension, but no effusion was noted. In a separate April 2000 VA treatment record, a VA clinician noted that the Veteran's pain had decreased with the use of a knee brace. The clinician observed that the Veteran's knee was tender medially, but there was no erythema or warmth. A November 2000 medical record indicated that the Veteran's knee was grossly normal in appearance with focal tenderness with deep palpation of the knee medially. There was no abnormal opening of the joint space, and there was no abnormal mobility of the knee. The clinician observed no warmth or swelling. In April 2002, the Veteran underwent a Synvisc injection to treat his right knee disability. The Veteran denied experiencing pain, fever, or joint swelling after the injection. The clinician observed mild suprapatellar effusion of the right knee, but no warmth or erythema of the knee. A September 2002 MRI indicated that the Veteran had medial compartmental osteoarthrosis with reactive subchondral edema, a grade 2 sprain of the medial collateral ligament, patellofemoral arthrosis, and a capsular avulsion. In December 2002, a VA rheumatologist noted that medications mildly controlled the symptoms associated with the Veteran's right knee. The clinician indicated that the Veteran's condition significantly affected his quality of life. The Veteran could walk only short distances, and he could stand for about 10 minutes before experiencing knee pain. In March 2003, the Veteran had a full range of movement with crepitus. No effusion was noted. In July 2003, the Veteran complained of knee pain that medication did not relieve. Bilateral crepitus and mild swelling was noted. In October 2003, the Veteran complained of swelling with prolonged walking or standing. Medication provided the Veteran with good relief. The Veteran had a full range of motion with crepitus and no effusion. In November 2003, the Veteran complained of knee swelling after prolonged standing and walking. Medication relieved the Veteran's pain minimally. The Veteran had an active range of motion from 0 degrees to 140 degrees with crepitus. No erythema or effusion was noted, but the Veteran had tenderness along the medial and lateral joint line. In August 2004, a VA examiner noted that the Veteran treated his condition with anti-inflammatory medications, and he had undergone several cortisone injections. The Veteran complained of frequent flare-ups of pain in the right knee that he treated with decreased activity. The Veteran could stand for ten minutes and walk for ten minutes. The Veteran experienced pain with bending and squatting. The Veteran had a range of motion from 5 degrees to 110 degrees. The examiner observed mild crepitation and effusion, and a moderately severe genu varum deformity. In November 2004, a VA clinician noted that the Veteran had severe osteoarthritis of the right knee with crepitus and bony enlargement. No warmth or redness was noted. In March 2005 and July 2005, the Veteran had crepitus, bony enlargement, and mild swelling in the right knee. No warmth or redness was noted. In November 2005, a VA clinician observed that the Veteran had a severe varus deformity in his knee. The examiner noted the Veteran's complaints of pain, and the examiner observed crepitus in the Veteran's knee. In December 2005, the Veteran had a range of motion from 10 degrees to 120 degrees. There was no effusion, and the knee was non-tender. In April 2006, the Veteran denied experiencing acute right knee swelling, warmth, or discoloration. The right knee had no edema or effusion. In July 2006, a VA clinician noted the Veteran's complaints of knee pain. The Veteran wore a knee brace and was able to walk for one block. The clinician noted prominent crepitus in the Veteran's knees, a limited range of motion, minimal effusion, and no inflammatory changes. In August 2006, a VA clinician noted that the Veteran was wearing an unloader knee brace. The knee was in marked varus alignment, and the Veteran had an active range of motion from 0 degrees to 125 degrees with crepitus. In September 2006, a VA clinician noted that the Veteran had genu varus and crepitus in both knees. The Veteran complained of pain over the tibial plateau, but he had no effusion. The Veteran had a limited range of motion in both knees. The Veteran underwent a VA examination in September 2007, at which time the examiner noted that the Veteran complained of constant, dull, aching pain. The pain increased in severity with activity. The Veteran complained of knee stiffness that subsided with activity by mid-morning. The Veteran indicated that he had constant swelling in the knee, but he denied feeling heat or redness. The Veteran used a walker, and he could not walk more than a quarter-mile without experiencing fatigue. The Veteran experienced flare-ups of pain once or twice monthly, primarily related to weather changes. The VA examiner noted that the Veteran's right knee did not significantly impact his activities of daily living. The examiner observed a moderate effusion in the Veteran's knee with marked tenderness. The knee had a significant varus deformity of approximately 12 degrees. The Veteran had a range of motion from -15 degrees to 125 degrees, with pain noted from 75 degrees to 125 degrees. The examiner observed no objective clinical evidence that the Veteran's functioning was additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance. X-ray examination showed severe degenerative changes involving the right knee joint. The Veteran underwent a VA examination in September 2008. The Veteran indicated that he experienced pain of approximately a 5/10 severity. The Veteran indicated that his pain occasionally flared up to 10/10. The examiner observed trace swelling in the right knee, and the knee had a range of motion from 10 degrees to 120 degrees. The Veteran complained of tenderness, but there was no redness or increased warmth. The Veteran had no weakness, lack of endurance, lack of coordination, or fatigability in the knee. The Veteran was unable to engage in prolonged walking, stairs, sitting, stooping, or squatting. In March 2010, the Veteran's range of motion in his right knee was within functional limits. The Veteran had knee flexion to 111 degrees and "neutral" knee extension. The Veteran had 4/5 strength. In July 2010, the Veteran had a range of motion from 5 degrees to 120 degrees, with crepitus. The clinician diagnosed the Veteran with severe tri-compartmental osteoarthritis with a varus deformity. In October 2010, a VA clinician noted no edema or effusion of the knees. The Veteran had an active range of motion from 0 degrees to 130 degrees. The Board has considered the applicability of each of the Diagnostic Codes applicable to the knees. There is no evidence of ankylosis, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5262, and 5263 do not apply. 38 C.F.R. § 4.71a (2012). With those Diagnostic Codes excluded, the issue is whether the Veteran is entitled to a greater level of compensation under the Diagnostic Codes that are potentially applicable to the Veteran's left knee disability: 5003 (applicable to degenerative arthritis), 5260 (applicable to limitation of flexion of the leg), or 5261 (applicable to limitation of extension of the leg). The Board will first evaluate whether a greater rating is available to the Veteran under the Diagnostic Codes based on limitation of motion of the leg: 5260 and 5261. With regard to flexion, the Veteran consistently demonstrated flexion to 75 degrees or greater. Accordingly, with flexion never limited to 60 degrees or fewer, a compensable rating is unavailable to the Veteran on the basis of impairment of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). With regard to extension, the Veteran consistently demonstrated extension to 10 degrees or fewer. Accordingly, with extension never limited to 15 degrees or more, a disability rating in excess of the currently assigned 10 percent rating is unavailable to the Veteran on the basis of impairment of extension. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). The Board must additionally consider functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45 (2012). VA examiners and clinicians have noted the Veteran's complaints such as pain and tenderness, and the Board has taken these complaints into consideration in its above discussion. The Board finds that the evidence does not support a finding that the Veteran's functional loss causes disability beyond the above-discussed range of motion testing. While the Board accepts the credible contentions of the Veteran that his right knee disability causes him to experience significant pain, the Board has taken that into account in its consideration of the range of motion of the Veteran's knee. The rating schedule does not require a separate rating for pain. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Accordingly, a greater rating is not warranted based on functional loss. With regard to a higher rating based on arthritis, the Diagnostic Code applicable to traumatic arthritis does not provide for a rating in excess of 10 percent with the involvement of a single major joint. A greater increased rating based on arthritis is accordingly unavailable to the Veteran. Furthermore, a rating based on limitation of motion cannot be combined with a rating based on arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). The Board finds that a separate disability rating based on instability is unwarranted. In April 2000, a VA examiner noted that the Veteran had varus alignment in both knees. Varus, valgus, anterior drawer, and posterior drawer testing were all normal. In July 2003, the Veteran indicated that he wore a knee brace. In October 2003, the Veteran indicated that he felt a sense of instability, giving way, popping, and creaking. A VA clinician observed no valgus or varus laxity at 0 degrees and 30 degrees, and drawer testing was negative. In November 2003, the Veteran indicated that he had experienced increased knee popping. No valgus or varus laxity was noted, and anterior and posterior drawer testing was negative. The Veteran experienced pain with McMurray's testing. In December 2005, a VA clinician noted that the Veteran's knee was ligamentously stable. In August 2006, a VA clinician noted that the Veteran had no instability to anterior, posterior, valgus, and varus stress testing. Lachman's testing was negative. In September 2007, the Veteran denied feeling as if his right knee would give way. The Veteran denied any locking episodes. The examiner observed only a minimal amount of pseudo-laxity of the medial collateral ligament with a fixed varus deformity. The Veteran's knee stability was significantly affected by the fixed varus deformity, but stability was generally intact with negative anterior drawer and Lachman's testing. In September 2008, the right knee was stable to varus and valgus stress and anterior and posterior drawer testing. The examiner observed no lateral instability involving the right knee, and there were no signs of recurrent subluxation. In March 2010, Lachman's test, anterior drawer testing, valgus and varus testing, and posterior drawer testing were all normal. In July 2010, a VA clinician noted that the Veteran had grade 2 medial laxity with valgus stress. The knee was stable to varus, anterior, and posterior testing. In October 2010, the Veteran's knee was stable to varus and valgus stress in neutral position and at 30 degrees of flexion. Lachman's test was negative. The Veteran denied any subluxation, dislocation, locking, or giving way. The Veteran complained of pain of a 6/10 severity. Applying the law to the facts in the instant case, the Board finds that the evidence does not support the award of a separate disability rating for knee instability. A separate rating requires mild lateral instability of the knee. The evidence does not support a finding of mild recurrent instability of the knee. With the exception of a July 2010 finding that the Veteran had grade 2 medial laxity with valgus stress, testing has consistently revealed normal stability of the Veteran's right knee. The Board acknowledges the Veteran's contention regarding the severity of his condition. However, considering the lack of clinical findings of mild instability, the Board places greater probative weight on the medical evidence of record finding no instability than on the Veteran's subjective accounts of instability. Accordingly, the Board finds that a separate rating based on instability is not warranted at any time during the period under consideration. The Board finds that the preponderance of the evidence is against the assignment of any higher or separation rating prior to January 20, 2011. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As of March 1, 2012 On January 20, 2011, the Veteran underwent a total knee joint replacement, and the Veteran is in receipt of a temporary total rating effective from January 20, 2011, to February 29, 2012. The Veteran is in receipt of a 30 percent rating under Diagnostic Code 5055 as of March 1, 2012. In August 2012, September 2012, and November 2012, VA clinicians noted that the Veteran's right knee had a range of motion that was grossly within functional limits. The Veteran underwent a VA examination in April 2013. The Veteran denied experiencing flare-ups associated with his right knee. The right knee had a range of motion from 15 degrees to 110 degrees, without evidence of painful motion. Repetitive motion did not result in an additional loss of motion. The examiner indicated that the Veteran did not have any functional loss or functional impairment of the knee and lower leg. The Veteran had pain to palpation. The Veteran had never had a meniscal condition. The examiner noted that the Veteran had a scar associated with his total knee joint replacement, but the scar was not painful or unstable, and the total area of all related scars was not greater than 39 square centimeters. Instead, the Veteran's right knee scar was non-tender and 16 centimeters in length. The Veteran regularly used a brace for ambulation. In May 2013, a VA clinician noted that the Veteran had a full range of motion in the right knee. The Veteran had tenderness but full strength. Turning to the possibility of a rating in excess of 30 percent for the right knee, the Board first finds that the Veteran is not entitled to a 60 percent rating under Diagnostic Code 5055, which applies to chronic residuals consisting of severe painful motion or weakness in the affected extremity. The Diagnostic Code does not define the word "severe," but the Board's review of the entirety of the evidence does not support a finding of severe symptoms associated with the Veteran's bilateral knee condition. The April 2013 examiner found that the Veteran did not have any functional loss or impairment in his right knee. The Veteran has maintained full strength in his knee. The Board finds that the Veteran does not suffer from severe painful motion or weakness in the knees, and a 60 percent rating under Diagnostic Code 5055 is therefore unavailable. Diagnostic Code 5055 also allows for a rating greater than 30 percent when the Veteran's symptoms consist of intermediate degrees of residual weakness, pain or limitation of motion. VA may then rate the disability by analogy under Diagnostic Code 5256 (ankylosis of the knee), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). With respect to Diagnostic Code 5256, ankylosis is immobility and consolidation of a joint due to disease, injury, surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Veteran's disability is not analogous to ankylosis because he is able to move his right knee, although with a limitation of flexion to 110 degrees. With respect to Diagnostic Code 5261, applicable to limitation of extension, the Veteran's right knee demonstrated extension limited, at worst, to 15 degrees at the time of the April 2013 examination. That limitation warrants only a 20 percent rating, which is less than the Veteran's currently-assigned 30 percent rating. The Veteran is not entitled to a greater rating based on Diagnostic Code 5261. With respect to Diagnostic Code 5262, applicable to impairment of the tibia and fibula, the Veteran's knee disability is not manifested by nonunion or malunion of the tibia and fibula. While a higher rating of 40 percent is available under that Diagnostic Code based on nonunion of the tibia and fibula with loose motion requiring a brace, no such nonunion is of record. Therefore, a higher rating is not warranted under any of the Diagnostic Codes 5256, 5261, or 5262. The Board must additionally consider functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45 (2012). VA examiners and clinicians have noted the Veteran's complaints such as pain and tenderness, and the Board has taken these complaints into consideration in its above discussion. The Board finds that the evidence does not support a finding that the Veteran's functional loss causes disability beyond the above-discussed range of motion testing. While the Board accepts the credible contentions of the Veteran that his right knee disability causes him to experience significant pain, the Board has taken this into account consideration of the range of motion of the Veteran's knee. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Accordingly, a greater rating is not warranted based on functional loss. The Board finds that a separate disability rating based on instability is unwarranted. In April 2013, the Veteran's joint stability testing was normal. There was no history of recurrent patellar subluxation or dislocation. In May 2013, a VA clinician noted that the Veteran's right knee had no abnormal laxity. Accordingly, the Board finds that a separate rating based on instability is not warranted at any time during the period under consideration. The Board finds that the preponderance of the evidence is against the assignment of any higher or separation rating as of March 1, 2012. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-Schedular Considerations In addition, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57 (1993). There is a three-step inquiry to determine a veteran's entitlement to an extra-schedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Second, if the schedular rating does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran'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 rate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the rating criteria are not inadequate, and it does not appear that the Veteran has an exceptional or unusual disability. He merely disagrees with the assigned rating for his level of impairment. In other words, he does not have any symptoms from his service-connected disability that are unusual or are different from those contemplated by the schedular criteria. The available schedular ratings for that service-connected disability are adequate and the evidence does not show marked interference with employment or frequent hospitalization. Therefore, referral for extra-schedular consideration is not warranted. 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER A disability rating in excess of 10 percent prior to January 20, 2011, and in excess of 30 percent as of March 1, 2012, for a right knee disability is denied. REMAND TDIU is part of an increased rating claim when a request for a TDIU is reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board finds that possible entitlement to a TDIU has been raised by the record, and the claim must be remanded for additional evidentiary development. Pursuant to the Board's March 2013 Remand, a VA examiner opined as to the Veteran's employability in an April 2013 examination report. However, that examination concluded that it was most likely that the Veteran was unemployed as a combination of "mostly spine problems and less so the right knee." That examination did not consider the combined effects of all of the Veteran's service-connected disabilities, including his left knee total replacement, on his ability to obtain and maintain gainful employment. Accordingly, an additional examination should be performed on remand. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination to evaluate the effects of his service-connected disabilities on his ability to obtain and maintain substantially gainful employment. The examiner should offer an opinion regarding the Veteran's ability to procure and maintain gainful employment consistent with his education and occupational experience. The opinion should be offered irrespective of age and any nonservice-connected disabilities. The examiner must review the claims file and must note that review in the report. Specifically, the examiner is requested to offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities preclude his obtaining or retaining substantially gainful employment. If the Veteran is found to be capable of employment, the examiner should state what type of employment and what accommodations would be needed due to the service-connected disabilities. The complete rationale for all opinions expressed should be provided. 2. Then readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The Veteran has the right to submit additional evidence and argument on the matter that 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs