Citation Nr: 1326491 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 04-00 094A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for postoperative residuals of a right knee injury prior to September 20, 2011 2. Entitlement to an evaluation in excess of 20 percent for postoperative residuals of a right knee injury as of September 20, 2011. 3. Entitlement to an initial evaluation in excess of 10 percent for scleroderma with rheumatoid arthritis prior to September 23, 2011. 4. Entitlement to an evaluation in excess of 60 percent for scleroderma with rheumatoid arthritis, to include separate 20 percent ratings for rheumatoid arthritis of the right shoulder, left shoulder, left hip, with limitation of abduction, right hip, with limitation of abduction, and left knee with limitation of extension; separate 10 percent ratings for rheumatoid arthritis of the left elbow, right elbow, left wrist, left hip, with limitation of extension, right hip, with limitation of extension, and left knee with limitation of extension; and separate noncompensable ratings for left hip, with limitation of flexion, and right hip, with limitation of flexion; as of September 23, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. J. Vecchiollo INTRODUCTION The Veteran served on active duty from May 1968 to June 1969, including combat service in Vietnam, and his decorations include the Purple Heart Medal. The disabilities at issue come before the Board of Veterans' Appeals (Board) on appeal from May 2003 and July 2011 rating decisions of the VARO in Roanoke, Virginia. The Board remanded the claim in January 2009 for further development and consideration. A June 2011 Board decision granted service connection for scleroderma. A July 2011 rating decision implemented that grant (scleroderma with rheumatoid arthritis), and assigned a 10 percent rating, effective May 19, 1999. The Veteran filed a notice of disagreement (NOD) regarding entitlement to in increased initial rating in August 2011. In that June 2011 decision, the Board remanded the right knee injury increased rating claim in for further development and consideration. A March 2012 rating decision granted an increased, 20 percent rating for the right knee injury, effective September 20, 2011. As such, the Board has identified the Veteran's right knee claims as separate issues as set forth on the title page. A hearing was held before a Veterans Law Judge in August 2008. In a January 2013 letter, the Board informed the Veteran that the individual who presided at the August 2008 hearing was no longer employed by the Board and that the Veteran had the right to a hearing before another Veterans Law Judge. The Veteran requested, and was scheduled to appear, for another Board hearing in July 2013. However, in May 2013, he cancelled the hearing due to health problems, and did not request another hearing. His hearing request is thus deemed withdrawn. An April 2012 rating decision granted entitlement to an initial evaluation of 60 percent for scleroderma with rheumatoid arthritis, to include separate 20 percent ratings for rheumatoid arthritis of the right shoulder, left shoulder, left hip, with limitation of abduction, right hip, with limitation of abduction, and left knee with limitation of extension; separate10 percent ratings for rheumatoid arthritis of the left elbow, right elbow, left wrist, left hip, with limitation of extension, right hip, with limitation of extension, and left knee with limitation of extension; and separate noncompensable ratings for left hip, with limitation of flexion, and right hip, with limitation of flexion; as of September 23, 2011. As such, the Board has identified the Veteran's scleroderma claims as separate issues as set forth on the title page. The issue of entitlement to an increased, initial evaluation for scleroderma with rheumatoid arthritis is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to July 10, 2009, the preponderance of the evidence shows, even considering his pain, the Veteran's right knee flexion is not limited to 30 degrees or less; he does not have any limitation of extension of the right knee; and no instability or subluxation has been objectively confirmed. 2. From July 10, 2009, to September 19, 2011, the Veterans right knee flexion is limited to 25 degrees; he does not have any limitation of extension of the right knee; and no instability or subluxation has been objectively confirmed. 3. As of September 20, 2011, the Veteran's right knee flexion, when considering that he only has 5 to 30 degrees of right knee flexion with pain, is analogous to limitation of flexion to 15 degrees 4. As of September 20, 2011, the Veteran's right knee extension was limited to 20 degrees. 5. The preponderance of the evidence shows that the Veteran has no right knee instability or subluxation. CONCLUSIONS OF LAW 1. The criteria are not met for ratings higher than 10 percent for the right knee injury prior to July 10, 2009. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5259, 5260, 5261 (2012). 2. The criteria for a 20 percent rating have been met from July 10, 2009, to September 18, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5259, 5260, 5261 (2012). 3. The criteria for a separate 30 percent rating for limitation of right knee flexion have been met as of September 19, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5259, 5260 (2012). 4. The criteria for a separate 30 percent rating for limitation of right knee extension have been met as of September 19, 2011. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5259, 5260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The RO provided the appellant with notice in February 2009, subsequent to the initial adjudication. While the notice was not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to meaningfully participate in the adjudication process. The claim was subsequently readjudicated in an April 2010 supplemental statement of the case, following the provision of notice. The appellant has not alleged any prejudice as a result of the untimely notification, nor has any been shown. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. The Board finds that VA has secured all available and identified pertinent in-service and post-service evidence. The Board's remands directed the agency of original jurisdiction (AOJ) to obtain and associate with the record additional treatment records, which were associated with the Veteran's claims file. In addition, the remands also directed the AOJ to obtain a VA examination. A compensation examination adequate for rating purposes was obtained in September 2011. Therefore, the Board finds that there was substantial compliance with the Board remand directions and VA adjudication of the current claim may proceed. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Veteran has been afforded a hearing before a VLJ in which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ asked specific questions directed at identifying whether the Veteran had symptoms meeting the schedular criteria for a higher rating. The VLJ did not specifically seek to identify any pertinent evidence not currently associated with the claims. This was not necessary, however, because the Veteran volunteered his treatment history and his symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of this claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Analysis Ratings for service-connected disabilities are determined by comparing the symptoms the Veteran is presently experiencing with various criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. Also, when making determinations concerning the appropriate rating to be assigned, VA must take into account the Veteran's entire medical history and circumstances. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). The RO has assigned staged ratings to the Veteran claim. The Board must also consider whether to "stage" the ratings to compensate him for times since the filing of his claim when his disability may have been more severe than at other times during the course of his appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007) The Veteran's right knee injury is rated under hyphenated Diagnostic Code 5259-5260. In the selection of diagnostic codes assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that , under Diagnostic Code 7338, is the service-connected disorder and that a scar, under Diagnostic Code 7804, is a residual condition. Diagnostic Code 5260 provides that flexion limited to 15 degrees warrants a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a 0 percent (noncompensable) rating. Diagnostic Code 5261 provides that extension limited to 45 degrees warrants a 50 percent rating; extension limited to 30 degrees warrants a 40 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 5 degrees warrants a 0 percent (noncompensable) rating. For comparison, normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). "Other" impairment of the knee, namely, if due to recurrent subluxation or lateral instability, is rated under DC 5257 as 10-percent disabling if "slight", as 20-percent disabling if "moderate", and as 30-percent disabling if "severe". VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (July 1, 1997; revised July 24, 1997). The General Counsel subsequently clarified in VAOPGCPREC 9-98 (August 14, 1998) that for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. VA's General Counsel further explained that, if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, a separate rating for arthritis also could be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. This is because, read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). VA's General Counsel has additionally held that separate ratings may be assigned, as well, for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59, 990 (2004). Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same knee, the limitations must be rated separately to adequately compensate him for functional loss associated with injury to his leg and knee. Id. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). As a preliminary matter, the Board notes that the Veteran is in receipt of service connection for scleroderma and rheumatoid arthritis of multiple joints. The evidence shows that his right knee, which is already service connected based on an in-service injury, is also affected by scleroderma/ rheumatoid arthritis. For purposes of determining whether a veteran is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions. 38 C.F.R. § 4.14 (2012); Esteban v. Brown, 6 Vet. App. 259 (1994). The RO has not service connected the Veteran's right knee based on scleroderma/ rheumatoid arthritis, nor has it attributed any right knee symptoms, pain, limitation of motion, etc., to his service-connected scleroderma/ rheumatoid arthritis. Thus, the Board will attribute all the right knee pathology to the service-connected disability under the existing Diagnostic Code. See 38 C.F.R. § 4.14; Esteban. Further, the Board notes that the Veteran has reported that he does not seek VA outpatient treatment care for his right knee disability. Prior to July 10, 2009 A May 2004 treatment note indicted that the Veteran right knee flexion was to 90 degrees. A fee basis examination was conducted in May 2004. Right knee flexion was 140 degrees with pain; extension was between 5 and 0 degrees with discomfort. There was no further limitation, fatigue, weakness, lack of endurance or incoordination. Drawer and McMurray tests were within normal limits. An X-ray study found osteoarthritic changes of the right knee. A separate compensable rating for limitation of extension also is not warranted under Diagnostic Code 5261 according to VAOPGCPREC 9-2004. The VA examination reports do not reflect any limitation of motion on extension such as to warrant a compensable evaluation because there is no additional disability. Achieving even the most minimum compensable rating of 10 percent under Diagnostic Code 5261 requires extension limited to 10 degrees. However, there simply is no clinical evidence of such limited extension, much less to an even greater extent. The Veteran had almost full extension, even when considering his painful motion. These results clearly exceed the required 10-degree limitation of extension, even with consideration of any associated pain. Thus, a separate rating for limitation of extension, including on account of his pain, is not warranted, especially inasmuch as he does not even meet the criteria for a noncompensable (0 percent) rating under Diagnostic Code 5261, requiring extension limited to at least 5 degrees. Considering 38 C.F.R. § 4.71a, Diagnostic Code 5257, there have been no objective findings of instability or subluxation of Veteran's right knee. The VA examinations in October 2008 and November 2011 revealed his knees were stable to stress testing and ligaments intact. All of the tests for instability during those examinations (varus valgus stress, anterior and posterior drawer, and McMurray's) were normal. Thus, the Board finds that a separate rating under Diagnostic Code 5257 is not warranted. There also is no objective clinical evidence of any knee ankylosis to warrant consideration of a higher rating under Diagnostic Code 5256. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."). Because the Veteran is able to move his knee joints in both flexion and extension (albeit less than normally would be expected in flexion), by definition, his knees are not immobile or fixated and therefore not ankylosed. From July 10, 2009, to September 18, 2011 A VA examination was conducted in July 10, 2009. Right knee flexion was 0 to 25 degrees; extension was normal. There was pain on motion but no additional pain, limitation of motion, or functional loss with repetitive motion. The Veteran is entitled to an increased, 20 percent, rating as the Veteran's right knee flexion is less than 45 degrees. However, entitlement to a 30 percent rating is not warranted as the Veteran does not approximate limitation of flexion approaching 15 degrees, even considering pain because the Veteran's pain did not result in further limitation of motion. As discussed above, entitlement to a separate increased rating based on limitation of extension is not warranted as extension was normal. No subluxation or instability has been shown. So a separate rating under Diagnostic Code 5257 is also not warranted. As of September 19, 2011 The September 19, 2011, VA examiner noted that the Veteran had 5 degrees of fixed flexion contracture and could then only slowly and painfully flex to 30 degrees. The examiner also stated that the Veteran's mobility was severely compromised by his right knee injury and that he could barely flex his right knee while walking. The examiner found no right knee instability. A fee basis examination was conducted in December 28, 2011. The Veteran denied effusion or subluxation of the right knee. Right knee flexion ended at 90 degrees with pain; extension ended at 20 degrees with pain. After repetitive movement, right knee flexion again ended at 90 degrees; extension again ended at 20 degrees. A history of right knee subluxation/dislocation was noted. However, instability tests were normal. No diminished function of the lower extremities was found. The level of right knee flexion noted on September 19, 2011, (5 degrees to 30 degrees) combined with severely compromised mobility, approximates limitation of flexion to 15 degrees. Further, the Board notes that the Veteran's limitation ofextenion to 20 degrees warrants a separate 30 percent rating under Diagnostic Code 5261. No subluxation or instability has been shown. So a separate rating under Diagnostic Code 5257 is also not warranted. Separate Rating for Scar The Veteran's right knee surgical scar due to surgery on the right knee performed in service, is superficial, stable, not tender, not painful, not poorly nourished, not ulcerated, measures less than 6 square inches in size, and does not limit motion or function. Therefore, a separate compensable rating for the scar is not warranted. Extraschedular Considerations Consideration has also been given regarding whether the schedular evaluation is inadequate, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating, otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The schedular evaluation in this case is adequate. Ratings in excess of that assigned are provided for certain manifestations of the service-connected disorder but the medical evidence reflects that those manifestations are not present in this case. The Veteran has not required hospitalization due to the service-connected disability, and marked interference of employment has not been shown. Therefore, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. ORDER An evaluation in excess of 10 percent for postoperative residuals of a right knee injury prior to July 10, 2009, is denied. An evaluation of 20 percent for postoperative residuals of a right knee injury from July 10, 2009, to September 18, 2011, is granted, subject to the regulations governing monetary awards. An evaluation of 30 percent for limitation of right knee flexion as of September 19, 2011, is granted, subject to the regulations governing monetary awards. An evaluation of 30 percent for limitation of right knee extension as of September 19, 2011, is granted, subject to the regulations governing monetary awards. REMAND In a July 2011 rating decision implementing the Board's determination that service connection was warranted for scleroderma with rheumatoid arthritis, the RO assigned an initial 10 percent rating, effective May 19, 1999. The RO notified him of the determination and of his appellate rights in a July 2011 letter, and in a statement received in August 2011 the Veteran challenged the rating assigned. The Board accepts the Veteran's August 2011 statement as a Notice of Disagreement with the July 2011 rating decision. See 38 C.F.R. § 20.201 (2012). To date, however, the RO has not issued the Veteran a Statement of the Case (SOC) with respect to this claim, although higher and separate evaluations were assigned by the RO in an April 2012 rating decision. Under the circumstances, the Board has no discretion and is obliged to remand this issue to the RO for the issuance of an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); Holland v. Gober, 10 Vet. App. 433, 436 (1997). Accordingly, the case is REMANDED for the following action: Issue the Veteran an SOC with respect to his claims seeking higher ratings for his scleroderma with rheumatoid arthritis, both prior to and since September 23, 2011, to include notification of the need to timely file a Substantive Appeal to perfect his appeal on this issue. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs