Citation Nr: 1328064 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 08-02 541 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for a right knee disability. 2. Entitlement to a disability rating in excess of 10 percent for a left wrist disability. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Veteran represented by: American Red Cross ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1977 to December 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which continued a 30 percent evaluation for the right knee, internal derangement and instability with traumatic arthritis, and a 10 percent evaluation for traumatic arthritis of the left wrist, status post fracture. In February 2007, the Veteran submitted a notice of disagreement and subsequently perfected his appeal in January 2008. While the Veteran did request a Travel Board hearing on his January 2008 VA Form 9, in a subsequent communication received in April 2008, he withdrew his request for a Board hearing. Accordingly, the Veteran's hearing request is considered withdrawn. See 38 C.F.R. § 20.704(e) (2012). In February 2010 and January 2012, the Board remanded the Veteran's claims of entitlement to increased ratings for his right knee and left wrist disabilities, and a claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) under Rice v. Shinseki, 22 Vet. App. 447, 453 (2009), to the Appeals Management Center (AMC) for further evidentiary development, including providing the Veteran with VA examinations and opinions on the Veteran's employability from a vocational specialist. The Board is obligated by law to ensure that the AMC complies with its directives; 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. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the Veteran was afforded VA examinations to address the Veteran's employability in March 2010 and February 2012 with a March 2012 addendum opinion. With regard to his increased rating claims, these examinations are adequate, as discussed below. As such, all remand instructions issued by the Board have been substantially complied with for the increased rating claims and these matters are once again before the Board. However, with regard to the TDIU claim, the Board finds that the February/March 2012 examination and opinion do not comply with the Board's remand directives, as discussed in detail in the remand section below. The Board notes that these issues may be bifurcated at this point as further development on the TDIU claim will focus solely on the Veteran's employability in light of his education and work experience based on the established severity of his service-connected orthopedic disabilities. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC, in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. Throughout the entire claims period, the Veteran's service-connected right knee disability has been manifested by instability, arthritis, and painful motion with flexion limited to no less than 90 degrees and extension limited to no more than 0 degrees, with no signs of ankylosis or semilunar cartilage dislocation or removal. 2. Throughout the entire claims period, the Veteran's service-connected left wrist disability has been manifested by arthritis with painful and limited motion, with no signs of ankylosis, impairment of the ulna and/or radius, or impairment of supination and pronation. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for service-connected right knee internal derangement and instability have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Code 5257 (2012). 2. The criteria for a 10 percent disability rating, but not greater, have been met for traumatic arthritis of the right knee for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5010 (2012). 3. The criteria for a disability rating in excess of 10 percent for service-connected traumatic arthritis of the left wrist, status post fracture, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Code 5010 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the AOJ of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. A June 2006 letter fulfilled all the above-described notice requirements. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, Social Security Administration (SSA) records, VA treatment records, and VA examination reports have been included in the claims file for review. The Veteran has not identified any private or other outstanding treatment records that he felt were relevant to his claims or that he wished for VA to obtain. The RO also provided the Veteran with VA examinations for his right knee and left wrist disabilities in July 2006, November 2008, and March 2010. The examiners obtained a complete history from the Veteran, considering his complaints, and provided thorough physical examinations, including the appropriate range of motion testing. The examinations of record are adequate for determining the disability rating for the Veteran's service-connected right knee and left wrist disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Additionally, there is no medical evidence indicating that there has been a material change in the severity of the Veteran's service-connected right knee or left wrist disabilities since he was last examined in March 2010. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. A new VA examination is not necessary at this time. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Under Diagnostic Code 5010, arthritis, due to trauma, as substantiated by x-ray findings is rated as degenerative arthritis (under Diagnostic Code 5003). See 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Additionally, the evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Where arthritis results in painful motion of the joint, the rating criteria allow for at least the minimum compensable evaluation for the joint. See 38 C.F.R. § 4.59 (2012). A. Right Knee The Veteran's service-connected right knee internal derangement and instability with traumatic arthritis has been evaluated as 30 percent disabling under Diagnostic Code 5257. He seeks a higher evaluation for the entire period on appeal. Under Diagnostic Code 5257, a 10 percent evaluation is assigned for other impairment of the knee with slight recurrent subluxation or lateral instability. A 20 percent evaluation is assigned for other impairment of the knee with moderate recurrent subluxation or lateral instability. A 30 percent evaluation is assigned for other impairment of the knee with severe recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). Diagnostic Codes 5260 and 5261 provide the criteria for rating limitation of motion of the knee and leg. Normal range of motion for the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II (2012). Under Diagnostic Code 5260, a noncompensable rating is assigned for flexion of the leg limited to 60 degrees. A 10 percent rating is assigned for flexion of the leg limited to 45 degrees. A 20 percent rating is assigned for flexion of the leg limited to 30 degrees. And a 30 percent rating is assigned for flexion of the leg limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Under Diagnostic Code 5261, a noncompensable rating is assigned for extension of the leg limited to 5 degrees. A 10 percent rating is assigned for extension of the leg limited to 10 degrees. A 20 percent rating is assigned for extension of the leg limited to 15 degrees. A 30 percent rating is assigned for extension of the leg limited to 20 degrees. A 40 percent rating is assigned for extension of the leg limited to 30 degrees. And a 50 percent rating is assigned for extension of the leg limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same joint. See VAOPGCPREC 9-04. The General Counsel for VA, in a precedent opinions dated July 1, 1997, (VAOPGCPREC 23-97) (and as reiterated in VAOPGCPREC 9-98, August 14, 1998) held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. General Counsel stated that when a knee disorder is already rated under Diagnostic Code 5257, the Veteran must also have limitation of motion which at least meets the criteria for a 0 percent rating under Diagnostic Code 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. General Counsel subsequently held in VAOPGCPREC 9-98 that a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Where additional disability is shown, a veteran rated under Diagnostic Codes 5257 can also be compensated under Diagnostic Code 5003 and vice versa. The Veteran first underwent a VA examination in conjunction with his present right knee claim in July 2006. At that time, he complained of pain, stiffness, and swelling in his right knee. He denied using any medications or aids in ambulation or experiencing any flare-ups of pain, dislocation, or recurrent subluxation. He did indicate that he had ordered a knee brace and claimed that he had to quit his job as an auto body repair man due to his right knee disability. He denied any problems with his activities of daily living. The July 2006 examiner observed a long medial scar, a positive Lachman's test for some residual laxity of the anterior cruciate ligament, and no effusion or subpatellar crepitus. He recorded range of motion measurements from 0 degrees of extension to 90 degrees of flexion with reported pain at the end point. There was no change in range of motion with repetitive motion and no objective evidence of pain. X-rays showed a screw in the proximal tibia and moderate to severe arthritic changes. The examiner concluded that the Veteran had significant physical impairment due to his right knee. He also stated that he could not opine on any additional loss of range of motion or functional limitation during a flare-up. However, as noted above, the Veteran denied any flare-ups. The Veteran was next examined for his right knee in November 2008. At that time, he complained of constant right knee pain with episodes of swelling and increased pain with extended periods of walking and activities such as bending or lifting objects up from the floor. He reported recently having received a knee brace, but did not wear it because it was too small. The examiner observed that the Veteran moved somewhat slowly and stiffly with a trace limp on the right and no assistive devices. He noted well-healed surgical scars, prominence of the tibial tubercle, a positive patellar grind test, and guarding with no ligamentous instability. He recorded range of motion measurements from -5 degrees of extension and 100 degrees of flexion with pain at the endpoint of motion and no additional limitation after repetitive motion. He was unable to opine on any additional limitation of function during a flare-up of pain without resorting to mere speculation. However, the Veteran reported that his pain occurred constantly, rather than in intermittent flare-ups. X-rays showed degenerative and postoperative changes in the right knee. The examiner diagnosed the Veteran with internal derangement, instability, and traumatic arthritis of the right knee. He concluded that the Veteran would only be able to work in sedentary employment with limited lifting, carrying, standing, walking, squatting, stooping, and climbing. The Veteran was most recently provided a physical examination to evaluate the severity of his right knee disability in March 2010. At that time, he complained of similar symptoms as at the time of the November 2008 VA examination, including constant pain without intermittent flare-ups, episodes of swelling that seem to be occurring more frequently, pain with extended periods of weight bearing or activities such as bending or lifting, and episodes of the right knee giving way. The examiner observed that he was ambulatory with a very slight limp on the right and valgus alignment of the right knee. The Veteran did not use any assistive devices or a knee brace. The examiner noted well-healed surgical scars on the right knee, prominence of the tibial tubercle, tenderness over the medial and lateral joint line and the patellofemoral joint, a positive patellar grind test, and guarding without the presence of definite ligamentous instability. He recorded range of motion measurements of -5 degrees of extension and 90 degrees of flexion with pain at the end point of motion and crepitus on motion. There was no additional limitation after three repetitive motions and no problems with the activities of daily living. The March 2010 VA examiner again stated that he could not comment on additional limitation during a flare-up without resorting to mere speculation. He did not perform new x-rays and diagnosed the Veteran with internal derangement, instability, and traumatic arthritis of the right knee, status post multiple surgeries. The Board notes that the Veteran was afforded an additional VA examination to address the Veteran's employability in February 2012. However, as that particular VA examination evaluated only social and industrial impairment and was conducted by a VA social worker, not a physician or other healthcare provider qualified to comment on the severity of the Veteran's right knee disability, the February 2012 examination is of limited probative value as to the Veteran's right knee evaluation. The medical evidence also includes VA treatment records that discuss the Veteran's right knee disability and complaints of pain and are generally consistent with the VA examinations. Notably, a February 2008 VA treatment record includes a right knee x-ray and notes that the Veteran's right knee was not swollen and his range of motion was within normal limits. A July 2011 VA treatment record notes that the Veteran demonstrated a normal gait. Finally, an April 2012 VA treatment record noted no edema, erythema, or effusion of the right knee and that right knee strength was intact. In addition to the medical evidence, the Veteran has provided lay statements relating his symptoms of right knee pain, particularly with physical activity including standing. The evidence of record does not establish that the Veteran's service-connected right knee disability warrants more than a 30 percent disability rating under his currently assigned Diagnostic Code 5257 at any point throughout the appeals period. Although the evidence of instability has been relatively minimal, he has been assigned the maximum schedular rating under Diagnostic Code 5257. As such, there is no higher rating available under his currently assigned diagnostic code. Although an increased rating cannot be granted under Diagnostic Code 5257, the Board finds that a separate 10 percent evaluation under Diagnostic Code 5010 is appropriate for the right knee for the entire period on appeal. As noted above, x-rays performed at the July 2006 and November 2008 VA examinations showed traumatic arthritis of the right knee. The Veteran has complained of painful motion throughout the appeals period, including on his first VA examination in July 2006. Under 38 C.F.R. § 4.59, this warrants the minimal compensable rating for arthritis of the right knee joint, which is 10 percent. See 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003 (2012); VAOPGCPREC 9-98; see also Degmetich, supra. However, although an additional 10 percent rating is appropriate, a rating in excess of 10 percent is not warranted under Diagnostic Code 5010. There is no evidence showing flexion limited to 30 degrees or less or extension limited to 15 degrees or more. The Veteran's lowest measured range of motion, even when considering the point at which pain began, was 90 degrees of flexion and 0 degrees of extension. These ranges of motion simply do not meet the criteria for a 20 percent rating under either Diagnostic Code 5260 or 5261. As such, the Board finds that a separate rating in excess of 10 percent for arthritis is not warranted at any time during the appeals period. There is also no indication that the Veteran experiences any additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45 (2012); see also DeLuca, supra. Significantly, the Board considered the point at which the Veteran first experienced pain when determining his limitation of motion. Further, while the VA examiners noted the Veteran's complaints of additional pain with repetitive motion, there was not additional loss of motion or other symptoms, other than those already recognized by the Veteran's currently assigned evaluation. The Board emphasizes that there is a difference between pain that may exist in joint motion as opposed to pain that actually places additional limitation of the particular range of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, the Board notes that the Veteran denied flare-ups at each of his VA examinations. An increased rating is simply not warranted under 38 C.F.R. § 4.40 or 4.45. Additionally, there is no indication that the Veteran's right knee disability warrants an increased rating under any other diagnostic code relating to the knees. The claims folder contains no medical evidence indicating that the Veteran's right knee disability is manifested by ankylosis, flexion limited to 60 degrees or less, extension limited to 5 degrees or more, impairment of the tibia and fibula, genu recurvatum, or symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 5256 or 5260-5263. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5258, 5260-5263 (2012). Further, the Board notes that there is no indication in the medical evidence of record that the Veteran's right knee symptomatology warranted other than the currently assigned disability ratings throughout the appeal period. The assignment of staged ratings is not warranted. See Hart, supra. For all of the foregoing reasons, the Board finds that an evaluation in excess of 30 percent under Diagnostic Code 5257 is not warranted at any time during the appeals period and that a separate evaluation of 10 percent (but not higher) under Diagnostic Code 5010 is warranted for the entire period on appeal for the Veteran's right knee disability. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to evaluations in excess of these for his right knee disability, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). B. Left Wrist The Veteran's service-connected traumatic arthritis of the left wrist, status post fracture, has been evaluated as 10 percent disabling under Diagnostic Code 5010. He seeks a higher evaluation for the entire period on appeal. As noted above, Diagnostic Code 5010 allows for the evaluation of arthritis due to trauma based on the limitation of motion of the affected joint. See 38 C.F.R. § 3.71a, Diagnostic Codes 5003, 5010 (2012). Diagnostic Code 5215 provides the criteria for rating limitation of motion of the wrist. Normal range of motion for the wrist is from 80 degrees of palmar flexion to 70 degrees of dorsiflexion (extension) and from 45 degrees of ulnar deviation to 20 degrees of radial deviation. See 38 C.F.R. § 4.71, Plate I (2012). Under Diagnostic Code 5215, a 10 percent evaluation is assigned for palmar flexion in line with the forearm of the major or minor hand, or for dorsiflexion of less than 15 degrees of the major or minor hand. See 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2012). The Veteran first underwent a VA examination in conjunction with his present claim in July 2006. At that time, he complained of pain, particularly with certain movements including flexion of the wrist and increased activity, occasional swelling of the left wrist, and no flare-ups. He reported that he was right hand dominant and that he was able to perform his most recent employment and all activities of daily living despite his left wrist disability. The examiner observed no effusion of the left wrist and recorded range of motion measurements of 0 to 70 degrees of dorsiflexion, 0 to 80 degrees of palmar flexion, 0 to 20 degrees of radial deviation, and 0 to 45 degrees of ulnar deviation. The Veteran complained of pain at the endpoint of each of the ranges of motion, but the examiner did not observe any objective evidence of pain or additional limitation of motion with repetitive motion. X-rays showed slight deformity of the carpal scaphoid, some separation between the lunate and the scaphoid, and mild arthritic changes in the radial carpal joint. He concluded that the Veteran had minimal impairment due to his left wrist. He again concluded that he could not comment on additional functional limitation during a flare-up without resorting to mere speculation, despite the Veteran's denial of flare-ups. The Veteran's left wrist disability was next examined in November 2008. At that time, he complained of pain that increased with increased use. He did report flare-ups of pain with increased use, but was uncertain as to the frequency or duration. His pain was relieved by taking medication. He reported being right handed and denied using a wrist brace. The examiner observed well-healed surgical scars over the volar aspect of the left wrist and over the dorsal ulnar aspect of the left wrist. He recorded range of motion measurements of 0 to 60 degrees of dorsiflexion with pain at the endpoint of motion, 0 to 70 degrees of palmar flexion with pain at the endpoint of motion, 0 to 45 degrees of radial deviation with pain at the endpoint of motion, and 0 to 10 degrees of ulnar deviation without pain. There was no additional limitation of motion on repeated movement. The examiner noted that there was no swelling or tenderness of the wrist, that the Veteran could make a good fist of the hand and oppose the thumb to the fingers, and that his grip strength was normal. X-rays showed considerable degenerative changes of the left wrist. The examiner diagnosed the Veteran with traumatic arthritis of the left wrist, status post fracture, and concluded that he could not comment on additional functional limitation during a flare-up without resorting to mere speculation. The Veteran was most recently examined for his left wrist disability in March 2010. At that time, he complained of increased pain with use, including intermittent flare-ups of pain of uncertain frequency or duration, brought on by increased use and relieved by taking medication. He reported being right hand dominant. The examiner observed that there were well-healed surgical scars, that the Veteran could make a good fist and oppose the thumb to the fingertips, that the Veteran had a normal grip strength, and that there was an area of tenderness over a slightly moveable pea-sized nodule over the radial aspect of the wrist. He recorded range of motion measurements of 0 to 65 degrees of dorsiflexion, 0 to 70 degrees of palmar flexion, 0 to 40 degrees on ulnar deviation, and 0 to 10 degrees of radial deviation. The Veteran reported pain at the endpoint of motion, but had no additional limitation of wrist motion with repeated movements. The examiner concluded that he could not comment on additional functional limitation of motion without resorting to mere speculation. He did not repeat x-rays and diagnosed the Veteran with traumatic arthritis of the left wrist, status post fracture, postoperative. The Board notes that the Veteran was afforded an additional VA examination to address the Veteran's employability in February 2012. However, as that particular VA examination evaluated social and industrial impairment only and was conducted by a VA social worker, not a physician or other healthcare provider qualified to comment on the severity of the Veteran's left wrist disability, the Board finds that the February 2012 examination is of minimal probative value as to the Veteran's left wrist evaluation. The medical evidence of record does not establish that the Veteran's service-connected left wrist disability warrants more than a 10 percent disability rating under any applicable diagnostic codes. He is already in receipt of the maximum schedular rating for traumatic arthritis based on limitation of motion under Diagnostic Codes 5010-5215. The evidence also does not demonstrate occasional incapacitating episodes to warrant an increased rating under Diagnostic Code 5010, other than based on limitation of motion. As such, a higher rating cannot be granted under the Veteran's currently assigned diagnostic code. There is also no indication that the Veteran experiences any additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45 (2012); see also DeLuca, supra. Significantly, the Board considered the point at which the Veteran first experienced pain when determining his limitation of motion. Further, while the VA examiners noted the Veteran's complaints of additional pain with repetitive motion, there was not additional loss of motion or other symptoms, other than those already recognized by the Veteran's currently assigned evaluation. The Board emphasizes that there is a difference between pain that may exist in joint motion as opposed to pain that actually places additional limitation of the particular range of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, although the Veteran has reported flare-ups of pain, he has not indicated that it results in additional functional limitation to warrant an evaluation in excess of 10 percent. Notably, he is already at the maximum schedular rating for the left wrist. As such, even if he experienced additional limitation during a flare-up, it would not result in an increased evaluation. An increased rating is simply not warranted under 38 C.F.R. § 4.40 or 4.45. Additionally, there is no indication that the Veteran's left wrist disability warrants an increased rating under any other diagnostic code relating to the wrists. The claims folder contains no medical evidence indicating that the Veteran's right knee disability is manifested by nonunion or impairment of the ulna and/or radius, impairment of supination or pronation, ankylosis, or symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 5205-5214, 5216-5230. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205-5214, 5216-5230 (2012). Further, the Board notes that there is no indication in the medical evidence of record that the Veteran's left wrist symptomatology warranted other than the currently assigned disability rating throughout the appeal period. The assignment of staged ratings is not warranted. See Hart, supra. For all of the foregoing reasons, the Board finds that an evaluation in excess of 10 percent under Diagnostic Code 5010 is not warranted at any time during the appeals period for the Veteran's left wrist disability. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an evaluation in excess of 10 percent for his left wrist disability, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz, supra. C. Extraschedular Considerations 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. See 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, 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 his employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 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, 115-16 (2008), the United States Court of Appeals for Veterans Claims (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, a veteran's disability picture requires the assignment of an extraschedular rating. With regard to the Veteran's service-connected right knee and left wrist disabilities, the evidence of record does not reflect that the Veteran's disability picture 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 the Veteran's currently assigned disability ratings contemplate his complaints of pain and limited range of motion due to pain. 38 C.F.R. §§ 4.40 and 4.45 adequately contemplate any functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of the joint. Further, although the Veteran's right knee and left wrist arthritis does not result in compensable limited motion, 38 C.F.R. § 4.59 allows for the minimum compensable evaluation for his painful motion. As the Veteran's disability picture is contemplated by the rating schedule, 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 evidence does not support the proposition that the Veteran's service-connected right knee or left wrist disability presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Referral of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to a disability rating in excess of 30 percent for right knee internal derangement and instability is denied. Entitlement to a disability rating of 10 percent for traumatic arthritis of the right knee is granted for the entire period on appeal, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating in excess of 10 percent for traumatic arthritis of the left wrist, status post fracture, is denied. REMAND After a thorough review of the claims file, the Board finds that further evidentiary development is necessary prior to the adjudication of the claim for TDIU. The Board sincerely regrets the delay caused by this additional remand but finds that the development requested herein is necessary prior to a final adjudication of the appeal. In its January 2012 remand, the Board specifically directed the RO/AMC to provide the Veteran with an examination and opinion regarding his employability from a vocational specialist. In February 2012, the Veteran was afforded a Social and Industrial Survey examination with a VA social worker who is presumably a vocational specialist. However, the social worker failed to provide an opinion on his employability with regard to his service-connected disabilities only. Rather, she seemed to rely in great part on the Veteran's nonservice-connected psychiatric disability in her assessment of his occupational impairment. In light of this, the AMC obtained an addendum opinion in March 2012 from a VA physician. The physician's specialty is not listed and there is no indication in the opinion that she is a vocational specialist. She concluded that the Veteran could engage in sedentary employment when considering only his service-connected disabilities. However, she did not seem to consider his employment history or education in reaching this conclusion. Further, she is not shown to be a vocational specialist as was specifically required by the Board's January 2012 remand directive. As such, the Board finds that the opinion is inadequate and fails to comply with the Board's January 2012 remand. See Stegall, supra; see also Barr, supra. This case must be remanded once again for an addendum opinion. Accordingly, the case is REMANDED for the following actions: 1. The Veteran's claims file should be returned to the original February 2012 VA examiner (social worker/vocational specialist), if possible, for an addendum opinion. The claims folder should be provided to the examiner for review of pertinent documents therein in connection with the examination, and the examination report should reflect that such a review was conducted. The vocational specialist must state whether the Veteran's service-connected disabilities (right knee, left wrist, and left iliac crest scar) alone render him unable to secure and maintain substantially gainful employment. The examiner must specifically comment on the March 2012 VA physician's conclusion that the Veteran could engage in sedentary employment and whether this is possible in light of his education and employment history. The examiner is reminded that any effects from the Veteran's nonservice-connected psychiatric disability may not be considered. A complete rationale must be provided for any opinion provided. If the February 2012 VA examiner is unavailable, the Veteran should be afforded an examination with a vocational specialist in order to address the above questions. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. After completing the above action and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above (to include consideration of whether to submit the claim to the Under Secretary for Benefits or Director of Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 4.16(b)), the claim of entitlement to TDIU on an extraschedular basis should be readjudicated. If the claim remains denied, a supplemental statement of the case should be provided to the Veteran and his representative, and after they have had an adequate opportunity to respond, the case should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. See 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 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 2002 & Supp. 2012). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs