Citation Nr: 1328507 Decision Date: 09/06/13 Archive Date: 09/16/13 DOCKET NO. 07-38 155 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama THE ISSUES 1. Entitlement to a rating in excess of 10 percent for the residuals of left knee surgery with degenerative joint disease (DJD). 2. Entitlement to a rating in excess of 10 percent for the residuals of right knee surgery with DJD. 3. Entitlement to a rating in excess of 10 percent for left plantar fasciitis (heel spur), to include a plantar wart and callus of the left 5th metatarsal joint. 4. Entitlement to a rating in excess of 10 percent for a right foot heel spur and plantar fasciitis. 5. Entitlement to an effective date prior to March 8, 2011 for a grant of service connection for posttraumatic stress disorder (PTSD). 6. Entitlement to a total disability rating due to individual unemployability (TDIU), caused by service- connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty from November 1972 to September 1974. He also had service in the Army National Guard from October 1979 to March 2004, including a period of active duty from February 2003 to March 2004. This case was previously before the Board of Veterans' Appeals (Board) in December 2010, at which time, it was remanded to the VA Appeals Management Center (AMC) for further development. The Board directed the AMC to obtain all outstanding records of evaluation and/or treatment of the Veteran from the VA health care system. The Board also directed the AMC to examine the Veteran's service-connected disorders of his knees and feet to determine the extent of impairment attributable to those disorders. Following the requested development, the AMC confirmed and continued the 10 percent ratings for the Veteran's service- connected residuals of left knee surgery with DJD; residuals of right knee surgery with DJD; left plantar fasciitis (heel spur), to include a plantar wart and callus of the left 5th metatarsal joint; and right foot heel spur and plantar fasciitis. The AMC also confirmed and continued the denial of entitlement to a TDIU. Thereafter, the case was returned to the Board for further appellate action. In April 2010, during the course of the appeal, the Veteran had a hearing at the RO before the Acting Veterans Law Judge whose signature appears at the end of this decision. A review of the Virtual VA paperless claims processing system showed that there were VA medical records for the period from March 2004 to October 2012. However, upon examination of these records, they were six pages of notices showing negative responses for records requests. There are no additional documents pertinent to the present appeal associated with the Virtual VA paperless claims processing system. After reviewing the record, the Board finds that additional development of the record is warranted with respect to the issue of entitlement to a TDIU. The Board also finds that there is a potential issue of entitlement to an effective date prior March 8, 2011 for a grant of service connection for posttraumatic stress disorder (PTSD). That issue and potential issue are addressed in the REMAND portion of the decision below. FINDINGS OF FACT 1. The Veteran's service-connected residuals of left knee surgery with DJD are manifested primarily by pain to palpation, flexion to at least 60 degrees, and extension to 0 degrees. 2. The Veteran's service-connected residuals of right knee surgery with DJD are manifested primarily by pain to palpation, flexion to at least 90 degrees, and extension to 0 degrees. 3. The Veteran's service-connected left plantar fasciitis (heel spur), to include a plantar wart and callus of the left 5th metatarsal joint is manifested primarily by pain to palpation and a normal range of motion of the feet and ankles. 4. The Veteran's right foot heel spur and plantar fasciitis is manifested primarily by pain to palpation and a normal range of motion of the feet and ankles. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent have not been met for the residuals of left knee surgery with DJD. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2012). 2. The criteria for a rating in excess of 10 percent have not been met for the residuals of right knee surgery with DJD. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2012). 3. The criteria for a rating in excess of 10 percent have not been met for left plantar fasciitis (heel spur), to include a plantar wart and callus of the left 5th metatarsal joint. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2012). 4. The criteria for a rating in excess of 10 percent have not been met for a right foot heel spur and plantar fasciitis. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Prior to consideration of the merits of the Veteran's appeal, the Board must determine whether VA has met its statutory duty to assist him in the development of the issues of entitlement to a rating in excess of 10 percent for each of the following service-connected disorders: the residuals of left knee surgery with DJD; the residuals of right knee surgery with DJD; left plantar fasciitis (heel spur), to include a plantar wart and callus of the left 5th metatarsal joint; a right foot heel spur and plantar fasciitis. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. After reviewing the record, the Board finds that VA has met that duty. In July 2005, VA received the Veteran's claims, and there is no issue as to providing an appropriate application form or completeness of the application. Following the receipt of that application, VA notified the Veteran of the information and evidence necessary to substantiate and complete his claims, including the evidence to be provided by him and notice of the evidence VA would attempt to obtain. VA informed the Veteran that in order to establish an increased rating for a service-connected disability, the evidence had to show that such disability had worsened and the manner in which such worsening had affected his employment and daily life. 38 U.S.C.A. § 5103(a). In March 2012, the Veteran's representative acknowledged the schedular criteria applicable to rating the Veteran's service-connected knee and foot disorders. Following the notice to the Veteran, VA fulfilled its duty to assist him in obtaining identified and available evidence necessary to substantiate his claim. VA obtained or ensured the presence of the Veteran's service treatment and personnel records; records reflecting his VA treatment from December 2004 through November 2011; records reflecting his treatment by or through Montgomery Family Medicine from July 2003 through October 2006; the report of a July 2004 examination by J. O. C., M.D.; statements, dated in July and August 2004, from the Veteran's former employer; and the Veteran's records from the Social Security Administration. In December 2004, August 2005, January 2006, and February 2011, VA examined the Veteran to determine the extent of impairment due to his service-connected knee and foot disorders. The VA examination reports show during the two most recent examinations, the examiner reviewed the Veteran's medical history. With respect to all examinations, the examiners interviewed and examined the Veteran, documented the manifestations of his service- connected knee and foot disorders; and rendered diagnoses and opinions consistent with the remainder of the evidence of record. Therefore, the Board concludes that the VA examinations are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Finally, a transcript of the Veteran's April 2010 hearing has been associated with the claims folder. The transcript shows the presiding Acting Veterans Law Judge identified the material issues, afforded the Veteran representative an opportunity to question the Veteran, determined where the Veteran had received treatment for his service-connected disorders, and asked clarifying questions as to his manifestations and the types of treatment for those disorders. At the end of the hearing, pursuant to questions from the Acting Veterans Law Judge, the Veteran stated that he did not have anything to add. He also stated that he felt that he had had a fair hearing. As such, the conduct of the hearing was performed in accordance with the provisions of 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). Therefore, there is no prejudice to the Veteran's claim as a result of the conduct of that hearing. See Bryant, 23 Vet. App. at 498 (citing 38 U.S.C.A. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). In its October 2010 remand, the Board directed the AMC to obtain all outstanding records of evaluation and/or treatment of the Veteran from the VA health care system. The Board also directed the AMC to examine the Veteran's service-connected disorders of his knees and feet to determine the extent of impairment attributable to those disorders. These actions were accomplished; there was substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In sum, the Veteran has been afforded a meaningful opportunity to participate in the development of his appeal with respect to his knee and foot disorders. He has not identified any outstanding evidence which could support any of those claims; and there is no evidence of any VA error in notifying or assisting the Veteran that could result in prejudice to him or that could otherwise affect the essential fairness of the adjudication. Accordingly, the Board will proceed to the merits of the appeal. The Merits of the Appeal The Veteran contends that the ratings for his service- connected knee and foot disorders do not adequately reflect the level of impairment caused by those disorders. He states that his feet and knees are very tender and that he must wear orthotics in each of his shoes and a hinged brace on each knee. He also states that he requires a cane and wheelchair to help him get around. Indeed, he notes that his feet and knees are so disabling that he retired from service on disability and that he now receives Social Security disability benefits. Therefore, he maintains that increased ratings are warranted. However, after carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against those claims. Accordingly, the appeal will be denied. Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Codes of VA's Schedule For Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from service-connected disability. 38 C.F.R. § 4.1. Generally, the relevant temporal focus for adjudicating the level of disability of an increased rating claim is from the time period one year before the claim was filed (in this case, September 2003) until VA makes a final decision on the claim. 38 U.S.C.A. § 5110(b)(2) (West 2002); 38 C.F.R. § 3.400(o)(2) (2012). When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40 ; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). With any form of arthritis, painful motion is an important factor of disability. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance, in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, a veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, the following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Knees Arthritis established by X-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5003, if the limitation of motion is noncompensable, 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. Id. In the absence of limitation of motion, a 10 percent evaluation is warranted when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. 38 C.F.R. § 4.71a. There is-ray evidence that the Veteran has DJD of the knees. A 20 percent rating is warranted under DC 5003 where there is x-ray evidence of the involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. For the purposes of rating disabilities from arthritis, the following are considered major joints: shoulder, elbow, wrist, hip, knee, and ankle. 38 C.F.R. § 4.45(f). Limitation of motion of knee is rated in accordance with 38 C.F.R. §§ 4.71a, Diagnostic Codes 5260 and 5261. A 10 percent rating is warranted when flexion is limited to 45 degrees or when extension is limited to 10 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees or when extension is limited to 15 degrees. Normal flexion is 140 degrees. 38 C.F.R. § 4.71, Plate II. Normal extension is 0 degrees. Id. A review of the evidence, such as the VA treatment records and examination reports and the report of his September 2004 examination by J. O. C., M.D., discloses that the Veteran complains of chronic, severe bilateral knee pain for which VA has prescribed bilateral knee braces, a four-prong cane, and a TENS unit. He also uses a wheelchair to get around, though the evidence does not show that it was prescribed for him by a health care provider. The evidence tends to corroborate his complaints of pain to the extent that he has tenderness to palpation and crepitus in each knee. He also experiences limitation of knee motion. However, he is able to flex his left knee to at least 60 degrees and his right knee to at least 90 degrees (September 2004 examination report from J. O. C., M.D.). Subsequent reports, such as the VA examination reports dated in January 2006 and February 2011, show a greater range of motion with left knee flexion to at least 125 degrees and right knee flexion to at least 130 degrees. In any event, such limitation of flexion is non-compensable under the applicable Diagnostic Code, 5260. In addition, the evidence consistently shows that the Veteran is able to fully extend each knee. As such, that motion is also noncompensable. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Testing does not result in additional limitation of motion. Separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). As discussed above, the Veteran's limitation of flexion is non-compensable and his extension is normal. 38 C.F.R. § 4.71a. Because his limitation of flexion does not meet the criteria for a noncompensable evaluation and his extension is normal, separate evaluations under Diagnostic Codes 5260 and 5261 are not warranted. VAOPGCPREC 9-98 (1998); VAOPGCPREC 9-2004 (2004). Other than tenderness to palpation and limitation of flexion, the evidence is generally negative for objective manifestations of knee disability. With regard to instability, VA's General Counsel has held that a claimant who has arthritis as shown by x-ray and instability of the knee may be rated separately under diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). Under Diagnostic Code 5257, a 10 percent evaluation is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent evaluation is warranted when there is moderate recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Diagnostic Code 5257 is based upon instability and subluxation, not limitation of motion, as a result, the criteria set forth in DeLuca do not apply. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Despite the fact that the Veteran wears braces on each knee, objective testing shows that his knees are stable. At his January 2006 VA examination, it was noted that his gait was "unusual" and that he "has exaggerated limping when he walks and leans forward." At his February 2011 VA examination, it was noted that the Veteran "deliberately limp[ed] on his left leg." The examiner found that his "...sense is that he has normal gait." The examiner could not perform stability testing because of the Veteran's "complaints of pain." The Veteran is competent to report observable symptoms, such as his knee feeling unstable. Layno v. Brown, 6 Vet. App. 465 (1994). However, because the examiner found that the Veteran was limping on purpose, the Board finds that his credibility with regard to the issue of knee stability is damaged. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). His assertions regarding instability are not probative evidence in support of his claim. The criteria for a separate evaluation under Diagnostic Code 5257 for instability are not met because the evidence of record does not show that either of the Veteran's knees are unstable. Moreover, there is no evidence of deformity, edema, heat, redness, or neurologic deficits. Indeed, the reflexes and sensation in his lower extremities are normal, and there is no objective evidence of weakness, such as atrophy of disuse of either lower extremity. The Veteran did retire from the National Guard in 2004 due to disability associated, in part, with left knee pain. At that time, his civilian supervisors were reportedly happy with his work. By law, however, when he left the National Guard, he could no longer be retained in his civil service position as a National Guard Technician. Although he states that since that time, he has been unable to do anything because of his knees, the objective manifestations and competent medical opinions suggest otherwise. Following his examination of the Veteran in September 2004, J. O. C., M.D., opined that the Veteran could stand for 4 to 6 hours during an 8 hour workday, so long as he took frequent breaks. Dr. C. also opined that the Veteran could sit for 6 hours during an 8 hour workday, so long as he took routine breaks. Moreover, during a September 2005 VA Psychosocial Assessment, the Veteran was asked what he liked to do for fun and recreation. He responded that he liked to hunt and that he did it a lot. Such a response is inconsistent with someone who reports difficulty walking and tends to impugn the Veteran's credibility. In this regard, a February 2011 report from the Veteran's VA primary care physician and the report of the Veteran's February 2011 VA examination strongly suggest that the Veteran's subjective manifestations exceed the objective findings. They note that the Veteran's pain level is not consistent with his appearance and vitals. In addition, the VA examiner opines that the Veteran's current functional limitations are his choice and are not supported by objective medical evidence. As for other potentially applicable Diagnostic Codes, the Veteran's knee has never been ankylosed, there was no malunion or nonunion of the tibia and fibula, there were no symptoms from the removal or dislocation of semilunar cartilage, and no genu recurvatum. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262 (2010); see also VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9- 98, 63 Fed. Reg. 56704 (1998). Accordingly, application of these Diagnostic Codes is unwarranted. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of Diagnostic Code should be upheld if supported by explanation and evidence). While the Veteran's knee pain is compensated by the 10 percent rating in each knee, the preponderance of the competent evidence of record is against a finding that it meets or more nearly approximates the schedular criteria for a higher evaluation in either knee, even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40 and 4.45. Therefore, increased ratings are not warranted, and to that extent, the appeal is denied. The Feet There is no Diagnostic Code specifically applicable to rating plantar fasciitis. The RO has rated that disorder by analogy to 38 C.F.R. § 4.71a, Diagnostic Code 5276, acquired flatfoot. 38 C.F.R. § 4.20. Under that diagnostic code, 10 percent rating is warranted for moderate impairment, manifested by the weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is warranted for severe unilateral impairment, manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. 38 C.F.R. § 4.71a, Diagnostic Code 5276. A 30 percent rating is warranted for severe bilateral impairment, manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. Upon review of the evidence, the overall disability picture shows that separate 10 percent ratings, but no higher, are warranted for the Veteran's right and left foot. 38 C.F.R. § 4.7. The Veteran's treatment records and the reports of his VA examinations, show that his plantar fasciitis is manifested, primarily by tenderness to palpation of each foot and an inability to walk on his toes and heels. However, he does not demonstrate deformity or malalignment in either foot, and there is no evidence of associated heat, edema, redness, or neurologic deficits. His sensation and reflexes are generally within normal limits, and the preponderance of the evidence is against a findings of weakness in either foot, impaired muscles tone, or atrophy of disuse. During his December 2004 VA examination, there was limitation of foot motion. Plantar flexion was accomplished to 40 degrees, bilaterally, while dorsiflexion was accomplished to 10 degrees on the right and 0 degrees on the left. 38 C.F.R. § 4.71, Plate II (2012) (The standard range of ankle motion consists of 20 degrees of dorsiflexion and 45 degrees of plantar flexion.) Despite the restricted limitation of motion, the examiner found that the Veteran's plantar fasciitis was productive of no more than moderate impairment unilaterally or bilaterally. Repetitive testing was negative for weakness, fatigue, a lack of endurance, or any additional limitation of foot motion. Moreover, there was no edema, instability, callous formation, or skin breakdown in either foot. Such findings were, essentially, confirmed during the Veteran's August 2005 and January 2006 VA examinations. During his February 2011 VA examination, the Veteran did have a callous on the sole of his right foot, and the evidence shows that he has been prescribed orthotic inserts for his shoes and a cane for ambulation. However, the competent objective evidence of record shows that the plantar fasciitis is productive of no more than moderate impairment. The Veteran states that he is unable to put weight on his feet and that his plantar fasciitis impairs his ability, to walk or climb and that he can no longer perform his job as a sheet metal mechanic on helicopters. Although he left the National Guard, in part, due to right plantar fasciitis, it must be emphasized that in September 2004, could stand/walk/sit for 4 to 6 hours during an 8 hour workday, so long as he took recommended breaks. His frequent participation in hunting tended to support that finding, as did the opinions in February 2011 by his primary care physician and VA examiner that Veteran's subjective manifestations exceeded the objective findings. While the Veteran's foot pain is compensated by the 10 percent rating in each foot, the preponderance of the competent evidence of record is against a finding that it meets or more nearly approximates the schedular criteria for a higher evaluation either unilaterally or bilaterally. Therefore, increased ratings are not warranted, and to that extent, the appeal is also denied. Extraschedular Consideration The Board has considered whether referral for an extraschedular rating is appropriate under the provisions of 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extraschedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). While the Veteran's representative has raised the matter of entitlement to an extraschedular rating, the Board notes that the criteria for rating the Veteran's service-connected knee and foot disorders contemplate his symptoms of tenderness to palpation, limitation of motion, and calluses. It also contemplates the possibility of swelling, deformity, and spasms. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260. 5261, 5276. 5284. Therefore, the Veteran does not have symptoms associated with his service- connected knee and foot disorders that have been left uncompensated or unaccounted for by the assignment of a schedular rating. Thun, 22 Vet. App. at 115. In short, the preponderance of the evidence is therefore against a finding that the Veteran's knee and foot disorders present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Accordingly, further action is not warranted under 38 C.F.R. § 3.321 (b)(1) . ORDER Entitlement to a rating in excess of 10 percent is denied for the residuals of left knee surgery with DJD. Entitlement to a rating in excess of 10 percent is denied for the residuals of right knee surgery with DJD. Entitlement to a rating in excess of 10 percent is denied for left plantar fasciitis (heel spur), to include a plantar wart and callus of the left 5th metatarsal joint. Entitlement to a rating in excess of 10 percent is denied for a right foot heel spur and plantar fasciitis. REMAND The Veteran seeks entitlement to a TDIU. Since the Veteran was last examined by VA, service connection has been granted for PTSD and a 30 percent disability rating has been assigned, effective March 8, 2011. Although the Veteran underwent a VA psychiatric examination in March 2011, that examination did not squarely address the question of the Veteran's employability. Moreover, the Veteran has not had a comprehensive examination to determine the combined effect of his service-connected disabilities on his ability to secure and maintain substantially gainful employment. The Veteran also seeks entitlement to an earlier effective date for service connection for PTSD. In a November 2011 rating action, the RO granted the Veteran's claim for service connection for PTSD and assigned a 30 percent rating, effective March 8, 2011. In June 2012, the Veteran filed a Notice of Disagreement with that effective date. Since that NOD was submitted in a timely manner, the Board is required to remand the effective date issue to the RO for the issuance of a Statement of the Case (SOC). Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Issue an SOC concerning the claim of entitlement to a effective dated prior to March 8, 2011, for an increased rating for the Veteran's service- connected PTSD. If, and only if, the Veteran completes his appeal by filing a timely substantive appeal on the aforementioned issue should this claim be returned to the Board. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.200, 20.202 (2012). 2. Schedule the Veteran for a comprehensive examination to determine the impact of all of his service- connected disorders on his ability to secure and maintain substantially gainful employment. All indicated tests and studies must be performed, and any indicated consultations must be scheduled. The claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the examination, and the examiner must acknowledge receipt and review of these materials in any report generated as a result of this remand. Following the examination, the examiner must render an opinion as to whether the Veteran's service-connected disabilities, collectively, would preclude him from securing and maintaining substantially gainful employment consistent with his education and work experience. In performing the examination, the following should be taken into consideration: a) Substantially gainful employment is that which is ordinarily followed by the nondisabled to earn a livelihood, with earnings common to the particular occupation in the community where the employee resides. The ability to work sporadically or to obtain marginal employment is not substantially gainful employment. b) Any consideration as to whether the Veteran is unemployable is a subjective one, that is, one that is based upon the Veteran's actual level of industrial impairment, not merely the level of industrial impairment experienced by the average person. c) Advancing age and nonservice-connected disability may not be considered in the determination of whether a veteran is entitled to TDIU. d) The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. The examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. 3. The Veteran is advised that it is his responsibility to report for all scheduled VA examinations and to cooperate in the development of his claim. The consequences for failure to report for a scheduled VA examination, without good cause, may include denial of the claim. 38 C.F.R. § 3.655 (2012). In the event that the Veteran does not report for a scheduled VA examination, a copy of the notice informing him of the date, time, and location of the examination must be associated with the claims folder. If the notice was returned as undeliverable by the Post Office, that fact must be noted in writing and associated with the claims folder. 4. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 5. Readjudicate the issue of entitlement to a TDIU. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative must be furnished a Supplemental Statement of the Case and afforded an opportunity to respond. Thereafter, if in order, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to the final disposition of any unresolved issue. The Veteran need take no action unless he is notified to do so. However, he is advised that he has the right to submit any additional evidence and/or argument on the matters the Board has remanded to the AMC. Kutscherousky v. West, 12 Vet. App. 369, 372-73 (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. 2007). ______________________________________________ D. MARTZ AMES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs