Citation Nr: 1328853 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 10-27 553A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a disability rating greater than 20 percent for osteoarthritic changes in the left knee. 2. Entitlement to a disability rating greater than 20 percent for osteoarthritic changes in the right knee. 3. Entitlement to a compensable disability rating for hypertension. 4. Entitlement to a compensable disability rating for residuals of a fracture of the left first metacarpal joint. 5. Entitlement to an initial rating greater than 20 percent for degenerative joint disease and degenerative disc disease of the lumbar spine. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from July 1979 to June 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which granted the Veteran's claim of service connection for degenerative joint disease and degenerative disc disease of the lumbar spine and assigned a 20 percent rating effective November 20, 1997. This matter also is on appeal from a June 2010 rating decision in which the RO denied the Veteran's claims for a disability rating greater than 20 percent for osteoarthritic changes in the left knee, a disability rating greater than 20 percent for osteoarthritic changes in the right knee, a compensable disability rating for hypertension, a compensable disability rating for residuals of a fracture of the left first metacarpal joint, and a claim of entitlement to a TDIU. The issues of entitlement to an initial rating greater than 20 percent for degenerative joint disease and degenerative disc disease of the lumbar spine and to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The evidence shows that the Veteran's service-connected osteoarthritic changes in the left knee are manifested by, at worst, flexion to 130 degrees with complaints of pain at 90 degrees, full extension without evidence of painful motion, additional limitation of motion due to less movement than normal, pain on movement, swelling, disturbance of locomotion, interference with sitting, standing, and weight-bearing, and no subluxation or lateral instability. 2. The evidence shows that the Veteran's service-connected osteoarthritic changes in the right knee are manifested by, at worst, flexion to 125 degrees with complaints of pain at 90 degrees, full extension without evidence of painful motion, additional limitation of motion due to less movement than normal, pain on movement, swelling, disturbance of locomotion, interference with sitting, standing, and weight-bearing, and no subluxation or lateral instability. 3. The evidence shows that the Veteran's service-connected hypertension is under good control with continuous medication and no history of diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. 4. The evidence shows that the Veteran's service-connected residuals of a fracture of the left first metacarpal joint are manifested by, at worst, complaints of pain, a gap of less than 1 inch (2.5 centimeters) between the thumb pad and the fingers with the thumb attempting to oppose the fingers, less movement than normal, pain on movement, and swelling of the thumb. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 20 percent for osteoarthritic changes of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5010-5257 (2012). 2. The criteria for a disability rating greater than 20 percent for osteoarthritic changes of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5010-5257 (2012). 3. The criteria for a compensable disability rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.104, DC 7101 (2012). 4. The criteria for a compensable disability rating for residuals of a fracture of the left first metacarpal joint have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5299-5228 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters issued in January 2010 and in April 2011, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters informed the Veteran to submit medical evidence showing that his service-connected bilateral knee disabilities, hypertension, and residuals of a fracture of the left first metacarpal joint had worsened. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Court previously held that to satisfy the first Quartuccio element for an increased compensation claim, section 5103(a) compliant notice must meet a four-part test laid out in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The United States Court of Appeals for the Federal Circuit (Federal Circuit) overruled Vazquez-Flores in part, striking the claimant-tailored and "daily life" notice elements. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Recently, the Court issued an opinion incorporating those surviving portions of the first Vazquez-Flores decision, namely that VA must notify the claimant that 1) to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability, 2) a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment, and 3) provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation, and must also notify the claimant that to substantiate such a claim the claimant should provide or ask the Secretary to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 107 (2010) (Vazquez-Flores III). For the following reasons, the Board finds that the elements of the Vazquez-Flores test that remain under Vazquez-Flores III either have been met in this case or that any error in not providing such notice is not prejudicial to the Veteran. The first and third elements were met by the January 2010 and April 2011 notice letters. These letters informed the Veteran that he needed to provide information showing his service-connected disabilities had worsened. He was informed that such evidence could be a statement from his doctor or lay statements describing what individuals had observed about his disabilities. He was told that he needed to provide VA information as to where he had received medical treatment or he could send VA any pertinent treatment records. Examples of evidence needed to support the claims were provided, including laboratory tests, examinations, and statements from other individuals who could describe from their knowledge and personal observations the manner in which his disabilities had worsened. He also was informed of what evidence VA would obtain on his behalf and what he needed to do to help VA process his claims. The Veteran further has submitted personal statements with respect to his service-connected disabilities. As the Board finds the Veteran had actual knowledge of the requirement to show worsening of the disabilities and the variety of the medical and lay evidence which could support his claims, any failure to provide him with adequate notice as to the first and third Vazquez-Flores elements is not prejudicial. As to the second element of Vazquez-Flores notice, the Board acknowledges that the Veteran was not provided notice that a disability rating would be determined by application of the ratings schedule and relevant diagnostic codes based on the extent and duration of the signs and symptoms of his disability and their impact on his employment. See Vazquez-Flores III, 24 Vet. App. at 107. The Veteran received a statement of the case in October 2010 and supplemental statements of the case in May 2011 and in December 2012 addressing his claims. Specific VCAA notice to the Veteran of the ratings schedule to be applied to the symptomatology of his disabilities is unnecessary in light of repeated correspondence sent to the Veteran by the RO/AMC describing the Rating Schedule and applying the relevant regulations to his claims. The Board finds that the Veteran was on constructive notice of the existence and function of the Ratings Schedule. The Board further finds that any error in the third element of Vazquez-Flores notice is not prejudicial. In summary, the Board concludes that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. As will be explained below in greater detail, the evidence does not support granting increased ratings for osteoarthritic changes in either of the Veteran's knees, hypertension, or for residuals of a fracture of the left first metacarpal joint. Because the Veteran was fully informed of the evidence needed to substantiate his claims, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Additional notice of the five elements of a service-connection claim was provided in the January 2010 and April 2011 VCAA notice letters issued to the Veteran, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the January 2010 letter was issued to the Veteran prior to the June 2010 rating decision which denied the benefits sought on appeal; thus, this notice was timely. Because the Veteran's increased rating claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot and there can be no failure to notify the Veteran. See Dingess, 19 Vet. App. at 473. And any defect in the timing or content of the notice provided to the Veteran has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board, although he declined to do so. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed and no relevant evidence was located there. The Veteran's complete Social Security Administration (SSA) records also have been obtained and associated with the claims file. The Veteran was afforded VA examinations in 2009, 2010, and in 2012. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. The Veteran has contended, however, that the VA examinations of record do not present an accurate portrayal of the limitation of motion and flare-ups of pain that he experiences as a result of his service-connected osteoarthritic changes in his knees. In advancing an argument concerning the adequacy of the VA examinations conducted during the pendency of this appeal, the Veteran appears to be raising a general challenge to the professional competence of the VA examiners who conducted them. Both the Court and the Federal Circuit have held, however, that the Board is entitled to presume the competence of a VA examiner and specific challenges to a VA examiner's competency must be raised by the appellant to overcome this presumption. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009) and Bastien v. Shinseki, 599 F.3d 1301 (Fed. Cir. 2010); see also Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (citing Hilkert v. West, 12 Vet. App. 145, 151 (1999)). The Court held in Cox that "the Board is entitled to assume the competence of a VA examiner." Id. at 569 (citations omitted). Absent evidence or argument which called in to question a VA examiner's professional competence, the Court concluded in Cox that it is not error for the Board to presume that a VA examiner is competent. Id. See also Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (explicitly extending the presumption of competence discussed in Cox and Rizzo to VA examiners). Neither the Veteran nor his attorney has not raised a specific challenge to the professional medical competence or qualifications of the VA examiners who saw him during the pendency of this appeal. There has been no showing or even an allegation that the VA examiners who saw the Veteran during the pendency of this appeal were not competent or did not report accurately what they found in their review of the claims file. The Board also finds VA examinations of record are adequate for evaluation purposes because they addressed fully all of the Veteran's contentions regarding the severity of his service-connected disabilities. See 38 C.F.R. § 4.2 (2012). The Board further finds that a remand to obtain another opinion or examination would serve no purpose but to delay further the adjudication of the Veteran's claims with no benefit flowing to him. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (holding that strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran) and Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (holding that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided). Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Increased Rating Claims The Veteran contends that his service-connected osteoarthritic changes of the left knee, osteoarthritic changes of the right knee, hypertension, and residuals of a fracture of the left first metacarpal joint are all more disabling than currently evaluated. Law and Regulations In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The Veteran's service-connected osteoarthritic changes of the left knee and of the right knee currently are evaluated as 20 percent disabling in each knee under 38 C.F.R. § 4.71a, DC 5010-5257 (traumatic arthritis-other knee impairment). See 38 C.F.R. § 4.71a, DC 5010-5257 (2012). The Veteran's service-connected hypertension currently is evaluated as zero percent disabling (non-compensable) under 38 C.F.R. § 4.104, DC 7101. See 38 C.F.R. § 4.104, DC 7101 (2012). The Veteran's service-connected residuals of a fracture of the left first metacarpal joint currently are evaluated as zero percent disabling under 38 C.F.R. § 4.71a, DC 5299-5228 (other hand disability-limitation of motion of the thumb). See 38 C.F.R. § 4.71a, DC 5299-5228 (2012). DC 5010 provides that traumatic arthritis will be rated as degenerative arthritis under DC 5003. See 38 C.F.R. § 4.71a, DC 5010. Under DC 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. DC 5257 provides a 20 percent rating for moderate recurrent subluxation or lateral instability. A maximum 30 percent rating is assigned for severe recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, DC 5257. DC 7101 provides a 10 percent rating for hypertension with diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. A 10 percent rating also is the minimum evaluation under DC 7101 for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. See 38 C.F.R. § 4.104, DC 7101. DC 5228 provides a zero percent (non-compensable) rating for limitation of motion of the thumb with a gap of less than 1 inch (2.5 centimeters (cm)) between the thumb pad and the fingers with the thumb attempting to oppose the fingers. A minimum 10 percent rating is assigned for a gap of 1-2 inches (2.5 to 5.1 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers. These ratings are assigned for both the major (dominant) and minor (non-dominant) hands. See 38 C.F.R. § 4.71a, DC 5228. The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2012). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40 (2012). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. For the purpose of rating disability from arthritis, the knee is considered a major joint and multiple involvements of the metacarpal joints of the upper extremities are considered groups of minor joints ratable on a parity with major joints. 38 C.F.R. § 4.45 (2012). VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the diagnostic codes; "functional loss" may occur as a result of weakness, fatigability, incoordination or pain on motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). VA must consider any part of the musculoskeletal system that becomes painful on use to be "seriously disabled." If a Veteran has separate and distinct manifestations relating to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14 (2012). Where a Veteran has a limitation of flexion and a limitation of extension, the limitations must be rated separately to adequately compensate for functional loss which comports with the principle underlying Esteban. See VAOPGCPREC 9-2004. The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14 (2012). The Rating Schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomatology, since such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding. See Esteban, citing Brady v. Brown, 4 Vet. App. 203 (1993). VA's General Counsel has held that limitation of motion and instability of the knee involve different symptomatology and separate ratings specifically are allowed under the Rating Schedule with x-ray evidence of arthritis. See VAOPGCPREC 23-97 and VAOPGCPREC 9-98. Under 38 C.F.R. §§ 4.40 and 4.45, a Veteran's pain, swelling, weakness, and excess fatigability must be considered when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court held in DeLuca that all complaints of pain, fatigability, etc., shall be considered when put forth by a Veteran. Therefore, consistent with DeLuca and 38 C.F.R. § 4.59, the Veteran's complaints of pain have been considered in the Board's review of the diagnostic codes for limitation of motion. Factual Background As noted in the Introduction, in the currently appealed rating decision issued in August 2009, the RO granted the Veteran's claim of service connection for degenerative joint disease and degenerative disc disease of the lumbar spine and assigned a 20 percent rating effective November 2, 1997. In a letter dated on October 12, 2009, and date-stamped as received by the RO on October 16, 2009, the Veteran disagreed with the 20 percent rating assigned for his service-connected degenerative joint disease and degenerative disc disease of the lumbar spine. The Veteran also filed a TDIU claim. The RO interpreted this letter as a request for increased ratings for his service-connected osteoarthritic changes in the right knee, osteoarthritic changes in the left knee, residuals of a fracture of the left first metacarpal joint, and for hypertension. On VA joints examination in January 2010, the Veteran complained of bilateral knee pain, stiffness, inflammation, and tenderness. The VA examiner stated that he had reviewed the Veteran's medical records. The Veteran reported that he currently wore bilateral knee braces "whenever there is 'any amount of walking.'" He also took Motrin 800 mg 3 times a week. He denied any history of trauma to the joints or neoplasm. He was right-hand dominant. He denied any bilateral knee deformity, giving way, instability, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, or effusions. He experienced flare-ups that were moderate in severity and occurred 70 days per year and lasted 1-2 days. There were no constitutional symptoms or incapacitating episodes of arthritis. The Veteran was "[a]ble to stand 3 to 8 hours, with only short rest periods" and could walk 1/4 mile. He used a knee brace intermittently but frequently although he was not wearing any knee braces at the examination. Physical examination in January 2010 showed a normal gait and no evidence of abnormal weight-bearing, no loss of a bone or part of a bone, no inflammatory arthritis, no crepitation, mass behind the knee, clicks or snaps, grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, or other knee abnormalities in either of the Veteran's knees. Range of motion testing showed full flexion to 140 degrees and full extension to zero degrees without evidence of pain with active motion in both of the Veteran's knees. No joint ankylosis was present. X-rays of both knees showed mild osteoarthritic changes on the medial aspect of the joints. The diagnoses were radiographic evidence of mild osteoarthritic changes of both knees without patellofemoral pain syndrome of either knee. On VA hypertension examination in January 2010, no relevant complaints were noted. The VA examiner reviewed the Veteran's medical records. The Veteran reported that he had been diagnosed as having hypertension in 1990 following a stress test and being told that he had high blood pressure. He was on Cardizem 240 mg twice daily and "claims compliance with medication regimen[]." His hypertension had been stable since onset with medication. He denied a history of hypertensive renal disease, stroke/transient ischemic attack, nosebleeds, or headaches related to hypertension. He also denied any other cardiac history or history of other hypertensive related diseases. "Continuous medication is required for control of hypertension." Physical examination showed blood pressure of 150/94, 142/74, and 128/78, no evidence of congestive heart failure or pulmonary hypertension, a regular heart rate and rhythm, no evidence of abnormal breath sounds, and a normal heart size by x-ray. The Veteran's chest x-ray also was normal. The diagnosis was hypertension. On VA hand, thumb, and fingers examination in January 2010, the Veteran complained of an overall decrease in left hand strength and a decrease in left hand dexterity. The VA examiner reviewed the Veteran's medical records. The Veteran reported that, during active service, "he was playing football and he went to tackle someone and injured the thumb. The next day he went to sick call. X-ray was preformed and thumb was fractured. No surgery. It was casted. He was returned to duty. No current care for thumb now." He denied any history of neoplasm to the hands. He was right-hand dominant. Physical examination of the left index finger, left long finger, left ring finger, left little finger, and left thumb showed a normal range of motion with no objective evidence of painful motion, no gap between the index finger and proximal transverse crease of the hand on maximal flexion of the finger, no gap between the left thumb pad and the fingers, no objective evidence of pain or additional limitation of motion following repetitive range of motion testing, no amputation of a digit or part of a digit, no ankylosis or deformity of 1 or more digits, no decreased strength for pushing, pulling, and twisting, no decreased dexterity for twisting, probing, writing, touching, and expression, a "very strong and robust grip," no alteration in fine motor movements, and he was "able to undress and dress without difficulty." A left hand x-ray was normal. The diagnoses were no current residuals from the Veteran's previously fractured left first metacarpal joint, no radiographic (or x-ray) evidence of his past fracture, and his hand functioned normally. On VA outpatient treatment in February 2010, the Veteran complained of "right knee pain for 11/2 weeks" and right knee swelling. He denied experiencing any right knee trauma. Objective examination showed blood pressure of 156/92 and 136/70, a regular heart rate and rhythm, and a full range of motion in the right knee with no effusion. The VA clinician stated that the Veteran's "blood pressure is usually adequately controlled. No medication changes are indicated at this time." The assessment was hypertension under good control. The Veteran was advised to continue taking his medications. In statements on his July 2010 Notice of Disagreement, the Veteran contended that he was entitled to a compensable disability rating for his service-connected hypertension because he had been on continuous medication to treat this disability "for the past 20 plus years." (Emphasis in original.) He also contended that "I am losing more of the ability to go up and down the stairs in my house" due to worsening of his service-connected bilateral knee disabilities. He further experienced increased bilateral knee pain and swelling. On private musculoskeletal evaluation by H.G.S, M.D., in October 2011, the Veteran's complaints included right knee pain in the medial and lateral aspects, swelling, extension locking, occasional giving way, left knee pain under the left patella and occasional giving way, and left hand numbness affecting the index and long digits. The Veteran denied any left knee swelling or extension locking and any left hand pain. He was able to stand for 30 minutes "without leaning" and "approximately 45 minutes to an hour at a time with leaning." He was able to sit for 11/2 hours. He could walk 10-20 minutes. His maximum lifting and carrying capacity was 8 pounds. A history of hypertension was noted. Dr. H.G.S. reviewed certain of the Veteran's medical records which had been provided to him by the Veteran's attorney. Physical examination of the left hand in October 2011 showed a full range of motion in all joints, mild tenderness to palpation "and with range of motion testing" of the proximal interphalangeal (PIP) joint and dorsal interphalangeal (DIP) joints of the index and long fingers, no visible swelling of the joints, no thenar atrophy, a positive Tinel's sign at the carpal tunnel, and mild tenderness to palpation in the left cubital tunnel "with a negative Tinel's sign." Physical examination of the right knee showed "a mild flexion contracture with range of motion from 5-115 degrees," no warmth, swelling, or effusion, tenderness to palpation "limited to the medial joint line and lateral patellofemoral joint line, with the remainder of the knee nontender to palpation," and a stable knee. Physical examination of the left knee showed "a mild flexion contracture with range of motion from 3-118 degrees," no warmth, swelling, or effusion, tenderness to palpation "limited to the medial joint line and lateral patellofemoral joint line, with the remainder of the left knee nontender to palpation," and a stable knee. The Veteran had a moderately antalgic gait "favoring the right lower extremity." X-rays of the left hand and thumb showed a well-healed fracture at the base of the thumb metacarpal "which appears to be healed in satisfactory alignment. This x-ray series appears otherwise generally unremarkable." X-rays of the knees showed "satisfactory appearing clear space preservation of the weight bearing compartments of both knees" and otherwise were unremarkable. Dr. H.G.S.'s impressions included healed left thumb metacarpal fracture and pre-radiographic osteoarthritis of both knees. In a November 2011 letter, the Veteran's attorney contended that the Veteran was entitled to higher disability ratings for his service-connected bilateral knee disabilities because he had reported to Dr. H.G.S. that he experienced occasional giving way in both of his knees. On VA knee and lower leg Disability Benefits Questionnaire (DBQ) in May 2012, the Veteran complained that "his knees are still painful." He reported that "prolonged walking (going to the mall for example) cause pain and swelling in both knees." Range of motion testing showed flexion in each knee to 135 degrees with pain beginning at 90 degrees, full extension in each knee with no objective evidence of painful motion. Repetitive range of motion testing produced right knee flexion to 125 degrees, left knee flexion to 130 degrees, and no change in extension for either knee. The VA examiner concluded that there was additional limitation of motion following repetitive range of motion testing (a loss of 10 degrees in the right knee and a loss of 5 degrees in the left knee). Physical examination of the knees showed functional impairment due to less movement than normal, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing, tenderness to palpation of the bilateral joint lines, 5/5 muscle strength, no joint instability, no evidence or history of recurrent patellar subluxation/dislocation, no "shin splints" (medial tibial stress syndrome), no meniscal conditions, and no scars. The Veteran regularly used knee braces for his bilateral knee condition. X-rays of the knees showed bilateral traumatic arthritis and no evidence of patellar subluxation. The diagnosis was osteoarthritis of the bilateral knees. On VA hypertension DBQ in May 2012, no relevant complaints were noted. The Veteran's treatment plan for his currently diagnosed hypertension included taking continuous medication (diltiazem 240 mg by mouth twice daily). There was no history of diastolic blood pressure elevation to predominantly 100 or more. The Veteran's current blood pressure readings were 141/79, 131/77, and 138/80. The VA examiner stated that the Veteran's hypertension was "[r]elatively well controlled on medication." The diagnosis was hypertension. On VA hand and finger conditions DBQ in May 2012, the Veteran's complaints included "pain and difficulty grasping objects" and swelling in his left thumb. The Veteran described flare-ups of pain as "[c]hanges in temperature seem to exacerbate the 'tooth ache-type' pain in the left thumb." Physical examination showed limitation of motion or evidence of painful motion in the left thumb, a gap of less than 1 inch (2.5 cm) between the left thumb pad and the fingers with pain beginning at this gap, no gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, and no limitation of extension or evidence of painful motion in the index or long finger. Following repetitive range of motion testing, there was no additional limitation of motion in any fingers, a gap of less than 1 inch (2.5 cm) between the left thumb pad and the fingers, no gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, and no limitation of extension or evidence of painful motion in the index or long finger. The Veteran experienced functional impairment of the left thumb due to less movement than normal, pain on movement, and swelling. Hand grip strength was 5/5. No thumb ankylosis was present. X-rays of the hands were normal. The diagnosis was residuals of a fractured left first metacarpal joint. In an August 2012 addendum to the VA knee and lower leg DBQ completed in May 2012, the VA physician who conducted the earlier examination noted that there had been no medial-lateral instability in the Veteran's right knee at that time. Analysis The Board finds that the preponderance of the evidence does not support assigning disability ratings greater than 20 percent for either the Veteran's service-connected osteoarthritic changes of the left knee or for his service-connected osteoarthritic changes in the right knee. The Veteran has contended that his service-connected osteoarthritic changes of the bilateral knees are both more disabling than currently evaluated. The record evidence does not support his assertions, however. It shows instead that the Veteran's service-connected osteoarthritic changes of the bilateral knees are manifested by, at worst, right knee flexion to 125 degrees and left knee flexion to 130 degrees with complaints of pain at 90 degrees in both knees, full extension without evidence of painful motion, additional limitation of motion due to less movement than normal, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing, and no subluxation or lateral instability in either of his knees (as seen on VA examination in May 2012). For example, VA examination in January 2010 noted the Veteran's complaints of moderate flare-ups of bilateral knee pain. Physical examination showed no arthritis, a normal gait, no abnormal weight-bearing, a full range of motion, and no ankylosis in either knee, however. The diagnosis was radiographic (or x-ray) evidence of mild osteoarthritis in the bilateral knees. When examined by Dr. H.G.S. in October 2011, although the Veteran complained of occasional giving way in both of his knees, physical examination showed a mild left knee flexion contracture with range of motion from 3-118 degrees and a mild right knee flexion contracture with range of motion from 5-115 degrees. There was no warmth, swelling, or effusion, in either knee, tenderness to palpation "limited to the medial joint line and lateral patellofemoral joint line," and both knees were stable. X-rays of the knees were unremarkable. The diagnoses rendered by Dr. H.G.S. included mild osteoarthritis in the knees. At the Veteran's most recent VA examination in May 2012, his complaints included bilateral knee pain and swelling. Although he experienced a painful range of motion in each of the knees beginning at 90 degrees, he had an almost full range of motion to 135 degrees of flexion and full extension without painful motion in both knees. X-rays of both knees showed traumatic arthritis and no evidence of patellar subluxation. The diagnoses included osteoarthritis of the knees. The Veteran's attorney has contended that, because the Veteran complained to Dr. H.G.S. in October 2011 that he experienced occasional giving way of both knees, he is entitled to increased ratings for his service-connected osteoarthritic changes of the left knee and for his service-connected osteoarthritic changes of the right knee. The Board acknowledges that the Veteran's complaints included occasional giving way of both knees when he was seen by Dr. H.G.S. in October 2011. The Board also acknowledges that the Veteran is competent to report what he experienced in both knees to his treating physicians. See, for example, Layno v. Brown,6 Vet. App. 465, 469 (1994). Dr. H.G.S. specifically found that both of the Veteran's knees were stable on physical examination in October 2011, however. In other words, there is no objective evidence of worsening disability in either of the Veteran's knees due to giving way (or instability) in the October 2011 examination report which supports an increased rating for either the Veteran's service-connected osteoarthritic changes of the left knee or for his service-connected osteoarthritic changes of the right knee. Accordingly, the Board finds that the argument presented by the Veteran's attorney regarding the alleged worsening of the Veteran's service-connected bilateral knee disabilities when examined by Dr. H.G.S. in October 2011 is without merit. The Veteran's attorney also asserted in January 2013 correspondence that the May 2012 VA examination was inadequate because the VA examiner did not evaluate the additional limitation of motion experienced by the Veteran in either of his knees at that examination. The Board already has found the argument presented by the Veteran's attorney concerning the overall adequacy of the VA examinations conducted during the appeal period, to include the May 2012 VA examination, to be without merit. See, for example, Sickels, 643 F.3d at 1362. Having reviewed the May 2012 VA examination report, the Board observes that this report clearly shows that, following repetitive range of motion testing, the VA examiner concluded that there was additional limitation of motion in the Veteran's left knee and left knee flexion was limited to 130 degrees. Range of motion testing of the Veteran's left knee previously had found that flexion was limited to 135 degrees. There clearly was a loss of 5 degrees of additional motion following repetitive range of motion testing of the Veteran's left knee. With respect to the right knee, the May 2012 VA examiner also found that, following repetitive range of motion testing, there was additional limitation of motion in the Veteran's right knee and right knee flexion was limited to 125 degrees. Range of motion testing of the Veteran's right knee previously had found that flexion was limited to 135 degrees. There clearly was a loss of 10 degrees of additional motion following repetitive range of motion testing of the Veteran's right knee. Thus, the Board also finds that the argument presented by the Veteran's attorney concerning the alleged failure of the May 2012 VA examiner in not evaluating the Veteran's additional limitation of motion following repetitive range of motion testing of both knees is without merit. The record evidence does not demonstrate severe recurrent subluxation or lateral instability in either of the Veteran's knees (i.e., a 30 percent rating under DC 5010-5257) such that a disability rating greater than 20 percent is warranted for either the Veteran's service-connected osteoarthritic changes of the left knee or for his service-connected osteoarthritic changes of the right knee. See 38 C.F.R. § 4.71a, DC 5010-5257 (2012). The Veteran appears to be compensated appropriately for the level of disability that he experiences in each of his knees as a result of his service-connected osteoarthritic changes of the left knee and osteoarthritic changes in the right knee. He also has not identified or submitted any competent evidence demonstrating his entitlement to increased ratings for either of these disabilities. Nor is there record evidence demonstrating both limitation of motion and instability of either of the Veteran's knees with x-ray evidence of arthritis such that separate ratings for instability are warranted; instead, the record evidence demonstrates that both of the Veteran's knees have been stable on repeated physical examinations conducted during the appeal period. See VAOPGCPREC 23-97 and VAOPGCPREC 9-98. In summary, the Board finds that the criteria for disability ratings greater than 20 percent for the Veteran's service-connected osteoarthritic changes of the left knee and for the Veteran's service-connected osteoarthritic changes of the right knee are not met. See 38 C.F.R. § 4.71a, DC 5010-5257 (2012). The Board also finds that the preponderance of the evidence does not support assigning a compensable disability rating for the Veteran's service-connected hypertension. The Veteran has contended that his service-connected hypertension is more disabling than currently evaluated. He specifically has asserted that the fact that his hypertension requires continuous medication for control entitles him to a compensable disability rating under DC 7101. See 38 C.F.R. § 4.104, DC 7101 (2012). The Board acknowledges that the Veteran is on continuous medication to control his service-connected hypertension. The record evidence does not support his assertions regarding entitlement to a compensable disability rating for this disability, however. For example, on VA examination in January 2010, the Veteran himself reported that his service-connected hypertension had been stable since its onset in 1990 but continuous medication was required to control it. The Veteran's blood pressure was 150/94, 142/74, and 128/78. On VA outpatient treatment in February 2010, the Veteran's blood pressure was 156/92 and 136/70. The VA clinician stated that the Veteran's "blood pressure is usually adequately controlled. No medication changes are indicated at this time." The assessment was hypertension under good control. The Veteran was advised to continue taking his medications. At his most recent VA examination in May 2012, the VA examiner found no history of diastolic blood pressure elevation to predominantly 100 or more. The Veteran's current blood pressure readings were 141/79, 131/77, and 138/80. The VA examiner also stated that the Veteran's hypertension was "[r]elatively well controlled on medication." The record evidence shows that the Veteran's service-connected hypertension requires continuous medication for control. This evidence does not indicate, however, that this disability is manifested by diastolic pressure predominantly 100 or more, systolic pressure predominantly 160 or more, or a history of diastolic pressure predominantly 100 or more who requires continuous medication for control (as is required for a minimum compensable rating of 10 percent under DC 7101). Id. The May 2012 VA examiner specifically found that the Veteran's service-connected hypertension was not manifested by a history of diastolic pressure predominantly 100. Despite the Veteran's strenuous arguments to the contrary, the requirement of continuous medication for control of hypertension alone does not qualify him for a compensable disability rating for his service-connected hypertension under DC 7101. Id. The Veteran appears to be compensated appropriately for the level of disability that he experiences as a result of his service-connected hypertension. He also has not identified or submitted any competent evidence demonstrating his entitlement to a compensable rating for this disability. In summary, the Board finds that the criteria for a compensable disability rating for the Veteran's service-connected hypertension are not met. Id. The Board finally finds that the preponderance of the evidence does not support assigning a compensable disability rating for the Veteran's service-connected residuals of a fracture of the left first metacarpal joint. The Veteran has contended that this disability is more disabling than currently evaluated. The record evidence does not support his assertions regarding the alleged worsening of this disability, however. It shows instead that this disability is manifested by, at worst, complaints of pain, a gap of less than 1 inch (2.5 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers, less movement than normal, pain on movement, and swelling of the thumb. For example, although the Veteran complained of an overall decrease in left hand strength and a decrease in left hand dexterity on VA examination in January 2010, physical examination showed no decreased strength or decreased dexterity and a "very strong and robust grip." The fingers of his left hand also showed a normal range of motion with no objective evidence of painful motion, no gap between the index finger and proximal transverse crease of the hand on maximal flexion of the finger, no gap between the left thumb pad and the fingers, no objective evidence of pain or additional limitation of motion following repetitive range of motion testing, no amputation of a digit or part of a digit, no ankylosis or deformity of 1 or more digits, no alteration in fine motor movements, and he was "able to undress and dress without difficulty." A left hand x-ray was normal. The VA examiner diagnosed the Veteran as having no current residuals from his previously fractured left first metacarpal joint, no radiographic (or x-ray) evidence of his past fracture, and his hand functioned normally. Despite the Veteran's complaints of left hand numbness affecting the long and index fingers when he was seen by Dr. H.G.S. in October 2011, physical examination of his left hand showed a full range of motion in all joints, mild tenderness to palpation in the PIP and DIP joints of the index and long fingers, and no visible swelling of the joints. X-rays of the left hand and thumb showed a well-healed fracture at the base of the thumb metacarpal and otherwise were unremarkable. Dr. H.G.S.'s impressions included a healed left thumb metacarpal fracture. At his most recent VA examination in May 2012, although the Veteran's complaints included "pain and difficulty grasping objects" and swelling in his left thumb, physical examination showed 5/5 hand grip strength, limitation of motion or evidence of painful motion in the left thumb, a gap of less than 1 inch (2.5 cm) between the left thumb pad and the fingers with pain beginning at this gap, no gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, no limitation of extension or evidence of painful motion in the index or long finger, and no thumb ankylosis. There was no additional limitation of motion in any fingers following repetitive range of motion testing. The Veteran experienced functional impairment of the left thumb due to less movement than normal, pain on movement, and swelling. X-rays of the hands were normal. The diagnosis was residuals of a fractured left first metacarpal joint. The record evidence does not demonstrate a gap of 1-2 inches (2.5-5.1 cm) between the thumb and the fingers with the thumb attempting to oppose the fingers as is required for a minimum compensable 10 percent rating under DC 5299- 5228. See 38 C.F.R. § 4.71a, DC 5299-5228 (2012). The Veteran appears to be compensated appropriately for the level of disability that he experiences in his service-connected residuals of a fracture of the left first metacarpal joint. He also has not identified or submitted any competent evidence demonstrating his entitlement to a compensable rating for this disability. In summary, the Board finds that the criteria for a compensable disability rating for the Veteran's service-connected residuals of a fracture of the left first metacarpal joint are not met. Id. The Board finally finds that consideration of staged ratings is not warranted for the Veteran's service-connected disabilities adjudicated in this decision. As discussed above, the Veteran has experienced essentially the same level of disability due to each of these disabilities throughout the appeal period. Thus, consideration of staged ratings is not warranted. See Hart, 21 Vet. App. at 505. Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected osteoarthritic changes in the bilateral knees, hypertension, or for residuals of a fracture of the left first metacarpal joint. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration 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. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the 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. Id. 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. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluations assigned for the Veteran's service-connected osteoarthritic changes in the left knee, osteoarthritic changes in the right knee, hypertension, and for residuals of a fracture of the left first metacarpal joint are not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of each of these service-connected headaches. This is especially true because the 20 percent ratings currently assigned for the Veteran's osteoarthritic changes in each of his knees contemplate moderate disability and because the zero percent ratings currently assigned for the Veteran's hypertension and residuals of a fracture of the left first metacarpal joint contemplate no compensable disability. The Veteran appears to be compensated appropriately for the symptomatology attributable to each of these service-connected disabilities because, as outlined above, he experiences, at worst, moderate disability in each of his knees and minimal to no disability as a result of his hypertension and residuals of a fracture of the left first metacarpal joint. Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The Veteran has contended that his service-connected disabilities preclude him from securing or maintaining substantially gainful employment. The record evidence does not support his assertions, however. Following VA examination in May 2012, the VA examiner determined that the Veteran's service-connected hypertension had no impact on his ability to work. Because the Veteran is right-hand dominant, a different VA examiner concluded in May 2012 that his service-connected residuals of a fracture of the left first metacarpal would not preclude either physical or sedentary employment. Finally, although the VA examiner who evaluated the Veteran's service-connected bilateral knee disabilities in May 2012 opined that "[p]hysical labor, which involves prolonged standing, walking, or squatting is negatively impacted," she also found that "sedentary labor would not be impacted by his bilateral knee condition." The Board also notes that the Veteran's TDIU claim is being remanded for additional development (as outlined below). In light of the above, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a disability rating greater than 20 percent for osteoarthritic changes in the left knee is denied. Entitlement to a disability rating greater than 20 percent for osteoarthritic changes in the right knee is denied. Entitlement to a compensable disability rating for hypertension is denied. Entitlement to a compensable disability rating for residuals of a fracture of the left first metacarpal joint is denied. REMAND The Veteran contends that his service-connected degenerative joint disease and degenerative disc disease of the lumbar spine is more disabling than currently evaluated. He also contends that his service-connected disabilities, alone or in combination, preclude him from securing or maintaining substantially gainful employment, entitling him to a TDIU. The Board finds that additional development is necessary before the underlying claims can be adjudicated. With respect to the Veteran's higher initial rating claim for service-connected degenerative joint disease and degenerative disc disease of the lumbar spine, a review of the claims file shows that the most recent VA spine examination occurred in May 2011. The Veteran's attorney has submitted multiple letters to VA dated subsequent to this examination in which it is alleged that the service-connected degenerative disc disease and degenerative joint disease of the lumbar spine has worsened. It is not clear from a review of the claims file why an updated VA examination for the Veteran's service-connected degenerative disc disease and degenerative joint disease of the lumbar spine was not requested by the RO when updated VA examinations were requested for his service-connected osteoarthritic changes of the bilateral knees, hypertension, and residuals of a fracture of the left first metacarpal joint. The Board notes that VA's duty to assist under the VCAA includes obtaining an examination or medical opinion when necessary. The Court has held that when a Veteran alleges that his service-connected disability has worsened since he was examined previously, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Given the Veteran's contentions, and given the length of time which has elapsed since his most recent VA examination in May 2011, the Board finds that, on remand, he should be scheduled for updated VA examination to determine the current nature and severity of his service-connected degenerative disc disease and degenerative joint disease of the lumbar spine. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. With respect to the Veteran's TDIU claim, the Board notes initially that, as adjudication of the higher initial rating claim for service-connected degenerative disc disease and degenerative joint disease of the lumbar spine likely will impact adjudication of the TDIU claim, adjudication of the TDIU claim must be deferred. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The Board also notes that, although each of the VA examiners who saw the Veteran in May 2012 provided discrete opinions as to the functional impact of each of his service-connected disabilities on his employability, a review of the claims file shows that, to date, the Veteran has not been scheduled for appropriate examination to determine the impact of his service-connected disabilities, in combination, on his employability. The Board notes further that, despite the argument presented by the Veteran's attorney that Dr. H.G.S. provided an opinion supporting a grant of a TDIU, a review of the October 2011 examination report prepared by Dr. H.G.S. suggests that he considered both the Veteran's service-connected and non-service-connected disabilities when he opined that the Veteran was unemployable. The Veteran also does not meet the schedular criteria for a TDIU. See 38 C.F.R. § 4.16 (2012). Accordingly, the Board concludes that, on remand, the Veteran should be scheduled for appropriate VA examination to determine the impact of his service-connected disabilities, alone or in combination, on his employability. The RO/AMC also should attempt to obtain the Veteran's up-to-date VA and private treatment records. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and/or his attorney ask him to identify all VA and non-VA clinicians who have treated him for his service-connected disabilities in recent years. Advise the Veteran not to resubmit any records already provided to VA. Obtain all VA treatment records which have not been obtained already. Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already. A copy of any records obtained, to include a negative reply, should be included in the claims file. 2. Schedule the Veteran for appropriate in-person examination to determine the current nature and severity of his service-connected degenerative joint disease and degenerative disc disease of the lumbosacral spine. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of his claimed disorder, the examiner should report all relevant findings, to include ranges of motion and other indicia of functional impairment. The examiner finally is asked to state whether the Veteran's service-connected degenerative joint disease and degenerative disc disease of the lumbosacral spine results in any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment. A complete rationale must be provided for any opinions expressed. 3. Schedule the Veteran for appropriate in-person VA examination which addresses the impact of his service-connected disabilities on his employability. The claims file and a copy of this remand should be provided to the examiner for review. All appropriate tests and studies should be accomplished. The Veteran should be asked to provide a complete employment history, if possible. Based on a review of the Veteran's claims file and the results of his physical examination, and the Veteran's statements regarding the impact of his service-connected disabilities on his employability, the examiner is asked to opine whether the Veteran's service-connected disabilities, alone or in combination, preclude him from securing and following substantially gainful employment consistent with his education and occupational experience. A complete rationale must be provided for any opinions expressed. The examiner is advised that service connection currently is in effect for osteoarthritic changes of the left knee, osteoarthritic changes of the right knee, hypertension, and for residuals of a fracture of the left first metacarpal joint. 4. The Veteran should be given adequate notice of the requested examinations which includes advising him of the consequences of his failure to report to the examination. If he fails to report to the examinations, then this fact should be noted in the claims file and a copy of the scheduling of examination notification or refusal to report notice, whichever is applicable, should be obtained by the RO and associated with the claims file. 5. Review all evidence received since the last prior adjudication and readjudicate the Veteran's claims. If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the Veteran and his attorney. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters 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). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs