Citation Nr: 1329953 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 09-31 205 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for the service-connected status post osteochondritis dissecans with internal derangement and degenerative changes of the left knee (hereinafter "left knee disability"). 2. Entitlement to an evaluation in excess of 30 percent for the service-connected status post osteochondritis dissecans with loose bodies and degenerative changes of the right knee (hereinafter "right knee disability"). 3. Entitlement to an evaluation excess of 10 percent for the service-connected limitation of flexion of the left knee. 4. Entitlement to an initial compensable evaluation prior to June 12, 2008, and in excess of 10 percent thereafter for the service-connected limitation of flexion of the right knee. 5. Entitlement to service connection for bilateral shoulder and hip conditions. 6. Entitlement to service connection for a back condition. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from October 1981 to May 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO). In March 2013, the Board determined that new and material evidence had been submitted to reopen the previously denied claim for a back condition. The Board then remanded the de novo claim for a back condition, as well as the claims for service connection for bilateral shoulder and hip conditions and increased evaluations for the service-connected bilateral knee disabilities, for further development and adjudication. In June 2013, the RO awarded a separate 10 percent rating for limitation of flexion of the right knee effective from June 12, 2008. 38 C.F.R. §§ 4.7, 4.71a; See also VAOPGCPREC 23-97 (July 1, 1997, revised July 24, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 9-04 (September 17, 2004). The Board would note that the September 2008 rating decision indicated that the separate 10 percent rating for left knee arthritis was only in effect from 1999 to 2003; however, when the RO awarded the separate 10 percent rating for limitation of flexion of the right knee in June 2013, the end date of 2003 for the 10 percent rating for limitation of flexion of the left knee (classified as arthritis) was removed. Thus, the claims for increase for limitation of flexion of the bilateral knees is part and parcel of the issues on appeal. The claims on appeal have been characterized as they appear on the cover page of the instant decision. The claim for a low back condition is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran is receiving the maximum schedular rating available for recurrent subluxation or lateral instability of the left knee; throughout the appeal period, the service-connected left knee disability has not been productive of ankylosis or impairment of the tibia and fibula. 2. The Veteran is receiving the maximum schedular rating available for recurrent subluxation or lateral instability of the right knee; throughout the appeal period, the service-connected right knee disability has not been productive of ankylosis or impairment of the tibia and fibula. 3. Throughout the appeal period, the service-connected left knee arthritis has not been productive of limitation of flexion to 30 degrees; there is no evidence of compensable limitation of extension. 4. Throughout the appeal period, the service-connected right knee arthritis has been productive of limitation of flexion (i.e. prior to June 12, 2008); however, at no time has it been productive of limitation of flexion to 30 degrees; there is no evidence of compensable limitation of extension. 5. The competent and probative medical evidence of record preponderates against a finding that the Veteran's bilateral hip and shoulder conditions are due to events in active service or proximately due to, the result of, or aggravated by the service-connected bilateral knee disability; arthritis of the hips and shoulders was not diagnosed within one year following the Veteran's discharge from active service in May 1983. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent for the service-connected left knee disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2012). 2. The criteria for an evaluation in excess of 10 percent for the service-connected limitation of flexion of the left knee have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2012). 3. The criteria for an evaluation in excess of 30 percent for the service-connected right knee disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2012). 4. The criteria for a 10 percent rating prior to June 12, 2008, and no higher throughout the appeal period, for the service-connected limitation of flexion of the right knee have been met. 8 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (2012). 5. The criteria for service connection for bilateral hip and shoulder conditions have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the Veteran's claims. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the Veteran pre-adjudication notice by letters dated in January 2008 and June 2008. Additional letters were sent in November 2008, June 2009 (which contained the applicable rating criteria for the knees), and March 2013. VA has obtained service treatment records, assisted the Veteran in obtaining post-service VA and private outpatient treatment records and records from the Social Security Administration (SSA), and afforded the Veteran VA examinations. The Veteran was also afforded the opportunity to give testimony in support of his appeal, which he declined. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. Analysis The Board has reviewed all the evidence in the Veteran's paper claims file and virtual record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). A) Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some 'chronic diseases,' such as arthritis, presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With 'chronic disease' shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term 'chronic disease', whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, Fed. Cir. 2013). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. 38 C.F.R. § 3.310. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. §§ 5107(b), 7104(a); 38 C.F.R. § 3.303(a). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran claims that his bilateral shoulder and hip conditions are secondary to the service-connected bilateral knee disabilities, i.e. walking bent over since his lower body could not hold up under the weight due to his knee conditions. X-rays dated in 2005 revealed mild joint space narrowing of the hips and degenerative changes of the hips and shoulders was found in x-rays dated in 2008. Thus, the question of whether the Veteran has a current hip and shoulder disability is not in dispute. What is in dispute however, is whether such disability had its onset in service or is otherwise causally related to the Veteran's service or proximately due to, the result of, or aggravated by the service-connected bilateral knee disability. After review of the evidence, the Board finds service connection must be denied because the preponderance of the evidence is against such a finding. First, the Board shall discuss service incurrence. Arthritis is a "chronic disease" under 38 C.F.R. § 3.309(a). Thus, consideration under 38 C.F.R. § 3.303(b) is warranted. Where a combination of manifestations sufficient to identify a 'chronic disease' in service, and establish chronicity at the time are present, any later manifestation of the same 'chronic disease' is subject to service connection unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). The Veteran's service treatment records are negative for complaints or treatment referable to the hips or shoulders. The May 1983 separation examination was negative for complaints (the Veteran specifically denied painful or trick shoulder, bone and joint deformity, and arthritis on the medical history) or diagnosis of a hip or shoulder disability. Thus, a chronic hip and shoulder disability, to include arthritis, was not established during service. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Continuous symptoms have not been shown since service. The Veteran first complained of left hip and right shoulder pain on VA examination in 1987. X-rays were normal at that time. The Veteran was simply diagnosed with multiple joint pain. This is 4 years after the Veteran's separation from service and the long time lapse can be considered, along with other factors, as evidence of whether an injury or disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). VA outpatient treatment records dated between 1987 and 1992 were negative as were September 1996 and August 1999 reports of VA examination. The next complaints of left shoulder arthralagia was in March 2000 and bilateral shoulder arthralgia in July 2003. As noted above, x-rays dated in 2005 (hips) and 2008 (hips and shoulders) revealed arthritis, which is clearly outside the one-year presumptive period for arthritis. 38 C.F.R. § 3.307, 3.309. While competent evidence indicates that the Veteran has a current diagnosis of bilateral hip and shoulder arthritis, no medical evidence links the current disorder to service. An opinion on direct causation is not necessary, as there is no evidence the Veteran suffered a hip or shoulder injury in service. The Veteran does not allege such incurrence and there is no medical evidence of record to suggest such a relationship. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). Hence, service connection is not warranted on a direct or presumptive basis for the claimed bilateral hip and shoulder conditions. As noted at the outset, the Veteran alleges secondary causation. Specifically, he claims that walking bent over since his lower body could not hold up under the weight due to his knee conditions. The June 2008 VA examiner opined the Veteran shoulder and hip conditions were not caused by or a result of the service-connected knee conditions. The examiner reasoned that the Veterans leg lengths were almost equal with a slight 0.5 centimeter difference. Medical literature stated degenerative joint disease which has been mediated by trauma did not travel from joint to joint but stayed in the affected joint. The examiner also noted the Veteran had a positive rheumatoid factor which may point to an inflammatory process such as rheumatoid arthritis, which can cause pain in multiple joints. In June 2013, the VA examiner opined it was less likely than not that any currently diagnosed bilateral hip and shoulder conditions, including arthritis, were proximately due to, the result of, or aggravated by the service-connected bilateral knee disabilities. The examiner reasoned that medical literature shows that traumatic arthritis did not change from joint to join but rather stays in the affected joint. Also, the Veteran has lumbar spinal stenosis, which is known to be relieved with standing/walking in a flexed position so as to provide more space in the spinal canal and provide intermittent relief from symptoms. Thus it was difficult to determine if the Veteran's walking bent was due to his stenosis or other pathology. Antalgic gait due to knee pain did not cause the Veteran to pursue a flexed position for increased stability or support. The Veteran's excessive fatigue and incoordination on examination were also not supported in the medical literature as a result of traumatic arthritis. They were most consistent with neurologic injury such as his cervical spinal stenosis or self-reported history of stroke. Thus, service connection is not warranted on a secondary causation basis. In sum, neither a bilateral hip nor shoulder condition was diagnosed during service or for many years thereafter. The competent evidence does not establish a link between a hip or shoulder condition and active service or the service-connected bilateral knee disability. Thus, the Board finds service connection for a bilateral hip and shoulder condition is not warranted. The evidence is not in relative equipoise. Thus, the preponderance of the evidence is against the claim, and the appeal must therefore be denied. 38 U.S.C.A § 5107(b). B) Increase Rating for Bilateral Knee Disabilities Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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, 1 Vet. App. at 594. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. 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. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). Additionally, if the knee condition involves arthritis, the knee disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, the disability is to be rated as follows: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Relevant criteria, under applicable Diagnostic Codes are as follows: A 60 percent evaluation may be assigned for extremely unfavorable ankylosis of a knee in flexion at an angle of 45 degrees or more. A 50 percent evaluation may be assigned for ankylosis of a knee between 20 degrees and 45 degrees. A 40 percent evaluation may be assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 30 percent evaluation may be assigned for ankylosis of a knee at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a; Diagnostic Code 5256. For other knee impairment, recurrent subluxation or lateral instability of the knee, a severe case is to be rated 30 percent disabling; a moderate case is to be rated 20 percent disabling. For a slight case a 10 percent rating is appropriate. 38 C.F.R. § 4.71a, Diagnostic Code 5257. A 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Limitation of flexion of the leg to 60 degrees warrants a 0 percent rating. When flexion is limited to 45 degrees, a 10 percent rating is assigned. A 20 percent rating is appropriate where flexion is limited to 30 degrees. A 30 percent rating is appropriate where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg to 5 degrees warrants a 0 percent rating. When extension is limited to 10 degrees, a 10 percent rating is assigned. A 20 percent rating is appropriate where extension is limited to 15 degrees. A 30 percent rating is appropriate where extension is limited to 20 degrees. A 40 percent rating is appropriate where extension is limited to 30 degrees. A 50 percent rating is appropriate where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Impairment of a tibia and fibula with slight knee or ankle disability may be assigned a 10 percent evaluation. Impairment of a tibia and fibula with moderate knee or ankle disability may be assigned a 20 percent evaluation; impairment of a tibia and fibula with marked knee or ankle disability may be assigned a 30 percent evaluation and nonunion with loose motion requiring a brace or malunion may be assigned a 40 percent evaluation. 38 C.F.R. § 4.71a; Diagnostic Code 5262. According to VA standards, normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. See 38 C.F.R. § 4.71, Plate II (2011). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The VA Office of General Counsel has stated that compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 (degenerative arthritis) does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). See also VAOPGCPREC 9-04 (which finds that separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg may be assigned for disability of the same joint). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Historically, service connection was awarded for the left knee disability in July 1987 rating decision. An initial 10 percent evaluation was assigned effective in October 1986. In October 1996, the RO awarded service connection for the right knee disability. An initial noncompensable evaluation was assigned effective from October 1986 and a 10 percent from July 1996. In August 1999, the RO assigned a separate 10 percent rating for degenerative arthritis of the left knee effective from July 1999. In May 2002, the RO assigned a temporary total rating for the left knee disability from June 2001 and then a 20 percent from January 2002. The 10 percent for arthritis of the left knee remained in effect. A temporary total rating for the right knee was made effective from February 2002 and a 10 percent was assigned from April 2002. In May 2009, the RO awarded increased 30 percent ratings for the bilateral knee disabilities effective from September 2003. The Veteran filed a claim for increase in August 2007. The RO continued the 30 percent ratings for the bilateral knee disabilities. The Veteran appealed the decision and initiated the instant appeal. The Board would note that the September 2008 rating decision indicated that the separate 10 percent rating for left knee arthritis was only in effect from 1999 to 2003; however, when the RO awarded the separate 10 percent rating for limitation of flexion of the right knee in June 2013, the end date of 2003 for the 10 percent rating for left knee arthritis was removed. The Veteran currently receives ratings for both instability and arthritis. His claims remain in controversy as less than the maximum benefit available has been awarded. See AB v. Brown, 6 Vet. App. 35 (1993). As delineated above, the Veteran's service connected right and left knees have been assigned a 10 percent rating under Diagnostic Codes 5003 and 5260 for arthritis, left knee effective from July 1999 and right knee effective from June 2008. They have also been assigned separate 30 percent ratings for lateral instability and recurrent subluxation under Diagnostic Code 5257 effective from September 2003. In order to afford the Veteran the broadest scope of review, and to ensure that each separate disability involving the knees is evaluated properly, the Board shall consider the service-connected symptomatology involving the knees under each and every applicable Diagnostic Code that provides rating criteria for evaluating knee disabilities. The pertinent facts found in the medical evidence of record are discussed below. Having carefully considered the Veteran's claims in light of the evidence of record and the applicable laws and regulations, and as outlined in the reasons and bases below, the Board finds that the neither the left or right knee disability warrants a rating in excess of 30 percent for recurrent subluxation or lateral instability as this is the maximum schedular rating available. 38 C.F.R. § 4.71a. The Board has noted the Veteran's complaints of pain experienced in his knees and thus, considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, 38 C.F.R. §§ 4.40 and 4.45, with respect to pain, are inapplicable to ratings under Diagnostic Code 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 12 (1996). The Board has also considered other potentially applicable diagnostic codes that provide for the assignment of higher evaluations for the Veteran's bilateral knee disability. After review, however, the Board observes that no other code provisions can be applied for a higher rating based on the evidence of record. There was no evidence of ankylosis of either knee (Diagnostic Code 5256) or impairment of the tibia and fibula (Diagnostic Code 5262) to warrant a higher rating. Affording the Veteran all reasonable doubt, the Board finds that an initial 10 percent rating for limitation of flexion of the right knee is warranted throughout the appeal period. However, ratings in excess of 10 percent for limitation of flexion of the bilateral knees and a separate rating for limitation of extension of either knee is not warranted under any Diagnostic Code applicable for rating knee disorders, or any combination thereof. 38 C.F.R. § 4.7. In rating the Veteran's knee disabilities, the Board notes that there is radiographic evidence of arthritis of the knees. Under Diagnostic Codes 5003 and 5010, traumatic/degenerative arthritis established by x-ray findings is rated according to limitation of motion for the joint or joints involved. The criteria for rating extension and flexion of the knee are found at Diagnostic Codes 5260 and 5261, and detailed above. Here, review of the evidence shows that flexion has been at worse limited to 130 degrees (left) and 135 degrees (right) upon VA examination in June 2008. On VA examination in June 2013 flexion was limited to 125 degrees bilaterally. This does not meet the criteria established for a 20 percent rating under Diagnostic Code 5260, which would require flexion limited to 30 degrees. Extension was to 7 degrees bilaterally upon VA examination in June 2008 and full on examination in June 2013, which does not meet the criteria established for a compensable rating under Diagnostic Code 5261. 38 C.F.R. § 4.71a. Thus, the criteria do not provide for ratings in excess of 10 percent for limited flexion or an additional separate compensable rating for either knee based on limitation of extension. 38 C.F.R. §§ 4.7, 4.25, 4.71a; See also VAOPGCPREC 23-97 (July 1, 1997, revised July 24, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 9-04 (September 17, 2004). The Board has noted the Veteran's complaints of pain experienced in his knees and thus, considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, even with painful motion, the Veteran did not have any additional loss of limitation of motion during repetitive testing on VA examination in June 2008. There was no evidence of fatigability, incoordination, or weakness of either knee. In June 2013, while there was pain with right knee flexion beginning at 115 degrees and the left knee at 120 degrees, flexion was still possible to 125 degrees bilaterally. Despite indications of fatigability and incoordination, there was no change with repetitive testing. The examiner also noted some left sided weakness in the lower extremity due to residuals of a stroke. The complaints of pain are clearly accounted for in the current 10 percent ratings as the Veteran's limitation of flexion does not even meet the criteria for even a noncompensable rating under this code section. 38 C.F.R. § 4.71a. The same can be said of limitation of extension. Extension was only limited to 7 degrees on VA examination in 2008, otherwise it was full. Repetitive testing showed no change in extension in either 2008 or 2013. As such, based on its review of the medical evidence, the Board finds that: ratings in excess of 30 percent for the bilateral knee disabilities based on recurrent subluxation or lateral instability are not warranted; a 10 percent rating, and no higher, is warranted throughout the appeal period for limitation of flexion of the right knee; a rating in excess of 10 percent is not warranted for limitation of flexion of the left knee; and a separate rating for arthritis productive of limitation of extension is not warranted for either knee. 38 C.F.R. §§ 4.7, 4.25, 4.71a; See also VAOPGCPREC 23-97 (July 1, 1997, revised July 24, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 9-04 (September 17, 2004). "Staged" ratings, other than what is already in effect or awarded in the instant decision, are not warranted for any period of the appeal. 38 C.F.R. § 4.71a; see Fenderson, supra; Hart, supra. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. The United States Court of Appeals for Veterans Claims (Court) has held that, when evidence of unemployability is presented, the issue of whether a total compensation rating based on individual unemployability (TDIU) will be assigned, should be handled during the determination of the initial disability rating assigned at the time disabilities are determined to be service connected. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). In Rice, the Court determined that there is no freestanding claim for a TDIU rating. Id. at 451. In the instant case, the Veteran has not raised the issue of a TDIU rating with respect to his knee claims. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). The evidence of record shows the Veteran was retired in 1997 as an oil field engineer. SSA adjudged the Veteran disabled as of 1999 due to his schizoaffective disorder and substance abuse. As the Veteran has not raised such a claim and there is no objective evidence of unemployability due to the service-connected knees, a claim for a TDIU rating is not presented in the instant case. Finally, the Board has considered whether extraschedular consideration is warranted. The symptoms and resulting impairment demonstrated with regard to the bilateral knee disability falls within the schedular criteria. The rating criteria contemplates a higher rating for the bilateral knee disability, as well as separate ratings, for manifestations, to include, but not limited to, arthritis, subluxation/lateral instability, ankylosis, and limitation of flexion and extension, but as explained above, there has been no objective evidence of the necessary criteria to warrant such a rating. See Diagnostic Codes 5276-5284. The effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an evaluation in excess of 30 percent for the service-connected left knee disability is denied. Entitlement to an evaluation in excess of 30 percent for the service-connected right knee disability is denied. Entitlement to an evaluation excess of 10 percent for the service-connected limitation of flexion of the left knee is denied. Entitlement to a 10 percent rating prior to June 12, 2008, and no higher, throughout the appeal period, for the service-connected limitation of flexion of the right knee is granted subject to the controlling regulations governing monetary awards. Entitlement to service connection for bilateral shoulder and hip conditions is denied. REMAND Regrettably, further development is necessary prior to analysis of the Veteran's claim of service connection for a back condition. The most recent VA examination dated in June 2013 while addressing secondary causation, did not address whether the Veteran's current back disability is directly related to his active duty service. The Veteran's service treatment records show the Veteran was treated for muscular strain in April 1982 after complaints of a back injury while lifting a bomb. He informed treatment providers that he heard a pop, twisted his back and felt something pop back into place. The Veteran has been diagnosed with DDD. An addendum opinion is necessary to decide the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). The most recent VA treatment records associated with the record contained within Virtual VA (VA's electronic database storage) are dated in June 2013. Any missing and/or updated records of any treatment the Veteran has received for the back disability on appeal, are pertinent evidence that must be secured. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Obtain copies of any VA clinical records not on file pertaining to treatment of the claimed back condition dated from June 2013 to the present. All records and/or responses received should be associated with the claims file 2. After completion of the foregoing, seek an addendum opinion from the examiner who conducted the June 2013 VA examination. If unavailable, the opinion must be sought from a similarly qualified provider. The Veteran's entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA or Veterans Benefits Management System (VBMS), CAPRI, and AMIE) must be available for review. If the examiner does not have access to Virtual VA or VBMS, any relevant treatment records in Virtual VA that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should offer an opinion in response to the following: is it at least as likely as not (a 50% or higher degree of probability) that any currently diagnosed back condition, including arthritis/DDD, was incurred during the Veteran's active duty service? In answering this question, the examiner must address the service treatment records showing the Veteran was treated for muscular strain in April 1982 after complaints of a back injury while lifting a bomb. He informed treatment providers that he heard a pop, twisted his back and felt something pop back into place. A detailed rationale should be furnished for all opinions. Note: if the examiner concludes that there is insufficient information to provide an etiology opinion without resorting to mere speculation, the examiner should state whether the inability to provide a definitive opinion was due to a need for further information (please identify) or because the limits of medical knowledge had been exhausted regarding the etiology of the claimed conditions. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. In the interest of avoiding further remand, the RO should ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. 4. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the issue in light of all evidence of record, to include any pertinent evidence contained within Virtual VA or VBMS. If any benefit sought on appeal remains denied, the RO must furnish to the Veteran and his representative with an appropriate supplemental statement of the case and afford a reasonable opportunity for response. The Veteran has the right to submit additional evidence and argument on the 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). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs