Citation Nr: 1330190 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 11-00 083A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for degenerative joint disease, right knee with limitation of extension. 2. Entitlement to a disability rating in excess of 10 percent for residuals, injury with ligamentous laxity, weakness, swelling and limitation of motion, right knee. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD A. VanValkenburg, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Navy from February 1980 to May 1983. These matters come before the Board of Veterans' Appeals (Board) on appeal from the December 2009 decision by the Jackson, Mississippi, Regional Office (RO) of the United States Department of Veteran Affairs (VA), which denied an evaluation in excess of 10 percent under Diagnostic Code 5257 for the Veteran's right knee disability, but granted a separate rating of 20 percent under Diagnostic Code 5261 for limitation of extension. The Veteran appeared and testified at a personal hearing in November 2011 before a Decision Review Officer. A transcript of the hearing is contained in the record. The Board has not only reviewed the Veteran's physical claims file but also the electronic records maintained in the Virtual VA system to ensure complete review of the evidence of record. The Veteran has asserted his service-connected disabilities have precluded him from sustaining meaningful employment; see the November 2011 personal hearing and September 2011 VA examination. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU due to service-connected disability or disabilities is part and parcel of an initial or increased rating claim when such claim is raised by the record. In light of the Court's holding in Rice, the Board has considered the TDIU claim as part of his pending increased ratings claim for his right knee disabilities, and is listing the raised TDIU claim as an issue on appeal. The issue of TDIU 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. FINDING OF FACT The Veteran's degenerative joint disease of the right knee with limitation of extension is manifested by extension at worst 15 degrees and flexion with pain at worst 30 degrees, as well as no more than slight instability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for degenerative joint disease, right knee with limitation of extension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b) (1), 3.012, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2013). 2. The criteria for a disability rating of 20 percent, but no more, for degenerative joint disease, right knee with limitation of flexion have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b) (1), 3.012, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2013). 3. The criteria for a disability rating in excess of 10 percent for residuals, injury with ligamentous laxity, weakness, swelling and limitation of motion, right knee, on the basis of instability, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b) (1), 3.012, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duty to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). An October 2010 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Finally, the Veteran was informed of the need to show the impact of disabilities on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claim was subsequently readjudicated, most recently in the January 2012 supplemental statement of the case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). VA has met its duty to assist the Veteran in the development of the claim. The Veteran's VA treatment records and examinations have been obtained in the development of the claim. The Veteran has not indicated private treatment for his right knee problems. 38 U.S.C.A § 5103A, 38 C.F.R. § 3.159 (2013). The Veteran has clearly indicated he does not receive Social Security Administration (SSA) benefits and SSA has indicated medical records do not exist. The Veteran has been afforded several VA examinations conducted in September 2011 and November 2009; the Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A medical examination is adequate "where it is based upon consideration of the Veteran's prior medical history and examination and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet App. 120, 123 (2007). The VA examiners considered Veteran's description and history of his symptoms, conducted a thorough examination and provided a detailed report of the Veteran's condition. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Applicable Laws 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 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting 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 (2013); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2013); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2013); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2013). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. 38 C.F.R. §§ 4.1, 4.2 (2013); see also Francisco v. Brown, 7 Vet. App. 55 (1994). In addition, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "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. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). This includes the analysis of additional functional impairment above and beyond the limitation of motion objectively demonstrated involving such factors as painful motion, weakness, incoordination, and fatigability, etc., particularly during times when these symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. Id. See also 38 C.F.R. §§ 4.40, 4.45 and 4.59. In this regard, manifestation of pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different Diagnostic Codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The General Rating Formula for Diseases and Injuries of the knee are governed under 38 C.F.R. 4.71a. The Veteran's degenerative joint disease of the right knee with limitation of extension is currently rated under Diagnostic Code 5261 for limitation of extension at 20 percent. Residuals of an injury with ligamentous laxity, weakness, swelling and limitation of motion of the right knee is currently rated under Diagnostic Code 5257 for recurrent subluxation or lateral instability at 10 percent. Potential rating criteria applicable to the knee disabilities are noted below. Traumatic arthritis will be rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. 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 10 percent evaluation is assignable 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion of the knee is rated under Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II (2013). Under Diagnostic Code 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. See 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5257 provides for the assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability of a knee; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. Id. The Board observes that the words "slight," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). The VA General Counsel has held that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97 (1997); VAOPGCPREC 9-98 (1998). In VAOPGCPREC 9-98 (1998), the VA General Counsel explained that when a Veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. 64 Fed. Reg. 52,376 (1999). A separate rating for arthritis (in addition to Diagnostic Code 5257) could instead be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Alternatively, dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Symptoms due to the removal of the semilunar cartilage of either knee warrant a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Factual Background Historically, the records reflect the Veteran underwent right knee surgery during active duty in 1981 after sustaining a valgus stress twisting injury while falling down a ladder aboard ship. In a November 2011 hearing the Veteran provided lay evidence of symptoms including constant knee pain and swelling with a reduced ability to bend. Constantly walking and weather changes would make his condition worse. He reported an inability to climb a ladder or run, or walk more than a half mile before needing rest and difficulty climbing stairs. The Veteran indicated that his knee "sometimes" gave way when walking and might "lock up" if he is on it more than three to four hours and had feelings of weakness caused by standing for a period of time. He stated he had to leave his job because it put strain on his knee and has been unable to acquire the types of jobs he is qualified for due to his knee because they require a lot of walking, standing and lifting. The most recent VA examination was conducted in September 2011 which noted the Veteran's in-service knee injury and diagnosis of traumatic arthritis. The Veteran provided subjective complaints of right knee pain described as a constant minor knee ache. He reported stiffness most days and locking which had occurred two months prior to the examination. Flare ups caused swelling about twice monthly and lasted two to three days which was precipitated by too much activity. The September 2011 VA examination 's range of motion testing found right knee flexion to 40 degrees with pain beginning at 50, and extension to 10 degrees. Upon repetitive testing flexion increased to 50, and extension remained unchanged to 10 degrees. The muscle strength of the right knee flexion and extension was 5/5 normal. Stability testing was normal for posterior instability (posterior drawer test) and medial-lateral instability (apply valgus or varus pressure to knee in extension and 30 degrees of flexion). The anterior instability (Lachman test) was 1+ (0-5 millimeters) but there was no evidence or history of recurrent patellar subluxation/dislocation. There was functional loss, functional impairment or additional limitation of range of motion of the right knee in the form of less movement than normal, pain on movement, swelling and deformity. The 2011 VA examiner did not indicate weakened movement, excess fatigability, incoordination, atrophy of disuse, instability of station, disturbance of locomotion or any interference with weight bearing, sitting or standing. The VA examiner detailed the functional loss by describing that while the Veteran was seated on a table his knees allowed a flex to 50 degrees and his right knee circumference was 40.5 cm while his left was 37 cm. The right knee was severely swollen, deformed and abnormal in addition to being "mildly warm" in contrast to the left knee. There was tenderness or pain to palpation for joint line or soft tissues of the right knee. The Veteran did not have any tibial and/or fibular impairment. The VA examiner noted a functional impact on the Veteran's ability to work as described by the Veteran. The 2011 VA examiner noted the Veteran had a meniscal (semilunar cartilage) condition with frequent episodes of joint "locking" of the right knee. The Veteran had knee surgery with the exact nature of the operation unclear to the examiner but he agreed with the Veteran's orthopedist that it was most likely an operation to repair a torn Anterior Cruciate Ligament (ACL). The Veteran reported the operation was successful with the knee improved but started experiencing pain 3 to 4 years prior to the examination. The residual symptoms of knee surgery were described as severe right knee swelling and deformity. Stable and non-painful scars not greater than 39 square cm were observed. The Veteran reported using a brace on a regular basis and the condition indicated was for his unstable right knee and traumatic arthritis. Right knee traumatic arthritis was confirmed by imaging studies and has been documented with no evidence of patellar subluxation. The VA examiner remarked that he agreed with the opinion of the VA orthopedist that the Veteran was in need of a right knee replacement. The November 2009 VA examination included a history provided by the Veteran. The Veteran explained he was evaluated at an orthopedic clinic in October 2009 due to increased knee pain and subsequently received knee injections that provided no relief and was prescribed a right knee brace which controlled knee buckling. He took daily medication to control knee pain. He provided subjective complaints of intermittent aching of his entire knee joint with constant swelling and "occasional stiffness every morning." He had knee buckling once per week with occasional locking. His flare ups occurred daily while working and were caused by climbing over 8 stairs, standing over 2 hours, or walking more than 1/4 mile at a time. Since being laid off in June 2008 the Veteran reported having no flare ups. The VA examiner noted he was independent with ambulation using a right double hinged knee brace and without an assistive device. The Veteran reported being unemployed and stopped working due to his right knee condition and detailed past impact on work productivity. The 2009 VA examiner provided a diagnosis of status post surgery for a right knee injury with residual severe posttraumatic arthritis. Objective findings from February 2009 bilateral X-rays revealed an orthopedic screw in the right knee with severe degenerative joint disease involving the lateral joint compartment with a deformity of the tibial plateau, marked subchondral sclerosis, marginal spurring with essentially bone-on-bone articulation and joint effusion. There was moderate effusion localized mostly on the lateral aspect. The 2009 VA examiner conducted range of motion testing and found flexion of the right knee to 70 degrees with grimacing from 30 to 70 degrees. After repetitive testing flexion increased to 80, with grimacing from 40 to 80 degrees. Extension lacked 15 degrees was non-painful and unchanged upon repetition. There was a "mildly positive" anterior drawer sign with no other evidence of ligamentous laxity. The examiner was unable to adequately perform the McMurray's test due to marked muscle guarding. There was marked bony enlargement on both the medial and lateral aspect of the right knee and diffuse tenderness to palpation. The Veteran had difficulty performing a one leg stance on his right leg which gave way. The Veteran was wearing a double hinged right knee brace. While wearing a right knee brace his gait was moderately antalgic due to decreased weight shifting on his right leg. The VA examiner commented he was unable to clearly delineate the Deluca provisions. The physician explained during a flare up the Veteran could have an increased right knee pain and further limitations in joint range of motion which would affect his functional capacity but it could not be estimated without speculation. The VA treatment records span from March 2009 to December 2010 and include orthopedic treatment of the right knee. The March 2009 VA orthopedic consultation diagnosed the Veteran with right knee posttraumatic osteoarthritis. The physician found active and passive range of motion within normal limits in bilateral lower extremities with sensation intact. The physician noted right knee crepitus on range of motion and some pain with active and passive range of motion. He knee had medial and lateral joint line tenderness. Ligaments were indicated as stable and there was no instability to varus or valgus stress. He was negative for the anterior and posterior drawer tests and the Lachman test. X-rays revealed arthritis in the lateral compartment of his knee, with a screw in his tibia from a previous surgery which appeared intact. The Veteran had a valgus knee. The Veteran did not have a knee brace and was instructed to get a brace for offloading his lateral compartment from physical therapy. The Veteran was offered a total knee arthroplasty on numerous occasions between 2009 and 2010. The records do not show any other additional range of motion testing or other findings pertinent to the rating criteria as outlined above. Analysis The Veteran essentially contends that his degenerative joint disease with limitation of extension of the right knee warrants a rating in excess of 20 percent under Diagnostic Code 5260 and in excess of 10 percent under Diagnostic Code 5257. Although a diagnosis of traumatic arthritis has been established, Diagnostic Code 5010 is not applicable in this case. The Board notes the Veteran is already rated for limitation of motion under the Diagnostic Codes 5260 and 5261, as discussed below. As such, an additional compensable rating cannot be assigned under Diagnostic Code 5010 for the right knee. The Board finds that the Veteran is not entitled to a rating in excess of 20 percent under Diagnostic Code 5261 for degenerative joint disease of the right knee with limitation of extension. There is no lay or medical evidence that suggests extension is limited to greater than 15 degrees which is needed to warrant a 30 percent disability rating. The 2009 VA examiner found the Veteran's right knee extension was limited to 15 degrees, non-painful and was unchanged upon repetition. Notably, the most recent 2011 VA examination found improved extension which was limited to 10 degrees and unchanged upon repetition. Accordingly, the Veteran has not indicated and the evidence does not show that he has a limitation of extension to warrant a higher rating. The Board does find that the Veteran is entitled to a separate rating under Diagnostic Code 5260 at 20 percent for limitation of flexion in his right knee. The Veteran's flexion during the November 2009 VA examination was to 70 degrees with grimacing between 30-70 degrees. His flexion increased upon repetition to 80 degrees with grimacing between 40-80 degrees. Upon initial range of motion testing during the September 2011 VA examination the Veteran's flexion was to 40 degrees with pain beginning at 50 degrees. The Board notes the subsequent discrepancy indicating flexion pain beginning at 50 degrees. The Board has considered the Veteran's subjective complaints of symptoms and the 2011 VA examiner's description of functional loss, as discussed above. Based on limitation of flexion, results of physical examinations, subjective complaints of symptoms and resolving doubt in favor of the Veteran, the Board finds the disability picture more nearly approximates a 20 percent, but no higher, rating under Diagnostic Code 5260. The Board has considered the Veteran's subjective complaints of frequent episodes of pain, weakness after standing, inability to walk over half a mile without resting and flare-ups that cause swelling. The Board recognizes the Veteran is competent to describe his symptoms and has no reason to doubt their credibility. However, the Board has considered additional functional loss resulting from pain in assigning the 20 percent evaluation for limitation of flexion. Furthermore, the Board finds that the now separate disability ratings assigned for both limitation of flexion and extension, contemplated the overall degree of disability resulting from functional loss. The Board further finds the Veteran is not entitled to a rating in excess of 10 percent under Diagnostic Code 5257 for evaluation of residuals, injury with ligamentous laxity, weakness, swelling and limitation of motion, right knee. As noted above, the Diagnostic Code does not define the word "moderate" but the Boards review of the entirety of the evidence does not support a finding of moderate symptoms associated with the Veteran's right knee conditions. In the September 2011 VA examination, medial lateral and posterior joints tested normal with some right knee anterior instability at 1+. There was no evidence of recurrent patellar subluxation. The 2009 VA examiner found a "mildly positive" anterior drawer sign and no other evidence of ligamentous laxity. The majority of the objective evidence of record shows no instability. The Board recognizes the Veteran's reports of wearing a knee brace and having mobility issues. However, the Board ultimately finds the consistent objective findings of the competent health care providers to be more probative as to whether a higher rating is warranted under Diagnostic Code 5257. As neither VA examination revealed significant instability or evidence of subluxation on objective examination, the Board finds that the Veteran's right knee disability picture more nearly approximates no more than "slight" instability under Diagnostic Code 5257. No higher or alternative rating under a different Diagnostic Code can be applied for the timeframe on appeal. In this regard, the Board recognizes that there are symptoms of semilunar cartilage problems as contemplated by Diagnostic Code 5258 and 5259 including frequent locking and pain. However, the VA General Counsel explained in VAOPGCPREC 9-98 (August 14, 1998), that removal of semilunar cartilage may result in complications producing loss of motion, and consequently, Diagnostic Code 5259 contemplates limitation of motion as a symptom so as to warrant consideration of the holding in Deluca. Therefore, to award the Veteran a disability rating based on limitation of motion (Codes 5260 and/or 5261) and a separate disability rating under Diagnostic Code 5259 would violate 38 C.F.R. § 4.14 and the rule against pyramiding as these codes both contemplate limitation of motion. Based on the reasoning expressed in that opinion and the nature of the disabilities to which these codes apply, the Board believes that Diagnostic Code 5258, contemplates limitation of motion; thus, to assign a separate disability rating under Diagnostic Code 5258 would also violate the rule against pyramiding. See 38 C.F.R. § 4.14. Further, alternative ratings under Diagnostic Codes 5258 or 5259 would not result in a rating above 20 percent as currently afforded under Diagnostic Code 5261 and 5260 for limitations of extension and flexion. There has not been medical evidence of ankylosis or genu recurvatum, at any time during the claim. Therefore, Diagnostic Code 5256 and 5263 are not for application in this case. Although the 2009 examiner noted the Veteran had a deformity of the tibial plateau as seen on an X-ray, the 2011 examiner specifically indicated the Veteran did not have any tibial and/or fibular impairment. Thus, the Veteran is not entitled to a rating for impairment of tibia or fibula under Diagnostic Code 5262. The Board has also considered whether the Veteran is entitled to a separate rating for his scar, but finds that the Veteran's scar does not meet the requirement for a compensable evaluation and as such do not warrant a separate rating. See 38 C.F.R. § 4.118, DC 7800-7805 (2008). The Board has considered all potentially applicable provisions of 38 C.F.R. parts 3 and 4. Extra Schedular Considerations The Board notes that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1) (2013). Thun v. Peake, 22 Vet. App. 111. The Board, however, finds that the medical evidence fails to show anything unique or unusual about the Veteran's right knee disability that would render the schedular criteria inadequate. The Veteran's primary right knee symptoms include pain, swelling, mild instability, and some limitation of motion, and these factors are accounted for in the rating criteria. Consequently, a referral for extraschedular consideration is not indicated. ORDER Entitlement to a disability rating in excess of 20 percent for degenerative joint disease of the right knee with limitation of extension is denied. Entitlement to a disability rating of 20 percent for degenerative joint disease of the right knee with limitation of flexion, but no more, is granted, subjective to the regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 10 percent for residuals, injury with ligamentous laxity, weakness, swelling and limitation of motion, right knee is denied. REMAND Unfortunately, a remand is required in this case. Although the Board regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's TDIU claim. As discussed above, the Board notes that a claim for a TDIU may be presented informally or may be raised by the facts. The Veteran has raised the issue in his statements during his November 2011 hearing, September 2011 and November VA examinations and in VA treatment records. "Once a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability, the 'identify the benefit sought' requirement of 38 C.F.R. § 3.155(a) is met and the VA must consider TDIU." Roberson v. Principi, 251 F. 3d 1378, 1384 (Fed. Cir. 2001). Here, the Veteran has informally claimed that the disability on appeal is the cause of his inability to obtain or retain substantially gainful employment. The Veteran should be provided appropriate notice on how to substantiate a claim of entitlement to a TDIU. Also, the Veteran was provided vocational rehabilitation contact information during an October 2009 VA social work consultation. Relevant vocational rehabilitation records, if any exist, should be associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. The RO should provide all required notice in response to the Veteran's most recent claim of entitlement to TDIU and provide the Veteran a VA Form 21-8940, the Veteran's Application for Increased Compensation Based on Unemployability. The RO should undertake any additional development in response to a completed application, including necessary release forms. 2. The Veteran should be provided appropriate VCAA notice on the claim of entitlement to a TDIU. 3. The RO should associate additional vocational rehabilitation records with the claims file, if any. 4. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claims remaining on appeal. If the benefits sought on appeal are not granted, provide the Veteran and his representative with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs