Citation Nr: 1332391 Decision Date: 10/18/13 Archive Date: 10/24/13 DOCKET NO. 07-26 007 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased evaluation for post-operative residuals with traumatic arthritis in the right knee, rated as 10 percent disabling due to arthritis with painful motion for the period prior to December 30, 2010, and as 10 percent disabling due to arthritis with painful motion and 10 percent disabling due to limitation of flexion since December 30, 2010. 2. Entitlement to an increased evaluation for post-operative residuals with traumatic arthritis in the left knee (exclusive of a temporary total evaluation from November 4, 2008, to January 1, 2009), rated as 10 percent disabling due to arthritis with painful motion for the period prior to December 30, 2010, and as 10 percent disabling due to arthritis with painful motion and 10 percent disabling due to limitation of flexion since December 30, 2010. 3. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Zenzano, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1986 to October 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee (RO). In that rating decision, the RO continued the assigned 10 percent ratings for post-operative residuals with traumatic arthritis in each knee (previously evaluated under Diagnostic Codes 5257 and 5260). In an April 2009 decision, the RO granted a temporary total rating for convalescence for arthroscopic surgery on the left knee for the period from November 4, 2008, through December 31, 2008, and returned the assigned 10 percent rating in effect thereafter. In November 2010, the Board remanded the matters on appeal to the RO (via the Appeals Management Center (AMC)) for additional development. Pursuant to the remand directives, the RO/AMC obtained updated copies of the Veteran's VA treatment records and associated them with the claims folder, and provided the Veteran with a VA examination on December 30, 2010, to evaluate the severity of his right and left knee disabilities. By way of a March 2012 rating decision, the RO granted additional separate 10 percent ratings for limitation of flexion in each knee, each effective from December 30, 2010. However, as these grants do not represent a total grant of benefits sought on appeal, the claims for increase remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). In September 2012, the Board again remanded the case for further development, to include obtaining updated treatment records and scheduling the Veteran for reexamination of his knees, which occurred in October 2012. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. After a careful review of the Veteran's claims file, including his VA examinations, the Board finds that, although an appeal was not received on the issue of entitlement to TDIU, it is now before the Board because it has been reasonably raised during the adjudicatory process of the underlying claims and is a component of the instant appeal. See Rice v. Shinseki, 22 Vet. App. 447,454-455 (2009). Such is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's post-operative residuals with traumatic arthritis of the right knee have been manifested by painful motion with functional loss equal to flexion no worse than 90 degrees and extension no worse than zero degrees. There is no instability or subluxation, ankylosis, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. Since December 30, 2010, the Veteran's limitation of flexion of the right knee, based on functional loss due to pain, is not manifested by functional loss equivalent to limitation of flexion to 30 degrees or less. 2. For the entire appeal period, (exclusive of a temporary total evaluation from November 4, 2008 to January 1, 2009), the Veteran's post-operative residuals with traumatic arthritis of the left knee have been manifested by painful motion with functional loss equal to flexion no worse than 90 degrees and extension no worse than zero degrees. There is no instability or subluxation, ankylosis, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. Since December 30, 2010, the Veteran's limitation of flexion of the left knee, based on functional loss due to pain, is not manifested by functional loss equivalent to limitation of flexion to 30 degrees or less. CONCLUSIONS OF LAW 1. The criteria for an increased evaluation for post-operative residuals with traumatic arthritis in the right knee, rated as 10 percent disabling due to arthritis with painful motion for the period prior to December 30, 2010, and as 10 percent disabling due to arthritis with painful motion and 10 percent disabling due to limitation of flexion since December 30, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5010-5260 (2013). 2. The criteria for an increased evaluation for post-operative residuals with traumatic arthritis in the left knee (exclusive of a temporary total evaluation from November 4, 2008 to January 1, 2009), rated as 10 percent disabling due to arthritis with painful motion for the period prior to December 30, 2010, and as 10 percent disabling due to arthritis with painful motion and 10 percent disabling due to limitation of flexion since December 30, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5010-5260 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), 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 AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a June 2006 letter, sent prior to the initial unfavorable decision issued in November 2006, advised the Veteran of the evidence and information necessary to substantiate his increased rating claims as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the June 2006 letter advised him of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records, as well as post-service VA and private treatment records, have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded VA examinations in October 2006, December 2010, and October 2012, in conjunction with his increased rating claims on appeal. Neither the Veteran nor his representative have alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected bilateral knee disability, as they include an interview with the Veteran and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claims and no further examination is necessary. Moreover, the RO/AMC substantially complied with the prior remand directives, to include requesting additional records and scheduling the above October 2012 examination. Accordingly, the Board finds that the prior remand orders have been substantially complied with. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where Board's remand instructions were substantially complied with). Accordingly, the Board has satisfied its duties to notify and assist the Veteran, and will now proceed to the merits. II. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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 importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may also be assigned for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. See generally 38 U.S.C.A. § 5110(b)(2). In this regard, the Board notes that in a July 2000 rating decision, the RO maintained the Veteran's 10 percent ratings for each knee, effective October 12, 1996. The Veteran did not enter a notice of disagreement with respect to this rating decision. Moreover, no additional evidence referable to the Veteran's bilateral knees was associated with the claims file within one year of the issuance of such decision. 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). Thereafter, VA received the Veteran's current claim for an increased rating for his bilateral knee disability on April 6, 2006. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. In the instant case, for the entire appeal period, both of the Veteran's knees are rated as 10 percent disabling due to arthritis with painful motion, pursuant to Diagnostic Code 5010. See 38 C.F.R. § 4.27. For the period as of December 30, 2010, the Veteran was assigned an additional 10 percent rating for each knee based on limitation of flexion, under Diagnostic Code 5260. Id. Diagnostic Code 5010 provides ratings for arthritis due to trauma, substantiated by X-ray findings; it states to rate it as degenerative arthritis, Diagnostic Code 5003. Such provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating 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, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees, a 50 percent rating may be assigned. Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent evaluation for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. VA's General Counsel has stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). The rating schedule also provides that dislocation of semilunar cartilage, 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. Diagnostic Code 5259 provides for the assignment of a maximum 10 percent rating based on symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. III. Factual Background & Analysis Prior to December 30, 2010 After a careful review of the evidence of record, the Board finds that prior to December 30, 2010, the Veteran's bilateral knee disability does not warrant a rating in excess of 10 percent for either knee. Pertinent to this timeframe, the Veteran underwent a VA examination in October 2006 for his knees. It was noted that he had no constitutional symptoms of arthritis and no incapacitating episodes. He reported being able to stand more than one hour, but less than three hours, and able to walk one to three miles. Both knees involved pain and giving way, but instability, weakness, stiffness, flare-ups of joint disease, and inflammation were denied for both knees. On physical examination, both knees had flexion from 0 to 100 degrees, with no pain or additional limitation of motion reported on repetitive use. Both knees had crepitus, but no instability, clicks or snaps, grinding masses behind the knee, and no patellar or meniscus abnormalities. The examiner noted that the Veteran's bilateral knee pain had significant effects on his occupation. He referenced a 2004 X-ray report showing moderately advanced degenerative changes in the bilateral knees, and diagnosed bilateral joint disease. An April 2007 VA treatment note documented range of motion of 0 to 105 degrees in the left knee and 0 to 110 degrees in the right knee. The Veteran had bilateral medial joint line tenderness, but no effusion or instability. X-rays showed moderately advanced medial compartment disease in the right knee and to a lesser degree in the left knee. The Veteran was administered steroid injections. An August 2007 VA treatment note shows the Veteran reported complaints of right knee sharp pain and giving way, and that his left knee was hardly bothering him. Range of motion was from 0 to 110 degrees. The Veteran was administered an injection for his right knee. A February 2008 VA treatment note indicates that the Veteran had full range of motion for both knees, and no edema, swelling, or effusions. Crepitus was present, and McMurray's test was positive for discomfort bilaterally. Lateral medial collateral ligaments were intact, and Lachman's and drawer signs were negative. In August 2008, the Veteran began another series of injections for his right knee. Upon examination, the right knee had moderate medial joint line tenderness with full range of motion and no effusion or instability. X-rays showed no arthritic findings and a negative examination for both knees. In November 2008, the Veteran underwent left knee surgery. In April 2009, the Veteran reported to a VA clinician that his left knee pain was now as bad as his right, with pain of 8-9/10. Range of motion was 0 to 90 bilaterally. There was no instability, effusion, or inflammation. The Veteran began a series of injections for both knees. An April 2009 VA X-ray report showed mild to moderate right medial compartment osteoarthritis. In September 2009, the Veteran reported chronic knee pain with frequent exacerbations. A VA treatment note shows that the Veteran had full range of motion for both knees, and no edema, swelling, or effusions. Crepitus was present, and McMurray's test was positive for discomfort bilaterally. Lateral medial collateral ligaments were intact, and Lachman's and drawer signs were negative. In February 2010, the Veteran began another series of injections for both knees. The Veteran had full extension bilaterally, and flexion was limited to slightly past 90 degrees, due mostly to pain. There was no effusion in either knee. A May 2010 VA X-ray report showed mild degenerative changes in the right knee and no significant abnormalities in the left knee. An August 2010 VA orthopedic note shows the Veteran had range of motion from 0 to 110 degrees on the left and 0 to 90 degrees on the right. There was no effusion or ligamentous instability in either knee. Private treatment notes primarily reflect treatment for the Veteran's bilateral knees, prior to, and immediately following, his November 2008 left knee surgery. Here, a maximum 20 percent evaluation under Diagnostic Code 5003, for X-ray evidence of involvement of 2 or more major or minor joints and occasional incapacitating episodes, is inapplicable as the evidence does not show involvement of two or more joints, or any incapacitating episodes. The Board also finds that the Veteran is not entitled to higher evaluations under Diagnostic Codes 5260 or 5261 for limitation of flexion or extension. The record does not show that flexion is limited to 30 degrees or that extension is limited to 15 degrees for the appeal period to warrant a higher disability rating under these criteria. In fact, the above evidence shows that the Veteran's flexion for either knee was limited to, at most, 90 degrees, which corresponds to the criteria for a noncompensable rating. As such, the current rating assigned contemplates the Veteran's symptomatology of painful motion, and rating under these diagnostic codes is not appropriate in this case. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 and the holdings in DeLuca and Mitchell, supra, the reports from the examination and treatment records document consideration of these principles, and there is no indication that increased compensation would be warranted under these principles, as such factors do not result in functional loss that more nearly approximates flexion or extension limited to a higher disability rating. In reaching this conclusion, the Board has considered the Veteran's subjective complaints of pain and his knees giving way, and objective evidence of tenderness and crepitus; however, the additional functional loss has been contemplated by the already assigned 10 percent ratings for each knee. The Board has also considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5257; however, the Board finds no objective evidence of subluxation or instability in either knee. Accordingly, a separate rating for instability or subluxation for either knee under Diagnostic Code 5257 is not warranted in this case. Nor is a higher rating warranted under Diagnostic Code 5258, for which a maximum 20 percent evaluation is possible for dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion, as such is not shown by the evidence. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Additionally, as the evidence of record fails to demonstrate ankylosis, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5262, or 5263, respectively. In sum, the Board finds that prior to December 30, 2010, the Veteran does not warrant an increased rating in excess of 10 percent for either knee based on painful, limited motion with arthritis. Since December 30, 2010 In an April 2009 decision, the RO granted a temporary total rating for convalescence for arthroscopic surgery on the left knee for the period from November 4, 2008, through December 31, 2008, and returned the assigned 10 percent rating in effect thereafter. By way of a March 2012 rating decision, the RO granted additional separate 10 percent ratings for limitation of flexion in each knee (based on the Veteran's pain), each effective from December 30, 2010. In December 2010, the Veteran underwent a VA examination, where he reported pain, stiffness, weakness, instability, tenderness, and giving way of both knees. Flare-ups, effusion, and episodes of dislocation or subluxation were denied. The Veteran reported locking episodes occurring less than once a year. There were no incapacitating episodes of arthritis or constitutional symptoms of arthritis. He stated he could stand more than one hour, but less than three, and that he could walk a quarter mile, but less than one mile. On examination, both knees had crepitus, but no instability, clicks or snaps, grinding masses behind the knee, and no patellar or meniscus abnormalities. Both knees had flexion from 0 to 110 degrees and normal extension, with evidence of pain with active motion. There was pain following repetitive motion, but no additional limitation of range of motion. Joint ankylosis was negative. X-rays showed mild degenerative changes to the right knee, no significant abnormalities involving the left knee, and overall, no significant change to either knee since the April 2009 X-rays. The Veteran reported full time employment at the post office, and that he had missed two weeks of work in the prior 12-month period due to knee pain. The examiner found that the Veteran's bilateral knee disability had significant occupational effects. In October 2012, the Veteran underwent another VA examination. He reported that his right knee locks and makes a painful popping sound after he has been sitting for a while. Flare-ups were denied. Range of motion testing for both knees showed flexion to 140 degrees or greater and normal extension, with no objective evidence of pain for either motion. Repetitive use testing did not decrease the range of motion for either knee. Functional loss was present in both knees, due to weakened movement. Joint line tenderness for both knees was positive. There was no evidence of instability or subluxation/dislocation for either knee. It was noted that the Veteran had a mensicetomy in 1996 for both knees, and that he has residuals in both knees manifested by constant pain, as well as popping in the right knee. X-rays showed mild osteoarthritis in the medial compartment of the right knee and minimal marginal osteophyte of the medial left tibial plateau. Based on the above, the Board finds that the Veteran does not warrant a rating in excess of 10 percent for his traumatic arthritis, nor does he warrant a rating in excess of 10 percent for his limitation of motion, for either knee, from December 30, 2010, forward. As illustrated, the evidence does not show that the Veteran's left knee or right knee are productive of ankylosis, moderate recurrent subluxation or lateral instability, a dislocated semilunar cartilage, or a malunion of the tibia and fibula. Accordingly, the Board finds that DC's 5256, 5257, 5258, and 5262 are inapplicable. Additionally, a maximum 20 percent rating under Diagnostic Code 5003 is inapplicable, as the evidence does not show involvement of two or more joints, or any incapacitating episodes. In order for the Veteran to warrant a higher rating based on limitation of motion, for which he is already assigned separate 10 percent ratings for each knee under DC 5260, there needs to be evidence of range of motion of flexion limited to 30 degrees (DC 5260) or extension limited to 15 degrees (DC 5261). However, as shown above, the Veteran's range of motion was normal for extension, and range of motion for flexion does not meet the criteria for a higher rating, even in contemplation of his complaints of pain, as discussed below; therefore, he does not warrant a higher rating under DCs 5260 or 5261. See DeLuca, Mitchell, supra. Moreover, the evidence of record fails to demonstrate that the Veteran has extension of the bilateral knees limited to a compensable degree and, therefore, separate ratings for limited extension are not warranted. See VAOPGCPREC 9-04. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. § 4.45 and the holdings in DeLuca and Mitchell, supra, the reports from the examination and treatment records document consideration of these principles, and there is no indication that increased compensation would be warranted under these principles, as such factors do not result in functional loss that more nearly approximates flexion or extension limited to a higher disability rating. In reaching this conclusion, the Board has considered the Veteran's subjective complaints of pain and his knees giving way, and objective evidence of tenderness and crepitus; however, the additional functional loss has been contemplated by the already assigned 10 percent ratings for each knee, under DC 5260. The Board has considered whether the Veteran is entitled to a separate 10 percent rating for the symptomatic removal of semilunar cartilage under Diagnostic Code 5259, which is the maximum schedular rating available under this diagnostic code. In this regard, the Veteran underwent right and left knee meniscectomies during service and has had additional knee surgeries since that time. The Board notes that semilunar cartilage is one of the menisci of the knee joint. Stedman's Medical Dictionary 296 (27th ed., 2000). During the October 2012 VA examination, the examiner found that the Veteran had residuals in both knees from his in-service knee surgeries, manifested by constant pain, as well as popping in the right knee. However, as mentioned, the Veteran was assigned a separate 10 percent rating for both knees under DC 5260 in light of his functional loss due to pain. Accordingly, here, both DC 5260 and 5259 essentially address the same criteria. As mentioned previously, 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 rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2013). It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Therefore, in this case, a separate rating under Diagnostic Code 5259 would violate the rule against pyramiding since the functional loss of the Veteran's bilateral knees due to pain is already contemplated by the 10 percent rating already assigned under Diagnostic Code 5260. Accordingly, since December 30, 2010, the Veteran's traumatic arthritis, rated as 10 percent disabling, and limitation of flexion, also rated as 10 percent disabling, for both knees, does not warrant higher ratings. Other Considerations For the entire appeal period, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of his bilateral knee disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability ratings reflect. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board further observes that the Veteran has scarring of both knees as a result of his surgeries. As such scars are asymptomatic, linear, and no more than 0.5 centimeters in length, separate compensable ratings for the Veteran's scars are not warranted. See 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2013). The Board has considered whether staged ratings under Hart, supra, in addition to those already assigned, are appropriate for the Veteran's service-connected bilateral knee disability; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning additional staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected bilateral knee disability with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disability is rated. In this regard, the Veteran's disability ratings contemplate his functional limitations caused by his bilateral knee disability, to include painful, limited motion with arthritis. There are no additional symptoms of his bilateral knee disability that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). As indicated in the Introduction, in Rice, supra, the Court held that a claim for a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. However, as the Veteran's TDIU claim is being remanded for additional development, no further discussion of such is necessary at this time. In sum, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for either knee prior to December 30, 2010, for arthritis, and in excess of 10 percent for arthritis of either knee and in excess of 10 percent for limitation of flexion of either knee as of December 30, 2010. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER Entitlement to an increased evaluation for post-operative residuals with traumatic arthritis in the right knee, rated as 10 percent disabling due to arthritis with painful motion for the period prior to December 30, 2010, and as 10 percent disabling due to arthritis with painful motion and 10 percent disabling due to limitation of flexion since December 30, 2010, is denied. Entitlement to an increased evaluation for post-operative residuals with traumatic arthritis in the left knee (exclusive of a temporary total evaluation from November 4, 2008 to January 1, 2009), rated as 10 percent disabling due to arthritis with painful motion for the period prior to December 30, 2010, and as 10 percent disabling due to arthritis with painful motion and 10 percent disabling due to limitation of flexion since December 30, 2010, is denied. REMAND As indicated in the Introduction, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. See Rice, supra. Here, such issue has been raised in the context of the Veteran's claim for an increased rating for his bilateral knee disability. Specifically, at the Veteran's October 2012 VA examination, the examiner stated, "It is my medical opinion that this Veteran is severely limited in his ability to be gainfully employed in any occupation that requires prolonged sitting, walking, bending, squatting, or kneeling due to bilateral lower extremity weakness and constant pain." However, the Board finds that further development is necessary for a fair adjudication of the Veteran's TDIU claim. In this regard, upon remand, the AOJ should conduct all appropriate development, to include providing the Veteran with VCAA-compliant notice as to a TDIU, obtaining outstanding treatment records, and obtaining an opinion regarding the effect the Veteran's service-connected disabilities, to include his bilateral knee disability, have on his employability. See Friscia v. Brown, 7 Vet. App. 294, 297 (1994). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be provided with proper VCAA notice regarding the evidence and information necessary to substantiate his TDIU claim. He should also be requested to complete and return VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). 2. The Veteran should be given an opportunity to identify any healthcare provider who treats him for his service-connected disabilities. After securing any necessary authorization from him, obtain all identified treatment records. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After completing the above, the claims file should be forwarded to an appropriate medical professional to offer an opinion as to whether the Veteran's service-connected disabilities render him unemployable. The claims file and a copy of this Remand must be made available to the examiner, and the examiner shall indicate in the report that the claims file was reviewed. The need for an additional examination of the Veteran is left to the discretion of the examiner selected to write the opinion. Following a review of the record, the examiner should render an opinion as to whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, either singularly or jointly, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. In this regard, the Veteran is service-connected for glaucoma, traumatic arthritis of the left and right knees, and limitation of flexion of the left and right knees. The examiner should specifically consider the findings noted at the October 2012 VA examination regarding the impact the Veteran's knee conditions have on his ability to work as a mail carrier. All opinions offered should be accompanied by a rationale. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran 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 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). ______________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs