Citation Nr: 1333113 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 09-42 994 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for the left knee degenerative joint disease (DJD). 2. Entitlement to an extraschedular rating for the left knee disability. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The Veteran appellant served on active duty in the United States Marine Corps August 1985 to August 1989; subsequently he was member of the National Guard. This case originally came before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky that decreased the disability rating for the service-connected left knee degenerative joint disease (DJD) from 50 percent to 10 percent. In February 2012, the Board issued a decision that found the reduction of the disability rating for the left knee to be proper. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In February 2013, the Court issued a Memorandum Decision that reversed the Board's decision and remanded the case to the Board for reinstatement of the 50 percent left knee disability rating. That reinstatement was implemented by means of a rating decision issued by the RO in August 2013. In February 2009, the Veteran testified at a personal hearing conducted at the RO. He also provided testimony at a Board videoconference hearing before the undersigned in September 2011. A copy of the transcript from each hearing is of record. The record before the Board consists of the Veteran's paper claims files and an electronic record known as Virtual VA. The Board observes that a claim for a total disability rating based upon individual unemployability (TDIU) as due to the Veteran's service-connected left knee disability has been raised by the record during the pendency of this appeal. Thus, in light of the ruling in Rice v. Shinseki, 22 Vet. App. 447 (2009) and as the Veteran is seeking the maximum benefit available for his left knee disability on appeal, entitlement to a TDIU rating will be considered as part of the determination of the appropriate disability ratings for the service-connected left knee disability rather than as a separate claim. See, e.g. the reports of the VA examinations conducted in January 2010, and May 2012, wherein it was noted that the Veteran had not worked since 1991 due to his knee and his back (also service-connected). As such and in light of Court precedent, the Board has determined that this issue is before the Board. The issues of entitlement to an extraschedular rating for the left knee disability and entitlement to TDIU are addressed in the REMAND portion of the decision below and those matters are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The maximum schedular evaluation for limitation of extension of a knee is 50 percent; the appellant has been assigned a 50 percent evaluation for his left knee limitation of extension throughout the appeal period. 2. Throughout the appeal period, the limitation of flexion of the appellant's left knee has approximated 45 degrees. 3. The appellant has a left knee meniscal tear with a history, throughout the appeal period, of frequent episodes of locking, pain, and effusions into the left knee joint. 4. Throughout the appeal period, the evidence does not show any left knee ankylosis, any knee replacement surgery, or any removal of semilunar cartilage. 5. The appellant has been assigned a combined 60 percent evaluation for his left knee disability (DJD and ligamentous instability) since August 22, 2006. CONCLUSIONS OF LAW 1. The schedular criteria for an evaluation in excess of 50 percent for the service-connected left knee limitation of extension have not been met at any time. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp 2013); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5261 (2013). 2. The criteria for a separate schedular evaluation of 10 percent, but no more and subject to the amputation rule, for left knee limitation of flexion have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2013). 3. The criteria for a separate evaluation of 20 percent, but no more and subject to the amputation rule, for a left knee meniscal tear have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5258, 5259 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist With respect to the appellant's left knee increased rating claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. In February 2008, the appellant requested an increased rating for his left knee disability. A May 2008 letter provided the notice requirement for an increased rating. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). This letter also provided the appellant with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Accordingly, this letter satisfied the notice requirements with respect to the issue on appeal. The duty to assist the appellant has also been satisfied in this case. The RO has obtained relevant treatment reports. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The appellant was afforded VA examinations in April 2007, March 2008, January 2010, and May 2012. The Board finds the VA examinations adequate, as they were based on a complete review of the appellant's medical history and physical examination of the appellant, and they provide sufficient findings to evaluate the appellant's service-connected left knee disability. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A remand from the Board or the Court confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). This case was remanded by the Board in July 2013 to the RO for reinstatement of the 50 percent evaluation for the left knee disability, to allow the appellant to submit additional evidence and to obtain recent treatment reports. Additional VA medical records were added to the claims file and the 50 percent rating was restored. Consequently, there has been substantial compliance with the July 2013 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999). There is no indication in the record that additional evidence relevant to the issue being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The Veteran was duly afforded the opportunity to produce additional evidence to support his claim. Neither he nor his representative has identified any additional evidence that could be obtained to substantiate his increased rating claim. The Board is also unaware of any such evidence. Thus, the Board is also satisfied that the originating agency has complied with VA's duty to assist the Veteran in the development of the claim. The Board will therefore address the merits of the claim. II. The Merits of the Claim Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 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. In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). The evidence of record includes written statements and testimony from the appellant. The appellant has stated that his knee locks up and gives out, that the left knee has been getting worse over time, and that he has bone on bone contact in his knee. The appellant testified at his February 2009 personal hearing that the pain in his knee was not improved by the surgery (in December 2007) and that his knee function had not improved in that he still experienced limitation of his range of motion, instability and freezing up of the knee. He said that he experienced pain when he bent his knee, that walking too much made his knee throb and that the instability felt worse. The appellant further testified that he experienced flare-ups one to two times per week and that these lasted all day and night. He said that standing and walking would make the knee flare up. The appellant provided similar testimony at his September 2011 Board videoconference hearing. He also stated that his knee brace helps him, that he walked with a limp and that he could not walk as much. The appellant's VA medical treatment records include a November 2006 physical therapy note that indicated that the appellant had an antalgic gait with a limp to the left. On physical examination, he exhibited 5/5 strength with pain through extension. There was medical joint line tenderness. He was issued a knee brace. Later that month, he complained of knee pain during an orthopedic surgery clinic visit; he reported that his knee was doing a lot better than before the brace and that, overall, his left knee was feeling a lot better. The appellant was afforded a VA medical examination in April 2007; the examiner reviewed the history of the appellant's left knee problems. The appellant reported that his knee was progressively worse and that he always used a knee brace for walking. He said that he was able to stand for ten to thirty minutes and that he could walk one-quarter of a mile. His reported symptoms included knee joint tenderness, giving way, instability, pain, stiffness, weakness, locking one to three times per month and repeated effusions. He said that he had weekly flare-ups that were moderate in severity and that lasted one to two days with swelling and tenderness of the knee. On physical examination, the appellant had an antalgic gait. There was no evidence of abnormal weight bearing. The appellant exhibited a range of motion from 45 to 135 degrees. This motion was accomplished with pain. There was no joint ankylosis. There was crepitation, grinding, effusion, tenderness, moderate medial lateral instability and painful movement. X-rays revealed mild degenerative changes, especially involving the medial joint line compartment; small joint effusion was also seen. Private medical records indicate that the appellant underwent an arthroscopy of the left knee in December 2007. In a note written by his family practice doctor in that same month, the appellant exhibited tenderness to palpation of the left knee. He did not have any motor deficit in any extremity. The doctor rendered a diagnosis of left knee pain status post surgery. Similar findings were made in February 2008, and August 2008. The appellant also demonstrated limitation of motion in August 2008; no measurements were recorded. The appellant underwent another VA medical examination in March 2008; the examiner reviewed the appellant's medical history relating to his left knee. The appellant reported that he always wore his left knee brace and that his symptoms were alleviated by the use of pain medication, activity limitation and elevation of the leg. He said that he could stand for fifteen to thirty minutes and that he could walk for one-quarter of a mile. He complained of left knee pain and stiffness, as well as mild severe flare-ups occurring every two to three weeks. The flare-ups were described as mild in nature and lasting one to two days. The appellant said that he had difficulty ambulating during flare-ups. On physical examination, the appellant demonstrated zero to 120 degrees of left knee motion; this motion was accomplished with pain. There was no additional limitation of motion on repetitive use. There was no ankylosis. The appellant indicated that the effect of the flare-ups on the limitation of his range of motion or other functional impairment was mild. He said that he was able to perform all of his activities of daily living (ADL). The examiner indicated that the left knee disability had a mild to moderate effect on the appellant's ADLs. An x-ray showed evidence of a healed tibial plateau fracture; no significant degenerative changes were noted. The appellant underwent another VA medical examination in October 2008; the examiner reviewed the appellant's medical history relating to his left knee. The appellant reported that he experienced pain when going up and down steps and when he ambulated less than one-quarter of a mile. He said that he could stand for fifteen to thirty minutes and that he could walk for one-quarter of a mile. He complained of his knee giving way, instability, pain, stiffness, weakness, locking episodes and severe flare-ups every two to three weeks; the flare-ups were described as severe in nature and lasting one to two days. The appellant said that he had difficulty ambulating during flare-ups. On physical examination, the appellant demonstrated zero to 140 degrees of left knee motion; this motion was accomplished with pain. There was no additional limitation of motion on repetitive use. There was no ankylosis. The appellant had an antalgic gait. The examiner indicated that the left knee disability had a mild to moderate effect on the appellant's ADLs, in addition to preventing sports and exercise. An x-ray showed mild degenerative changes in the left knee joint. Review of the appellant's VA treatment records dated in 2009 indicates that the appellant requested pain medication. He reported that he was having increased pain in his back and legs. An MRI was reported to be normal. The appellant was afforded another VA medical examination in January 2010; the examiner reviewed the appellant's medical history relating to his left knee. The appellant complained of increasing pain, swelling and locking of the knee. He said that he could stand for fifteen to thirty minutes and that he could walk for one-tenth of a mile. The appellant reported using a brace, pain medication and limitation of activity due to the left knee. He complained of left knee instability, pain, stiffness, incoordination and reduced speed of joint motion, as well as locking and swelling. He said the locking episodes occurred weekly and that he experienced moderate flare-ups every two to three weeks; the flare-ups were described as lasting three to seven days. The appellant said that he was able to perform all ADLs during flare-ups, but that his mobility was reduced by 50 percent. On physical examination, the appellant demonstrated zero to 120 degrees of left knee motion; this motion was accomplished with pain. There was no additional limitation of motion on repetitive use. There was no ankylosis. Crepitus, tenderness and instability were present. The appellant had an antalgic gait; there was no evidence of abnormal weight bearing. The examiner indicated that the left knee disability had a mild to moderate effect on the appellant's ADLs, in addition to preventing sports. Review of the appellant VA treatment records dated in 2010, 2011, and 2012 indicates that the appellant was seen in the primary care clinic in May 2010; he was noted to be wearing a knee brace and to demonstrate a full range of motion. The left knee was not tender and there was no effusion. In January 2011, the appellant's left knee condition was noted to be basically unchanged. On physical examination there was no edema. The diagnosis was DJD with chronic pain controlled with Ultram. In February 2012, the appellant was noted to not have been seen for one year. The appellant was seen in March 2012; when his left brace was removed on physical examination, there was no tenderness and no effusion. Routine exercise was encouraged. In December 2012, the appellant was noted to be wearing a knee brace; there was no noticeable effusion or warmth on examination of the left knee. The appellant was most recently afforded a VA medical examination in May 2012; the examiner reviewed the claims file. The appellant complained of mild to severe pain that he said was continuous. He reported experiencing flare-ups as a consequence walking more than one-quarter of a mile or due to prolonged standing or sitting. The appellant reported having a 60 percent loss of normal function during the flare-ups; he said this loss of function occurred daily and secondary to his ADLs. He said that the flare-ups lasted for three hours and that his pain was relieved by ceasing activity, self imposed bed rest and analgesic medication. The appellant said that he always used a knee brace and that he occasionally used a cane or a walker. On physical examination, the appellant exhibited 10 to 100 degrees of motion; the motion was accomplished with pain. There was no additional loss of range of motion after repetitive testing, but the appellant did have weakened movement and excess fatigability. There was tenderness to palpation. Strength testing was 3/5 and instability was present. The examiner stated that the appellant had had a meniscal tear with joint locking, effusion and pain. The examiner also stated that the appellant's functioning was not so diminished that amputation with a prosthesis would equally serve the appellant. Disability evaluations are determined by the application of a schedule of ratings that is based upon an average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. 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 involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Where there is X-ray evidence of arthritis and limitation of motion, but not to a compensable degree under the diagnostic code, a 10 percent rating is for assignment for each major joint affected. 38 C.F.R. § 4.71, Diagnostic Code 5003. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. 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 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. 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). Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 (providing rating for arthritis) and instability of a knee under Diagnostic Code 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). When x-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998). VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003/5010 and 5257, respectively. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus, when evaluating musculoskeletal disabilities, VA may consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. The Veteran is currently assigned a 50 percent schedular disability rating for the left knee DJD under 38 C.F.R. § 4.71a, Diagnostic Code 5261, which provides that limitation of knee extension to 45 degrees warrants a 50 percent rating; this is the highest schedular evaluation available under this code. Turning to consideration of limitation of flexion, the evidence of record indicates that, at worst, the appellant's left knee flexion has been limited to 100 degrees. The appellant has reported a reduction of mobility/normal function of 50 to 60 percent during flare-ups. Thus, at worst, the appellant would have his flexion of the left knee joint diminished to 40 degrees. Under Diagnostic Code 5260, this would warrant the assignment of a 10 percent schedular evaluation. This assignment of a 10 percent schedular evaluation would take into consideration the DeLuca factors, wherein a higher rating may be assigned based on additional limitation of motion due to pain on use, including flare-ups. See 38 C.F.R. §§ 4.40 , 4.45, 4.71a, Diagnostic Code 5260; DeLuca v. Brown, 8 Vet. App. 202 (1995). Furthermore, even if the Veteran did not meet the rating criteria for a 10 percent rating based on his actual limitation of extension of the left knee, painful motion would warrant an evaluation of 10 percent as there is also x-ray evidence of degenerative joint disease present. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991) (painful motion of a major joint caused by arthritis is deemed to be limited motion and entitled to a minimum 10 percent rating even though there is no actual limitation). In this case, the Board observes that degenerative joint disease of the left knee was noted by radiology reports and the medical evidence prior to August 22, 2006. See rating decision of April 2005. In addition, the assignment of this 10 percent rating is subject to the amputation rule as discussed below. However, the findings for flexion in the appellant's left knee fail to meet the criteria for the next higher schedular evaluation of 20 percent as limitation of flexion of the left knee to 30 degrees, even during flare-ups or when considering pain on use, has not been demonstrated. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Furthermore, ankylosis of the left knee has not been shown, nor has a left knee replacement. Accordingly, ratings under the related provisions are not for application. Therefore Diagnostic Codes 5256 and 5055 not for application. 38 C.F.R. § 4.71a, Diagnostic Codes 5055, 5256. Moreover, removal of the semilunar cartilage has not been shown in the left knee and therefore, Diagnostic Code 5259 is not for application. 38 C.F.R. § 4.71a, Diagnostic Code 5259. A 20 percent evaluation may be assigned where there is evidence of dislocated cartilage, with frequent episodes of "locking," pain, and effusion of the knee joint. This is the maximum schedular evaluation available. 38 C.F.R. § 4.71a, Diagnostic Code 5258. There is objective clinical evidence of dislocated cartilage (meniscal tear) in the left knee in the May 2012 VA examination report. In addition, as noted in the reports of the various VA examinations, the appellant has provided a history of frequent episodes of locking, pain, and effusion into the joint of the left knee. Thus, a separate schedular rating of 20 percent for left knee meniscal tear, with frequent episodes of locking and effusion in the left knee joint, would be warranted under Diagnostic Code 5258 and subject to the amputation rule. The Board notes that, in a rating decision issued in March 2011, the RO assigned a 10 percent schedular evaluation for the left knee ligamentous instability, effective from January 25, 2010. In an April 2011 rating action, the RO assigned a 20 percent schedular evaluation for the left knee instability for the period from August 22, 2006 to January 24, 2010. The Board notes that the Veteran has not expressed disagreement with either one of these two rating decisions addressing the matter of left knee instability. Because no notice of disagreement with either one of these ratings has been submitted, the Board lacks jurisdiction to address the left knee instability ratings or their effective dates. See 38 U.S.C.A. § 7105(a) (appellate review will be initiated by a notice of disagreement). There is a general rule against the "pyramiding" of benefits. See 38 C.F.R. § 4.14; see also Brady v. Brown, 4 Vet. App. 203, 206 (1993). However, the Board acknowledges that a veteran is entitled to separate disability ratings for different manifestations of the same disability when the symptomatology of one manifestation is not duplicative or overlapping of the symptomatology of the other manifestations. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board also notes that, since August 22, 2006, the combined rating for the left knee limitation of extension and instability has been 60 percent. However, the "amputation rule" provides that the combined rating for disabilities of an extremity cannot exceed the rating for amputation at the elective level. 38 C.F.R. § 4.68. In relation to amputations of the lower extremity, a 60 percent disability rating is assigned if there was an amputation of the thigh, above the knee, at the middle or lower third. 38 C.F.R. § 4.71a, Diagnostic Code 5162. Amputation of a leg with defective stump and thigh amputation recommended or amputation not improvable by prosthesis controlled by natural knee action may also be assigned a 60 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Codes 5163 and 5164. A higher rating of 80 percent requires amputation in the upper third of the thigh. The evidence of record does not indicate that such an amputation has been approximated by the appellant's functional limitations. Thus, considering the "amputation rule" pursuant to 38 C.F.R. § 4.68 and 38 C.F.R. § 4.71a, Diagnostic Codes 5161, 5162-5164, a 60 percent disability rating would be the maximum assignable disability rating for the Veteran's left knee disability. The Board has also considered the appellant's and other lay statements regarding the symptoms of his knee disorders and that the left knee disability is worse. The Veteran's statements are competent evidence as to the symptoms of his left knee disorders as this comes to him through his senses. In fact, the grants of the evaluations on appeal have been based in large part on the Veteran's reports about his symptomatology associated with the left knee disability. However, his statements are not competent evidence as to a specific level of disability of any left knee disorder according to the appropriate diagnostic codes. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Evidence concerning the nature and extent of each one of the appellant's left knee disorders has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings as provided in the examination reports directly address the criteria under which this type of disability is evaluated. The nature of the original onset of the disabilities at issue has been reviewed and the functional impairment which can be attributed to pain or weakness has been taken into account. As noted, pain is the main symptomatology of the left knee disability and has been considered in arriving at the conclusions made herein. The Board has also taken into consideration the Veteran's consistent complaints of left knee pain and problems with mobility as evidenced by the clinical evidence of record including private and VA treatment records and the reports of VA examinations reflecting consistent and continued complaints of left knee pain and pain on use, as well as his reports relating to flare-ups and increased symptomatology during those flare-ups. Thus, taking into consideration the provisions of 38 C.F.R. §§ 4.7, 4.10 and 4.40, such chronic symptomatology warrants no more than the evaluations assigned herein. After review of the evidence of record, there is no evidence of record that would warrant a rating in excess of those assigned at any time during the period pertinent to this appeal. 38 U.S.C.A. 5110 (West 2002); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected left knee disorders, the evidence shows no distinct periods of time during which the Veteran's left knee disorders have varied to such an extent that a rating greater or less than those assigned would be warranted. Cf. 38 C.F.R. § 3.344 (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). In reaching these decisions, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for increased ratings in excess of those assigned, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A schedular evaluation in excess of 50 percent for the left knee limitation of extension is denied. A separate schedular evaluation of 10 percent for left knee limitation of flexion is granted, subject to the controlling regulations applicable to the payment of monetary benefits and subject to the amputation rule. A separate schedular evaluation of 20 percent for a left knee meniscal tear is granted, subject to the controlling regulations applicable to the payment of monetary benefits and subject to the amputation rule. REMAND As noted in the decision above, the appellant has been assigned a 60 percent combined evaluation for his left knee disability and the "amputation rule" applies to his left knee rating. Consideration of entitlement to an extraschedular evaluation must still be undertaken when a veteran is in receipt of the maximum combined schedular evaluation possible pursuant to the amputation rule. See Smallwood v. Brown, 10 Vet. App. 93 (1997). Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27. However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual appellant's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b). When evaluating musculoskeletal disabilities, VA may consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). In addition, an extraschedular evaluation can be assigned. 38 C.F.R. § 3.321. In this case, the May 2012 VA medical examination report includes findings by the examiner that the appellant has functional loss due to weakness, excess fatigability and incoordination after repetitive motion. Furthermore, the medical evidence of record does not address whether or not the appellant's left knee disability causes marked interference with employment as delineated in 38 C.F.R. § 3.321. Therefore, on remand, consideration of referral to the Director of the Compensation and Pension Service for extraschedular rating should be accomplished. Finally, VA is required to decide issues together when a determination on one issue could have a significant impact on the outcome of another issue. Harris v. Derwinski, 1 Vet. App. 180 (1991). As the matter of entitlement to an extraschedular evaluation for the left knee disability is inextricably intertwined with his claim of entitlement to TDIU. Therefore, the TDIU issue is remanded. To ensure that VA has met its duty to assist in developing the facts pertinent to the claim on appeal and to afford full procedural due process, the case is REMANDED for the following: 1. Ensure that all notification and development action required by 38 U.S.C.A. §§ 5102, 5103, and 5103A, the implementing regulations found at 38 C.F.R. § 3.159 and any other applicable legal precedent has been completed. 2. Obtain all of the appellant's outstanding VA medical treatment records dated since March 2012, and associate them with the claims file. Obtain all outstanding private records as well, if any. 3. To the extent an attempt to obtain any of these records is unsuccessful, the claims file must contain documentation of the attempts made. The appellant and his representative must also be informed of the negative results and be given opportunity to secure the records. 4. After completing any additional notification and/or development action deemed warranted by the record, consider referral of the appellant's claim to the Director of the Compensation and Pension Service for a ruling on entitlement to an increased rating for a left knee disability on an extraschedular basis. 38 C.F.R. § 3.321(b)(1). 5. After receiving the response from the Director of the Compensation and Pension Service if the claim is referred, and after completing any additional notification and/or development action deemed warranted by the record, afford the appellant a VA examination to ascertain the impact of all of his service-connected disabilities on his employability. The examiner must provide an opinion as to whether the Veteran's combined service-connected disabilities, including the lumbar spine and left knee, are sufficient by themselves to render the Veteran unemployable. The rationale for all opinions expressed must also be provided. 6. The Veteran must be advised of the importance of reporting to the scheduled VA examination and of the possible adverse consequences, to include the denial of his claim, of failing, without good cause, to so report. See 38 C.F.R. § 3.655 (2013). A copy of the notification letter sent to the Veteran advising him of the time, date, and location of the scheduled examination must be included in the claims folder and must reflect that it was sent to his last known address of record. If he fails to report, the claims folder must indicate whether the notification letter was returned as undeliverable. 7. Then, readjudicate the claims. If any benefit sought on appeal is not granted to the Veteran's satisfaction, provide a supplemental statement of the case and afford them the requisite notice to respond before the case is returned to the Board for further appellate action. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. These claims 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). ______________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs