Citation Nr: 1336355 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 07-34 652A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to an initial disability rating in excess of 10 percent for left knee, status post repair, medial meniscus and degenerative joint disease (degenerative joint disease) prior to August 2, 2012. 3. Entitlement to an initial disability rating in excess of 20 percent for left knee, status post repair, medial meniscus and degenerative joint disease (degenerative joint disease) beginning August 2, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1968 to July 1972, with additional service in the U.S. Air Force Reserves from 1982 until 2009. This matter comes before the Board of Veterans Appeals (Board) on appeal of a January 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cheyenne, Wyoming. Jurisdiction rests with the RO in Denver, Colorado, from which the Veteran's appeal was certified. The Veteran was afforded a Travel Board hearing before the undersigned in August 2011. A written transcript of that hearing was prepared and incorporated into the evidence of record. The issue of service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. Throughout the course of the appeal, the Veteran's left knee disability has been manifested by degenerative changes of the joint shown on x-ray. 2. At no point during the appeal has the Veteran's left knee been ankylosed; nor has there been objective evidence of recurrent subluxation or lateral instability, flexion limited to less than 85 degrees, extension limited to more than 4 degrees, or evidence of malunion of the tibia or fibula or genu recuvatum. 3. Since August 2, 2012, the Veteran's left knee has displayed dislocated semilunar cartilage with frequent episodes of "locking," pain and effusion. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for left knee, status post repair, medial meniscus and degenerative joint disease prior to August 2, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Code 5010, 5256-5263 (2013). 2. The criteria for an increased disability rating in excess of 20 percent for left knee, status post repair, medial meniscus and degenerative joint disease since August 2, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Code 5010, 5256-5263 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 U.S.C.A. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Veteran's claim arises from his disagreement with the initial evaluation assigned following the grant of service connection for his claimed left knee disability as noted above. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for this claim. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to his claim for benefits, such as obtaining private and VA medical records and providing the Veteran with VA examinations in October 2006, April 2010, and August 2012. As the Veteran has not indicated that he has received additional treatment for the issue on appeal, the Board thus concludes that there are no additional treatment records outstanding with respect to this claim. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2013). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2013). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2013). In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several 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. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board has reviewed all of the evidence in the Veteran's claims file, including his VA treatment records, private treatment records, VA examination reports, and statements submitted in support of his claim. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claim for an increased disability rating for a left knee disability. service connection was initially granted and a 10 percent rating assigned for left knee, status post repair, medial meniscus and degenerative joint disease, effective February 14, 2006, in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4.71a, Diagnostic Code 5010 (2013). Subsequently, a 20 percent rating was granted for his left knee disability under Diagnostic Code 5010-5258, effective August 2, 2012. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2013). Diagnostic Code 5010 provides that arthritis due to trauma that is substantiated by x-ray findings is to be rated as degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is 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 there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint (like the knee, see 38 C.F.R. § 4.45) 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. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under these codes. 38 C.F.R. § 4.71a. 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. 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. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. 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. See VAOPGCPREC 09-04 (September 17, 2004). When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling; unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling; and extremely unfavorable flexion at an angle of 45 degrees or more, is to be rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Code 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. 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 or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Malunion of the tibia and fibula with slight knee or ankle disability is rated 10 percent disabling; malunion of the tibia and fibula with moderate knee or ankle disability is rated 20 percent disabling; and malunion of the tibia and fibula with marked knee or ankle disability is rated 30 percent disabling. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated 40 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Diagnostic Code 5263 provides a 10 percent rating for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). 38 C.F.R. § 4.71a, Diagnostic Code 5263. Turning to the evidence of record, the Veteran was first afforded a VA examination in October 2006. The Veteran reported that he was never pain-free. The severity of pain was moderate to severe, occasionally as little as mild. The flare-ups were by any hard-impact activity, prolonged standing, prolonged sitting, and when he sat for a prolonged period of time and then stood up, the pain was accentuated. He would occasionally lose sleep. He missed work for doctor's appointments, but not otherwise. His activities of daily living were affected on the job, in the sense that he avoided prolonged standing, prolonged sitting, and any hard-impact activities involving the left knee. The Veteran reported stiffness and weakness, without a history giving way and occasional swelling. Examination of the left knee revealed very minimal peripatellar swelling. There was tenderness both medially and laterally about the knee joint, and no swelling or increase in local heat. Patella inhibition test was positive, drawer test was negative, muscle mass and strength were excellent, and there was no instability demonstrated. Extension was a maximum of 4 degrees, with significant pain. His flexion was from 4 degrees to 95 degrees, and he reported severe pain after 85 degrees. Post test, the Veteran reported stiffness and a sense of weakness as though the knee would "give way." He also had increasing tenderness in a circumferential fashion and evidence of impaired endurance. The examiner diagnosed the Veteran with left knee degenerative joint disease, status post repair, medial meniscus. Except as noted in the examination and history above, there was no further reduction in range of motion against resistance with repetition, nor additional evidence of impaired endurance due to painful motion, weakness, instability, incoordination, impaired endurance, or during flares. The Veteran was afforded another VA examination in April 2010. The Veteran reported current symptoms of daily intermittent pain, especially when on ladders, working with the weight of his tool belt, using stairs, and kneeling. The pain was 4 to 5 out of 10, especially at the end of the work days with occasional swelling, stiffness, popping, and a sense of catching about the patellar in particular when he was in the action of kneeling or standing up, but not buckling or locking. Despite his symptoms, he had not missed any days of work in the past year because of this condition. Additionally, it did not impact his activities of daily living and he did not have flare-ups. The Veteran reported such activities as walking and biking, but tried to avoid high impact activities. The Veteran reported that he was not currently using an assistive device, although he had previously worn a knee brace. Upon examination, there was mild prepatellar soft tissue swelling and slight suprapatellar effusion, without erythema or heat. Alignment was normal. There was subpatellar crepitus and tenderness. There was no sign of instability with a negative Lachman, McMurray, and drawer sign tests. Range of motion done actively, passively, and against resistance three times revealed the range of motion of the left knee to be 0 to 130 degrees with pain. The Veteran's scars measured 1 cm by 3 mm, and were deep, without evidence of underlying soft tissue loss, with the deep tissue disruption considered equal in size to the overlying skin scar. There was no scar induced limitation of motion. All of the scars appeared smooth without inflammation or ulceration, were normally pigmented throughout, and had no gross asymmetry or disparity of features. Further, the scars were level with the surrounding skin, flexible, non-indurate, non-edematous, non-adherent, and non-tender. The examiner diagnosed the Veteran with degenerative arthritis of the left knee, status post partial medial meniscectomy and chondroplasties, with residual arthroscopic scars, mild reduction in full flexion, and mild effusion and pain. The examiner further stated that except as previously noted, there was no change in active or passive ranges of motion during repeat testing of three times against resistance and no additional losses of range of motion were observed for the left knee due to painful motion, weakness, impaired endurance, incoordination, or instability. The Veteran was afforded another VA examination in August 2012. The examiner noted a diagnosis of left knee degenerative joint disease, status post partial medial menicectomy and chrondroplasty. The Veteran reported that there were no further tests or new treatment for his condition since his last visit. The Veteran reported increased left knee pain three to four times a week, most often related to work activities. He worked installing and repairing heat and air conditioning equipment since 1982. He had knee pain at work after climbing up and down a ladder, after walking up or down two flights of stairs, or after carrying more than 100 pounds while walking. The pain is 5 out of 10 and improved over an hour if he stopped the aggravating activity and took Aleve. He had a flare of knee pain once a week after doing more strenuous activities than those noted above and especially if he tried to squat at work, at which time the pain was and 8 out of 10. He reported that his knee would occasionally lock and he then had to pop it. He also reported that sometimes when he bent forward while his knees were straight, it felt like the left knee was unstable, like it might buckle (but never had). He had never been diagnosed with any knee ligament problems, or knee instability. He reported that his social activities were impacted mainly due to his inability to exercise regularly. He limited walking to 15 minutes or half a block, and standing to10 minutes due to left knee pain. He tried to limit stairs to two flights and tried not to carry and walk with anything over 100 pounds. He had not lost any work time due to his knee condition and did not have any work restrictions or work accommodations due to his knee. Upon examination, the Veteran's left knee ranges of motion were flexion to 130 degrees with pain, and extension to 0 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions with no additional limitation to his left. The Veteran's functional loss and/or impairment of the left knee included less movement than normal and pain on movement. The examiner stated that the Veteran did not have any additional loss of range of motion of the left knee or discomfort or significantly limited functional ability during flare-ups or when the knee was used repeatedly over a period of time. This was based on the fact that he had no significant increased pain with repetitive range of motion testing of the left knee. The Veteran did not have tenderness or pain to palpation for joint line or soft tissues. Additionally, the Veteran had normal muscle strength testing. Upon joint stability testing, the Veteran was noted to have normal anterior-posterior and medial-lateral stability. There was also no evidence or history of recurrent patellar subluxation/dislocation or "shin splints," stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran was noted to have a meniscal condition, to include a meniscal tear, with frequent episodes of joint locking, and pain of the left knee. Additionally, the Veteran had a meniscectomy of the left knee in May 1993, with residual joint pain. The Veteran did not have a total knee joint replacement or other knee surgery, than already noted. The Veteran had a scar that was neither painful, nor unstable, nor was the total area of all related scars greater than 39 square cm. Specifically, the examiner noted that the Veteran had three very faint, barely visible, arthroscopic linear scars of the left knee measuring 1.0 cm by 0.1 cm, 0.5 cm by 0.1 cm, and 1.5 cm by 0.1 cm. The examiner stated that the Veteran pointed to all of these as scars, but they were hard to distinguish from wrinkles in the skin. Additionally, the Veteran's left knee alignment was normal and there was no tenderness to palpation, swelling, or instability on examination. The Veteran reported regular use of a knee brace. Dramatic arthritis was noted on imagining studies; however, patellar subluxation was not found. Prior to August 2, 2012 The evidence does not warrant a higher disability rating in excess of 10 percent for left knee, status post repair, medial meniscus and degenerative joint disease prior to August 2, 2012. At all relevant points prior to that date, the Veteran has not had motion limited to less than 85 degrees of his left knee. However, to receive a 20 percent rating, the Veteran's flexion must be limited to 30 degrees, by pain or otherwise. His motion has not been shown to be so limited. Similarly, under Diagnostic Code 5261, limitation of extension to 15 degrees is required for a 20 percent rating. However, the Veteran's extension of the left knee has showed no limitation higher than 4 degrees, due to pain or otherwise. The Veteran's limitations of flexion and extension would be considered noncompensable under the appropriate diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The Board has considered whether there is additional functional loss due to fatigability, incoordination, pain on movement, deformity, or atrophy of disuse, and notes that, throughout the appeal, the Veteran has reported having knee problems affecting his ability to stand for prolonged periods, walk distances, squat, or climb stairs. In this regard, the Board acknowledges that the Veteran experiences recurrent pain as a result of his left knee disability. However, the severity of his left knee disability is contemplated in the current disability rating. Moreover, even when considering pain and functional impairment, the Veteran's flexion of the left knee was only limited 85 degrees. As noted above, as well, the left knee did not have any additional loss of range of motion or significantly limited functional ability during flare-ups or when the knee was used repeatedly over a period of time. , and as such, his range of motion findings do not approach the criteria for a compensable rating under Diagnostic Code 5260 (i.e., 45 degrees of flexion). Accordingly, the Board finds that the current 10 percent rating for the Veteran's left knee, status post repair, medial meniscus and degenerative joint disease appears to be based upon painful motion. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). As such, the pain experienced on motion has been considered in assigning the 10 percent evaluation and there is no additional documented range of motion lost that would warrant a higher rating due to pain. Furthermore, while range of motion studies discussed above would result in noncompensable evaluations under the limitation of motion codes (i.e. Diagnostic Codes 5260 and 5261), motion of the knee is nevertheless limited, and there was evidence of degenerative disease on X-ray. As such, a 10 percent evaluation is appropriate for the Veteran's left knee disability. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). In addition to the ratings based on limitation of motion, a separate rating may be assigned for instability of the knee. The Board has considered whether the Veteran is entitled to a separate rating for recurrent subluxation or lateral instability under Diagnostic Code 5257; however, there is no objective evidence of subluxation or instability. The Board acknowledges that the Veteran reported that he felt that his knee would give way, but also reported that his knee never actually gave way. Additionally, the October 2006 VA examiner noted that there was no instability demonstrated on examination. While the Veteran reported occasional use of a left knee brace, the April 2010 VA examiner noted that there was no sign of instability with a negative Lachman, McMurray, and drawer sign tests. Accordingly, a separate rating for instability or subluxation under Diagnostic Code 5257 is not warranted in this case. The Board has also considered whether the Veteran is entitled to an increased rating for bilateral knee ankylosis, dislocation of the semilunar cartilage, symptomatic removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. The Veteran is not entitled to an increased disability rating for removal of semilunar cartilage under Diagnostic Code 5259 or genu recurvatum under Diagnostic Code 5263. The Board notes that the maximum rating allowed under Diagnostic Code 5259 and 5263 is a 10 percent rating. Therefore, a higher disability rating cannot be granted under these diagnostic codes. Additionally, the evidence of record fails to demonstrate such symptomatology as knee ankylosis, dislocation of the semilunar cartilage, or impairment of the tibia or fibula. Specifically, the April 2010 VA examiner noted that the Veteran had mild effusion and occasional swelling, stiffness, popping, and a sense of catching about the patellar in particular when he was in the action of kneeling or standing up at the end of the work day, but the knee did not buckle or lock. Furthermore, the examination report did not document any other tibial and/or fibular impairment. Additionally, VA examination reports and x-rays did not document any left knee ankylosis. Therefore, the Veteran is not entitled to an increased rating under Diagnostic Code 5256, 5258, or 5262. Beginning August 2, 2012 The evidence also does not establish entitlement to a rating greater than 20 percent for left knee, status post repair, medial meniscus and degenerative joint disease since August 2, 2012. The Veteran's left knee, status post repair, medial meniscus and degenerative joint disease was rated 20 percent rating under Diagnostic Code 5010-5258. As stated above, when there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint (like the knee, see 38 C.F.R. § 4.45) 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. At all relevant points of the claims period, the Veteran has not had motion limited to less than 130 degrees of his left knee. However, to receive a 30 percent rating, the Veteran's flexion must be limited to 15 degrees, by pain or otherwise. His motion has not been shown to be so limited. Similarly, under Diagnostic Code 5261, limitation of extension to 20 degrees is required for a 30 percent rating. However, the Veteran's extension of the left knee has showed no limitation higher than 0 degrees, due to pain or otherwise. The documented limitation of flexion and extension are noncompensable under the appropriate diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. The Board has considered whether there is additional functional loss due to fatigability, incoordination, pain on movement, deformity, or atrophy of disuse, and notes that, throughout the appeal, the Veteran has reported having knee problems affecting his ability to stand for prolonged periods, walk distances, kneel, or climb stairs. In this regard, the Board acknowledges that the Veteran experiences recurrent pain as a result of his left knee disability. However, the severity of his left knee disability is contemplated in the current disability rating. Moreover, even when considering pain and functional impairment, the Veteran's flexion of the left knee was only limited 130 degrees, and as such, his range of motion findings do not approach the criteria for a compensable rating under Diagnostic Code 5260 (i.e., 45 degrees of flexion). In addition to the ratings based on limitation of motion, a separate rating may be assigned for instability of the knee. The Board has considered whether the Veteran is entitled to a separate rating for recurrent subluxation or lateral instability under Diagnostic Code 5257; however, there is no objective evidence of subluxation or instability. The Board acknowledges that the Veteran reported that he wore a knee brace for support. However, the August 2012 VA examiner noted that there was no evidence or history of recurrent patellar subluxation/dislocation. Upon examination, the Veteran was noted to have normal anterior, posterior, and medial-lateral stability. Further, the Veteran's left knee alignment was normal and there was no tenderness to palpation, swelling, or instability on examination. Accordingly, a separate rating for instability or subluxation under Diagnostic Code 5257 is not warranted in this case. The Board has also considered whether the Veteran is entitled to an increased rating for bilateral knee ankylosis, dislocation of the semilunar cartilage, symptomatic removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. The Veteran is not entitled to an increased disability rating for removal of semilunar cartilage under Diagnostic Code 5259 or genu recurvatum under Diagnostic Code 5263. The Board notes that the maximum rating allowed under Diagnostic Code 5259 and 5263 is a 10 percent rating. Additionally, the Veteran is currently receiving a 20 percent rating under Diagnostic Code 5258, which is the maximum rating assignable under that diagnostic code. Therefore, the Veteran would not be subject to a higher disability rating under these diagnostic codes. Additionally, the evidence of record fails to demonstrate such symptomatology as knee ankylosis or impairment of the tibia or fibula. The August 2012 VA examiner noted that there was no evidence or history of "shin splints," stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. Additionally, VA examination reports and x-rays did not document any left knee ankylosis. Therefore, the Veteran is not entitled to an increased rating under Diagnostic Code 5256 or 5262. The Board acknowledges that, at the April 2010 and August 2012 VA examinations, the Veteran was noted to have surgical scars on the left knee. Specifically, the April 2010 VA examiner noted that the scars appeared smooth without inflammation or ulceration, were normally pigmented throughout, and had no gross asymmetry or disparity of features. Further, the scars were level with the surrounding skin, flexible, non-indurate, non-edematous, non-adherent, and non-tender. Additionally, the August 2010 VA examiner noted that the Veteran had three very faint, barely visible, arthroscopic linear scars of the left knee measuring 1.0 cm by 0.1 cm, 0.5 cm by 0.1 cm, and 1.5 cm by 0.1 cm. The examiner stated that the Veteran pointed to all of these as scars, but they were hard to distinguish from wrinkles in the skin. The Board recognizes that, under certain circumstances, assigning a separate rating for a scar would not violate the rule against pyramiding. Esteban, 6 Vet. App. 259. Nevertheless, as stated in the April 2010 and August 2012 VA examination report, the Veteran's scars have not been shown to be at least 144 square centimeters, at least 39 square centimeters and deep and nonlinear, or unstable. Therefore, the Board finds that the relevant diagnostic criteria do not provide for a separate compensable rating for a left knee surgical scar. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804. In accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009), a Veteran's claim for an increased disability evaluation may require a determination as to whether the Veteran is entitled to a total disability rating based on individual unemployability. In this case, at the August 2012 VA examination, the Veteran reported that he was still employed. Additionally, the examiner noted that the Veteran's employment activities, which involved heavy physical labor, would be limited as a result of his service-connected disability of the left knee. His knee condition had a significant impact on his present physically active job as a HVAC technician. However, he was able to do sedentary work activities with the ability to stretch or move about every two hours. He could write and type, and had no limitations of his ability to communicate. He was also able to drive. The examiner concluded that the knee condition would not preclude the Veteran's ability to secure and maintain gainful employment. Despite these limits, the fact remains that the Veteran is still employed. Accordingly, Rice considerations are inapplicable in this case. The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran'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 those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran'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 C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's service-connected left knee disability include pain, limiting walking/standing, and limitation of motion. However, these symptoms of the Veteran's left knee are not shown to cause any impairment that is not already contemplated by the rating criteria, and the Board finds that the rating criteria reasonably describe his disability. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010, 5256-5263. For this reason, referral for consideration of an extraschedular rating is not warranted for this claim. ORDER Entitlement to an initial disability rating in excess of 10 percent for left knee, status post repair, medial meniscus and degenerative joint disease prior to August 2, 2012, is denied. Entitlement to an increased disability rating in excess of 20 percent for left knee, status post repair, medial meniscus and degenerative joint disease since August 2, 2012, is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The Veteran contends that his current hypertension had its onset in-service, while serving on active duty for the Air Force Reserves. The available records confirm that the Veteran served in the Air Force Reserves from January 1982 to March 2009. There are two Active Duty Training/Active Duty Forms of record, which show active duty from July 24, 1992 to August 8, 1992, and January 28, 2002 to February 8, 2002. However, it does not appear that all of the Veteran's ACDUTRA and INACDUTRA dates for his entire Reserves period have been obtained. Therefore, in order to fully and fairly consider the Veteran's appeal, an attempt must be made to confirm all periods of active duty, ACDUTRA, and INACDUTRA. The Veteran reports that he was first identified as having high blood pressure by a military dentist during a period of active duty for training in 1997. He also reported that while on active duty for training at Sembach Air Base, Germany, in 2003 and 2005, treatment providers there also noted that he had high blood pressure. The August 2012 examiner concluded that it was at least as likely as not that the evidence of record first supported a diagnosis of hypertension sometime between May 6, 2000 when blood pressure was still normal, and February or July 14, 2001, when he was noted to be on Accupril for hypertension. As noted above, the Veteran's period of active duty, ACDUTRA, and INACDUTRA are still unclear to the Board. Without further clarification, the Board is without medical expertise to determine whether the Veteran's hypertension is related to his active military service, to include periods of ACDUTRA. Godfrey v. Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Additionally, if the Veteran's hypertension had its onset outside of a period of active duty or ACDUTRA, the examiner must determine if his hypertension was aggravated during any subsequent periods of active duty/ACDUTRA. Therefore, an additional VA opinion should be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). On remand, the Veteran should be afforded another opportunity to submit any outstanding private treatment records pertaining to his hypertension. 38 C.F.R. § 3.159(c) (2) (2013). Accordingly, the issue of entitlement to service connection for hypertension is REMANDED for the following actions: 1. Obtain any relevant outstanding VA treatment records. Any attempts to obtain these records and responses received thereafter should be associated with the Veteran's claims file. Then, contact the Veteran and request that he provide a completed release form (VA Form 21-4142) authorizing VA to request copies of any outstanding treatment records from any private medical providers who have treated him for his hypertension. After the Veteran has signed the appropriate releases, those records not already associated with the claims file, should be obtained and associated therewith. All attempts to procure any outstanding treatment records should be documented in the claims file. If the RO cannot obtain records identified by the Veteran, a notation to that effect should be included in the claims file and the Veteran and his representative should be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. Contact the Air Force Reserves, the National Personnel Records Center, and/or any other necessary agency, and confirm all of the Veteran's Air Force Reserves service dates, specifically noting the dates of all periods of active duty, ACDUTRA, and INACDUTRA from 1982 to 2009. If these records are not available, a negative reply must be provided. Additionally, if a negative reply is received, the Veteran must be notified and given the opportunity to submit those records. 3. Schedule the Veteran for an appropriate VA examination to assess the nature and etiology of his hypertension. The claims file and a copy of this remand should be made available to and reviewed by the examiner. All necessary tests should be completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. The Veteran's periods of active duty and ACDUTRA should be provided to the examiner. The examiner should state whether it is at least as likely as not that the Veteran's hypertension had its onset during active duty service, is related to the active duty service, or had its onset during a period of ACDUTRA as provided. If the Veteran's hypertension is found to NOT have had its onset while in-service or during a period of active duty for training, the examiner should provide an opinion as to whether the evidence of record demonstrates that the Veteran's pre-existing hypertension was permanently aggravated (increased in severity) during service or any period of active duty for training, and if so, whether such worsening constituted either the natural progression of the disorder, OR whether such worsening constituted chronic aggravation due to service. In offering these opinions, the examiner should specifically acknowledge and comment on the evidence of record, to include service treatment records - the May 2000 and February 2002 dental records, July 2001 Annual Med Certificate, and September 2001, December 2001, March 2002, March 2003, January 2004, and March 2005 Reserve Component Health Risk assessments; private and VA treatment records; the October 2006 and August 2012 VA examination reports; lay statements; and any other relevant information. The term aggravation refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. 4. After undertaking the development above, readjudicate the Veteran's claim. If any benefit sought on appeal remains denied, provide a Supplemental Statement of the Case to the Veteran and his representative, and an appropriate period of time in which to respond. Then, return the appeal to the Board. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. All claims 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. ______________________________________________ J. MACIEROWSKI KIRBY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs