Citation Nr: 1341448 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 08-22 286 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Whether the reduction in the evaluation of the Veteran's unfavorable ankylosis of the right knee from 60 percent to 10 percent was proper. 2. Entitlement to an evaluation in excess of 10 percent for right knee degenerative arthritis between October 1, 2007 and July 28, 2011. 3. Entitlement to an evaluation in excess of 40 percent for right knee degenerative arthritis from July 28, 2011. 4. Entitlement to an evaluation in excess of 10 percent for complex regional pain syndrome associated with degenerative joint disease of the right knee, post-operative with scars. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from April 1989 to August 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2007 and September 2007 rating decisions of the Roanoke, Virginia, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran was scheduled for a hearing before a Veterans Law Judge in Washington D.C. in November 2013. She failed to report. As she has not requested another hearing or provided good cause as to why her hearing should be rescheduled, the Board will proceed with adjudication of her claim. The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case. It does not contain any evidence not already in the claims folder or considered by the RO. This appeal was previously before the Board in March 2011, at which time the complex procedural history of the appeal was outlined. In brief, the Board noted that the Veteran was service connected for two separate disabilities of the right knee. The first right knee disability had originally been diagnosed as right knee iliotibial band tendonitis, chondromalacia patella and lateral meniscus tear, post arthroscopic surgeries from June 2005 to November 2005. It was next diagnosed as unfavorable ankylosis of the right knee (or degenerative joint disease of the right knee, post operative with scar in a June 2013 rating decision) from November 2005 to July 2011. Since July 2011, the disability has been characterized as right knee degenerative arthritis. The evaluation for this first disability was reduced from 60 percent to 10 percent by the July 2007 rating decision. The Veteran submitted a notice of disagreement with the reduction, which initiated the current appeal. After the March 2011 remand, a June 2013 rating decision increased the evaluation for this disability from 10 percent to 40 percent, effective from July 2011. However, a veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). The appeal for an increased evaluation for this disability remains on appeal. However, for the sake of convenience it has been characterized as two separate issues based on the periods prior to the increased evaluation and after the increase. As explained in the March 2011 remand, the Veteran's claim for an increased evaluation for her right knee disability is interpreted to encompass both of her knee disabilities. The only other service connected knee disability at the time of the March 2011 remand was diagnosed as a complex regional pain syndrome associated with degenerative joint disease of the right knee, post-operative with scars. The Board recognized the Veteran's contention that not only was the reduction in evaluation from 60 percent to 10 percent improper, but her right knee disability had actually become worse. As she did not specify if she was referring to one or both of her disabilities as having become worse, the Board stated that the evaluation of both knee disabilities would be adjudicated. However, the issues of entitlement to an evaluation in excess of 10 percent for complex regional pain syndrome associated with degenerative joint disease of the right knee, post-operative with scars will require further development. This issue and the issue of entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's 60 percent evaluation for her right knee disability was in effect for less than five years; after notice of the proposed reduction she was provided 60 days in which to respond, and the effective date of the reduction was not until the last day of the month following 60 days from the notice of the actual reduction. 2. Although a December 2005 VA examination showed unfavorable ankylosis of the right knee at 50 degrees, a January 2007 VA fee basis examination shows that the right knee was no longer ankylosed. 3. The January 2007 VA fee basis examination shows that the Veteran had limitation of both flexion and extension, with flexion limited to 40 degrees and extension limited to 10 degrees by pain after repetitive use with no weakness, incoordination fatigability, instability, or subluxation. 4. A July 28, 2011 examination shows that there was limitation of extension to 30 degrees after repetitive use with full flexion, with no weakness, incoordination fatigability, instability, or subluxation. CONCLUSIONS OF LAW 1. The criteria for a reduction in the evaluation of the Veteran's unfavorable ankylosis of the right knee from 60 percent to 10 percent as of October 1, 2007 have been met. 38 C.F.R. §§ 3.105(e); 4.71a, Code 5003, 5010, 5256, 5259, 5260, 5261 (2013). 2. As of October 1, 2007, the criteria for a separate 20 percent evaluation for limitation of flexion of the right knee have been met; the criteria for an evaluation in excess of 20 percent have not been met. 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Code 5003, 5010, 5256, 5259, 5260, 5261 (2013). 3. The criteria for an evaluation in excess of 10 percent for limitation of extension of the right knee were not met between October 1, 2007 and July 28, 2011. 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Code 5003, 5010, 5256, 5259, 5260, 5261 (2013). 4. As of July 28, 2011, the criteria for an evaluation in excess of 40 percent for limitation of extension of the right leg have not been met. 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Code 5003, 5010, 5256, 5259, 5260, 5261 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA In a July 2011 letter, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013) and 38 C.F.R. § 3.159(b) (2013). The RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the he was expected to provide. The Veteran was informed of the process by which initial disability ratings and effective dates are assigned, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As the Veteran's appeal was in response to an action initiated by the RO, she was not provided with VCAA notification prior to this action. This does not result in any harm to her claim as it has been readjudicated since the receipt of the required notification. Mayfield v. Nicholson, 444 F.3d 1328 (2006). The Board concludes that the duty to notify has been met. The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2013). VA has done everything reasonably possible to assist the Veteran with respect to her claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2013). Relevant service treatment and other medical records have been associated with the claims file. The Veteran reported treatment from many private sources and the Board finds that information from each source has already been requested and a response has been received. He was provided a VA examination in July 2011, which is fully adequate in that it addressed the rating criteria necessary to evaluate her disability. The Veteran was scheduled for a hearing before a Veterans Law Judge in Washington D.C. in November 2013 but did not appear. The duty to assist has also been met. Evaluation of Ankylosis/Degenerative Arthritis of the Right Knee The Veteran contends that her right knee disability has never shown any improvement, and that the reduction in the evaluation for this disability from 60 percent to 10 percent was improper. In fact, she argues that her right knee disability has become worse. The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C.A. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances 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, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board acknowledges that a claimant may experience multiple degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). As previously noted, the Veteran's right knee disability has been evaluated under several different diagnoses. Service connection was originally established in a December 2005 rating decision. This decision assigned a 10 percent evaluation from June 2006, followed by a temporary total evaluation for convalescence from September 2006, and a return to the 10 percent evaluation on November 1, 2005. However, a February 2006 rating decision increased the evaluation to 60 percent, also effective from November 1, 2005. The evaluation was decreased to 10 percent effective from October 1, 2007 by the July 2007 rating decision on appeal. A 40 percent evaluation was assigned by a June 2013 rating decision, effective from July 28, 2011. The Veteran's right knee disability has been evaluated under several different rating codes, which must also be considered by the Board. The right knee disability has been evaluated under the rating code for traumatic arthritis. This rating code states that traumatic arthritis is to be evaluated as degenerative arthritis. 38 C.F.R. § 4.71a, Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Code 5003. The rating codes for limitation of motion of the knee state that limitation of extension to 45 degrees is evaluated as 50 percent disabling. Limitation of extension to 30 degrees receives a 40 percent evaluation. 20 degrees of extension is evaluated as 30 percent disabling. Limitation of extension to 15 degrees merits a 20 percent evaluation. Limitation of extension to 10 degrees is evaluated as 10 percent disabling. Limitation of extension to 5 degrees is evaluated as 0 percent disabling. 38 C.F.R. § 4.71a, Code 5261. Flexion that is limited to 15 degrees is evaluated as 30 percent disabling. Limitation of flexion to 30 degrees merits a 20 percent evaluation. Limitation of flexion to 45 degrees warrants a 10 percent evaluation. Limitation of flexion to 60 degrees is evaluated as zero percent disabling. 38 C.F.R. § 4.71a, Code 5260. The rating code for ankylosis of the knee states that extremely unfavorable ankylosis that is in flexion at an angle of 45 degrees or more is evaluated as 60 percent disabling. Ankylosis at an angle between 20 and 45 degrees is evaluated as 50 percent disabling. Ankylosis at an angle between 10 and 20 degrees is 40 percent disabling. Ankylosis at a favorable angle in full extension or in slight flexion between zero degrees and 10 degrees is 30 percent disabling. 38 C.F.R. § 4.71a, Code 5256. Semilunar cartilage that is dislocated with frequent episodes of locking, pain, and effusion is 20 percent disabling. 38 C.F.R. § 4.71a, Code 5258. Removal of the semilunar cartilage is 10 percent disabling when symptomatic. 38 C.F.R. § 4.71a, Code 5259. A final rating code for consideration is that for other impairment of the knee due to subluxation or lateral instability. Slight impairment is evaluated as 10 percent disabling; moderate impairment is 20 percent disabling, and severe impairment is 30 percent disabling. 38 C.F.R. § 4.71a, Code 5257. There are other factors which must be considered in addition to those contained in the applicable rating codes. In this regard, the Board recognizes that the disability of the musculoskeletal system is primarily the inability due to damage or an infection in parts of the system to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. Factors to be considered include pain on movement, weakened movement, excess fatigability, and incoordination. 38 C.F.R. §§ 4.40, 4.45. Functional impairment due to pain must be considered. 38 C.F.R. § 4.59. Reduction There are two aspects of the reduction in the evaluation of the Veteran's right knee disability that must be considered by the Board. First, the Board must determine whether or not the proper procedures were followed prior to the reduction. Then the Board will consider whether or not the reduction was supported by the evidence. Where the reduction in evaluation of a service-connected disability or employability status is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefore, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. If additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e). At this juncture, the Board notes that the provisions of 38 C.F.R. § 3.344 (2013), contain certain protections and procedures that are applicable when the rating for a disability is reduced. These protections apply to ratings that have been in effect at the same level for five years or more. As the 60 percent disability evaluation assigned to the Veteran's right knee disability was in effect for less than five years, the provisions of 38 C.F.R. § 3.344 are not for consideration. First, the Board finds that the proper procedures were followed prior to the reduction of the evaluation. The Veteran was notified of the proposed reduction by letter dated March 19, 2007. This notice informed her that she could submit argument and evidence as to why the current evaluation should be maintained. The final rating action that effectuated the reduction to 10 percent was in July 2007, which provided the Veteran with more than the required 60 days to respond. The Veteran was notified of the reduction in a July 11, 2007 letter. The 60 percent rating remained in effect until the last day of September, and the 10 percent rating was effective from October 1, 2007. This was the last day in which a 60-day period from the date of notice to the Veteran of the final rating action expired. The provisions of 38 C.F.R. § 3.105(e) were met, and this aspect of the reduction was proper. Next, regarding whether the reduction was supported by the medical evidence, the February 2006 rating decision that established entitlement to a 60 percent evaluation for the right knee disability did so based on the findings of a December 2005 VA fee basis examination. This examination noted that the Veteran had a history of a torn right lateral meniscus; iliotibial band syndrome; and chondromalacia patella. Her gait was abnormal in that she was limping. The general appearance of the knee was abnormal with swelling on the right side. The knee was bent at a 50 degree angle. There was locking, pain, joint effusion, crepitus, and the knee was fixed at 50 degrees of flexion. There was knee joint ankylosis in an unfavorable position at 50 degrees. Range of motion was not performed because the joint was ankylosed. The diagnosis was right knee iliotibial band tendonitis, chondromalacia patella, and lateral meniscus tear status post arthroscopic surgeries. Private medical records from 2006 indicate that the Veteran was followed for her right knee disability. February 2006 records state that she had reduced motion due to pain, and that she in essence had a failed knee. However, while September 2006 records show continued tenderness, the Veteran had a full range of motion. The July 2007 rating decision based the reduction on the report of a January 2007 VA examination. She had a history of five surgeries for the right knee. Her current symptoms included stiffness and pain. The pain was constant but did not radiate to the other anatomical regions. It was elicited with physical activity and relieved with rest or pain medication. On examination, the Veteran had a normal range of motion from zero degrees of extension to 140 degrees of flexion. Ankylosis was not present. There was further limitation due to pain after repetitive motion at 40 degrees of flexion and negative 10 degrees of extension, but with no fatigue, weakness, lack of endurance or incoordination. An examination of the ligaments was normal. The examiner stated that the diagnosis has progressed from unfavorable ankylosis of the right knee and status post arthroscopy to status post open surgical repair of the knee. The Board finds that the reduction of the Veteran's 60 percent evaluation is supported by the evidence. The 60 percent evaluation was entirely based on the December 2005 VA examination that showed the Veteran's right knee was in unfavorable ankylosis at 50 degrees. That merits a 60 percent rating. See 38 C.F.R. § 4.71a, Code 5256. However, the Veteran's knee was no longer ankylosed by January 2007, and it follows that a rating under the code for ankylosis was no longer appropriate. The Veteran did not meet the requirements for a 60 percent evaluation under any of the applicable rating criteria; in fact none of these criteria even provide for a 60 percent evaluation. Moreover, under the facts of this case, the improvement was maintained under the conditions of ordinary life. Kitchens v. Brown, 7 Vet. App. 320, 324 (1995). Indeed, no subsequent evidence demonstrated ankylosis. For the above reasons, the Board concludes that the reduction from 60 percent for the Veteran's right knee disability as of October 1, 2007 was proper. Evaluation of the Right Knee The Board will next determine the proper evaluation for the Veteran's right knee beginning from the October 1, 2007 date of reduction to the present. In addition to the evidence previously discussed, the Veteran underwent another VA fee basis examination on August 8, 2007. The right knee was tender, but with no edema, effusion, weakness, redness, heat, guarding or movement or subluxation. There was 85 degrees of flexion out of 140, and a normal zero degrees of extension. Although the Veteran experienced pain, fatigue, and lack of endurance with repetitive use, there was no additional limitation of motion due to these factors. The stability tests of the ligaments were normal. A May 2008 private magnetic resonance imaging study (MRI) of the right knee showed that both the meniscus and the ligaments were intact and without tear. The impression included patellar chondromalacia, grade 4, and prior anterior tibial transfer surgery. The most recent examination of the Veteran's right knee was conducted on July 28, 2011. On examination, there was pain of the right knee, but no dislocation, subluxation, or locking. She did have effusions and swelling, as well as flare-ups every two to three weeks. The Veteran could stand for 15 to 30 minutes and walk about a quarter of a mile. She occasionally used a cane. There was no instability, but she reported locking and patellar abnormality. Range of motion showed that flexion was from zero to 140 degrees, with no additional limitation due to pain after repetitive use. However, extension was limited by 25 degrees, with additional limitation to 30 degrees after repetitive use. There was no ankylosis. An X-ray study showed mild degenerative changes with no definite joint space narrowing. The Veteran worked part time as a nurse, and was only able to manage 20 to 24 hours a week due to the need to have a day off between shifts. She would have difficulty standing for more than 30 minutes or lifting more than 30 pounds due to her disability. The Board finds that for the period between October 1, 2007 and July 28, 2011, the evidence supports entitlement to a separate 20 percent evaluation for limitation of flexion of the right knee and 10 percent evaluation for limitation of extension of the right knee. This is based on the July 2007 VA examination that shows the Veteran was limited to 40 degrees of flexion and 10 degrees of extension by pain after repetitive use. This equates to a 20 percent rating under the rating code for limitation of flexion and a 10 percent rating under the rating code for limitation of extension. There were 85 degrees of flexion and zero degrees of extension in August 2007, so these findings do not support even higher evaluations for limitation of either flexion or extension, even considering additional limitation due to factors such as pain. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Codes 5260, 5261. A VA General Counsel Precedent Opinion, states that separate evaluations are to be assigned when there is loss of both extension and flexion of the knee. As the January 2007 examination showed the Veteran to have limitation of motion to at least a compensable degree for both extension and flexion, separate evaluations must be assigned, with 20 percent for limitation of flexion to 40 degrees after testing for repetitive use and 10 percent for limitation of extension to 10 degrees after repetitive use. VAOPGCPREC 9-04. A separate evaluation based on the removal of the Veteran's cartilage has been considered, but another precedent opinion notes that this rating code may involve limitation of motion, so that a separate evaluation under 38 C.F.R. § 4.71a, Code 5259 cannot be assigned. VAOPGCPREC 9-98. Entitlement to higher evaluations has been considered under other rating codes but is not supported by the evidence. Every examination shows that the knee did not have recurrent subluxation or lateral instability during this period, so that an evaluation under this code would not be appropriate. 38 C.F.R. § 4.71a, Code 5257. The Veteran no longer had ankylosis, so that an evaluation under the rating code for ankylosis is no longer appropriate. 38 C.F.R. § 4.71a, Code 5256. The ratings providing for removal of the cartilage have already been met or exceeded and the pain associated therewith has been contemplated by the ratings already in effect. Thus, while a separate 20 percent evaluation for limitation of flexion and 10 percent evaluation for limitation of extension are warranted, there is no basis for a higher evaluation under any other rating criteria. Finally, the evidence supports a 40 percent evaluation, but no more, for limitation of extension as of the date of the July 28, 2011 examination, such rating has already been awarded. This examination shows that there was limitation of extension to 30 degrees, which merits a 40 percent rating under the rating code for limitation of extension. The limitation of extension was not sufficient to warrant an evaluation of more than 40 percent. 38 C.F.R. § 4.71a, Code 5261. The evidence does not support entitlement to an evaluation in excess of 20 percent based on limitation of flexion. In fact, the Veteran had full flexion on the July 28, 2011 examination, with no additional loss of motion after repetitive use. The Board has considered entitlement to a higher evaluation based on other rating codes for the period beginning July 28, 2011, but this is not supported by the record. The Veteran did not have recurrent subluxation or lateral instability during this period, so that an evaluation under this code would not be appropriate. 38 C.F.R. § 4.71a, Code 5257. She did not have a return of her previous ankylosis. Finally, consideration has also been given regarding whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2011); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate. The scheduler criteria adequately describe the Veteran's symptoms for her right knee disability. These symptoms include limitation of motion of the knee and pain, all of which are provided for in the rating criteria. Moreover, even if the scheduler criteria were to prove inadequate, there is no record of marked interference with employment due to these service connected disabilities. She has not been hospitalized for her knee disability during the period under consideration. The Veteran is employed on a part time basis. She is able to perform all activities of daily living. Accordingly, referral for consideration of an extra-schedular rating is not warranted. ORDER The reduction in the evaluation of the Veteran's unfavorable ankylosis of the right knee from 60 percent to 10 percent was proper; the appeal is denied. Entitlement to an evaluation in excess of 10 percent for limitation of extension of the right knee between October 1, 2007 and July 28, 2011 is denied. Entitlement to a separate 20 percent evaluation for limitation of flexion of the right knee from October 1, 2007 is granted. Entitlement to an evaluation in excess of 40 percent for limitation of extension of the right knee from July 28, 2011 is denied. REMAND As noted in the March 2011 remand and in the introduction to this decision, the Veteran argues that her knee disability has become worse. As she was already service connected for two separate knee disabilities at that time and did not limit her claim to one or the other, the Board must consider an increased evaluation for both disabilities. The only other knee disability for which the Veteran was service connected as of March 2011 was a complex regional pain syndrome associated with degenerative joint disease of the right knee, post operative with scars. This disability is evaluated under the rating criteria for neuritis of the sciatic nerve. 38 C.F.R. § 4.124a, Code 8620. The Veteran was last afforded a VA examination of her knee in July 2011. Unfortunately, this examination did not include the information necessary to evaluate the Veteran's complex regional pain syndrome associated with degenerative joint disease of the right knee, as a neurological examination was not conducted. Therefore, the Board finds that the Veteran should be scheduled for a neurological examination. In regards to the TDIU, the outcome of the claim for an increased rating for the complex regional pain syndrome associated with degenerative joint disease of the right knee will affect the adjudication of the TDIU. Issues which are inextricably intertwined must be considered together. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Moreover, the RO has not had an opportunity to consider this claim in light of the separate evaluation assigned for limitation of flexion by this decision. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA neurological examination for her complex regional pain syndrome associated with degenerative joint disease of the right knee. The claims folder must be provided to the Veteran for use in the study of this case, and the examiner must state that it has been reviewed. The electronic record must also be reviewed. All indicated tests and studies should be conducted, and the criteria necessary for an evaluation for neuritis of the right sciatic nerve should be included in the examination report. 2. After the development requested above has been completed to the extent possible, review the record. The claim for TDIU should also be readjudicated. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the Veteran should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs