Citation Nr: 1341476 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 07-17 390 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to increased initial ratings for right knee instability rated 0 percent prior to July 3, 2008, 10 percent disabling as of July 3, 2008, and 20 percent as of December 10, 2012. 2. Entitlement to increased initial ratings for right knee limitation of motion rated 0 percent prior to December 10, 2007, and 10 percent as of December 10, 2007. 3. Entitlement to increased initial ratings for right knee scars rated 0 percent prior to July 3, 2008, 10 percent disabling as of July 3, 2008, and 0 percent as of December 10, 2012. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Cryan, Counsel INTRODUCTION The Veteran served on active duty from July 1994 to July 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in April 2010. The Board remanded the Veteran's claims for additional development in July 2010 and June 2012. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to increased initial ratings for right knee instability and limitation of motion are REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. Prior to July 3, 2008, the Veteran's service-connected right knee surgical scarring was manifested by one superficial, non-painful surgical scar 2. Since July 3, 2008, the Veteran's service-connected right knee surgical scarring was manifested by several painful, deep scars; none of the scars had a total area measuring greater than 6 square inches (39 square centimeters). 3. On September 17, 2013, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant's representative that a withdrawal of the appeal for the issue of entitlement to a TDIU was requested. CONCLUSIONS OF LAW 1. Prior to July 3, 2008, the criteria for a compensable rating for right knee scars were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7804 (2007). 2. As of July 3, 2008, the criteria for a rating of 10 percent, but not higher, for right knee scars have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2013); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7804 (2007). 3. The criteria for withdrawal of an appeal on the issue of entitlement to TDIU by the appellant have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in July 2005, March 2006, June 2008, July 2010, January 2011, July 2012, and October 2012. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the September 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claim. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Rating for Right Knee Scars Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Where entitlement to compensation has already been established and an increase in the assigned rating is at issue, it is the present level of disability that is of primary concern. Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7. Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14 (2013); Esteban v. Brown, 6 Vet. App. 259 (1995). The Veteran claims that his service-connected right knee scars warrant higher ratings. The service medical records show that the Veteran underwent an anterior cruciate ligament (ACL) reconstruction in 1997. He subsequently underwent a hardware removal procedure fro the right knee with post surgical infected wound in March 1998. At an August 2005 VA examination, the Veteran reported daily knee pain and subluxation with twisting motions. He indicated that he wore a brace occasionally most often in winter. He indicated he could walk one mile. He avoided sports, running, and ladders, and found it difficult to go downhill because of instability of the knee. Physical examination revealed that the Veteran ambulated without a limp and used no assistive devices. He had no trouble rising from a chair or changing positions on the examining table. He was able to do squats without difficulty. He had an 11 centimeter scar over the right anterior knee and a 4 centimeter by 1 centimeter scar over the proximal right posterior calf. The scars were flat, well-healed, nontender, and nonadhering. The right knee flexed to 140 degrees and extended to 0 degrees. The examiner diagnosed the Veteran with status post right knee arthrotomy with anterior cruciate ligament replacement and meniscal repair with residual scar and degenerative joint disease. Private medical records from Kaiser Permanente and H. Hunt, M.D., of Advanced Orthopedic and Sports Medicine indicate that the Veteran was treated for right knee meniscus tear and degeneration. However, none of the records include any objective findings with regard to the right knee scars. At a July 2008 VA examination, the Veteran complained of stiffness of the knee in the morning, daily pain, and flare-ups of increased pain with weather changes. The Veteran indicated that he did not usually wear a knee brace unless he walked a lot. The Veteran was noted to have a sales job and could function in his usual occupation. The examiner noted that the Veteran had to stop working as a computer lab technician due to his knee. The Veteran reported using a cane in bad weather. Physical examination revealed that the Veteran ambulated with a normal gait, with no brace or assistive devices. He was noted to have a well-healed scar on the right knee that measured 10 millimeters by 5 millimeters on the center of the knee and was flat, mildly tender, hyperpigmented, superficial, stable, and not adhered to underlying tissue. On the medial side of the knee there were three small post arthroscopic scars that were 3 millimeter each and were brownish colored, flat, well-healed, and nontender. At the back of the knee in the popliteal area, he had a 4 centimeter hardly visible scar that was the same color of the surrounding skin, linear, flat, well-healed, and nontender. Active range of motion was 0 degrees of extension without pain to 110 degrees of flexion with pain at the end range of motion following three repetitions. The Veteran was diagnosed with status post arthrotomy of the right knee with ACL replacement and meniscal repair twice with residuals of well-healed scars and patellofemoral arthritis. VA treatment reports show that the Veteran underwent right knee scope with removal of loose body and partial lateral meniscectomy in February 2009. In December 2009, the Veteran underwent an ACL debridement with reconstruction. No reference to the right knee scarring was included with the records. At an August 2009 VA examination, the Veteran reported continuous knee pain with locking of the knee on standing for prolonged periods. The Veteran also reported bucking of the knee and popping out of the knee which required him to push it back into place at times. Physical examination revealed that the Veteran ambulated with a slight limp favoring his right knee. He had a well-healed surgical scar in the anterior knee with a slight indentation and a scar in the posterior medical aspect of the knee and arthroscopic scars with no erythema. The scar on the anterior knee measured 11 centimeters by one-half centimeter; the distal scar had a mild indentation to the bone and was 5 centimeters. He had a 3 centimeter by 1 centimeter well-healed hypopigmented scar on the posterior calf; and a 3 centimeter by 1.5 centimeter scar in the medial calf which was pruritic. None of the scars were inflamed, indurated, ulcerated, or had keloid. There were hypopigmented with the exception of the anterior scar where there were some areas of hyperpigmentation particularly the arthroscopic scars. The appearance of those scars was smooth. Other than the depression on the anterior scar, the rest of the scars had no alteration of skin contour. There was no pain on palpation of the scar and the scars were superficial. There was pain on palpation of the medial joint line. Range of motion testing revealed extension to 5 degrees with pain at 5 degrees, and flexion to 135 degrees with some discomfort and pulling at 135 degrees. The examiner assessed the Veteran with right knee status post ACL reconstruction status post lateral meniscus tear and removal of loose bodies with residual chronic pain, limitation in range of motion, and radiographic evidence of possible intraarticular calcified loose bodies and residuals scars that affect less than one percent of the total body area and 0 percent of the exposed area. At an August 2010 VA examination, the Veteran reported pain, locking, stiffness, swelling, and instability. The Veteran reported that he stopped working in June 2010 as a car dealership finance manager because he was unable to walk out to see customers. Physical examination revealed tenderness of the right knee. All scars were somewhat tender and well-healed with no sign of infection or swelling. He had a linear 10 centimeter anterior right knee scar from previous ACL donor graft sites and two transverse scars 5 millimeters along the medical joint line anteriorly and 1 centimeter along the lateral joint line anteriorly, both somewhat dark. He also had a diagonal 3 centimeter anteromedial darker scar on the anterior proximal leg and a 2.5 centimeter barely visible white, nontender scar of normal skin color along the medical joint. Superomedially, just proximal and medial to the patella, there was a 2 millimeter barely visible scar and a 3 millimeter scar that was slightly visible just medial to the former scar from previous arthroscopic portal placement. He also had a 2 centimeter by 1 centimeter popliteal scar from previous hardware removal which was nontender and normal skin color. The scars were noted to be minimally disfiguring with no ulceration, depression, or elevation of any scars, and with normal texture, and tenderness. There was no erythema, hyperemia, or ecchymosis of the scars and no fluctuance with normal texture of the skin and no keloid formation or underlying tissue loss. The examiner indicted that the scars of the right knee were superficial and in his opinion did not result in any limitation of function and the examiner noted that he was unable to explain the severe sensitivity that the Veteran claimed in relation to the scars. With regard to the Veteran's ability to work, the examiner indicted that there was no reason the Veteran should not be able to function in his former job capacity as a finance manager for an automobile dealership. The examiner noted that Veteran should be in a job where he did not have to be on his feet for over an hour at a time, or more than three to four hours per day. At a December 2012 VA examination, the examiner indicated that the Veteran was able to perform all activities of daily living. Specifically, he could sit one hour or longer, stand two hours, walk slowly on a level surface for two miles, and climb two flights of stairs. He was unable to run. He was able to perform light physical or sedentary work. The Veteran was noted to work twenty hours in retail and attend college full time and had missed no school or work in the past twelve months. The examiner noted a past medical history of various surgical procedures on his right knee from service until 2011 including two surgeries in service and six surgeries since service. Physical examination of the Veteran's right knee revealed several scars of the right knee: a linear 12 centimeters by 0.5 centimeter anterior scar; a linear 6 centimeters by 0.7 centimeter anterior scar; an oval medial scar 3 centimeters by 2 centimeters; an oval posterior scar 5 centimeters by 1 centimeter; and 3 small oval 0.4 centimeter arthroscopic scars. The scars were all non-tender and deep. None of the scars were painful, unstable, or had a total area measuring greater than 39 square cm (6 square inches). They did not cause any limitation of motion of the right knee. Range of motion testing revealed flexion to 115 degrees with pain at 115 degrees and 0 degrees of extension and no objective painful motion. The examiner diagnosed the Veteran with right knee recurrent ACL tears, right lateral meniscus tears, and degenerative joint disease. Effective October 23, 2008, VA amended the Schedule for Rating Disabilities by revising that portion of the Schedule that addresses the Skin. Specifically, the amendments concern 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. However, the amendments apply to applications for benefits received by VA on or after October 23, 2008. As the veteran's claim was already pending as of that date, the new regulations do not apply. The Board recognizes that these regulations appear to provide for consideration of the new regulations upon request by the Veteran. However, in this case, no such request has been made. Furthermore, the Board notes that, even in the event such requests are made, the regulations specifically prohibit application of the amended regulations prior to October 23, 2008. Under the regulations in effect prior to October 23, 2008, Diagnostic Code 7801 provided the rating criteria for scars, other than head, face, or neck, that are deep or that cause limited motion. A 10 percent rating is assigned for scars encompassing an area or areas exceeding 6 square inches (39 square centimeters). A 20 percent rating is assigned for scars encompassing an area or areas exceeding 12 square inches (77 square centimeters). A 30 percent rating is assigned for scars encompassing an area or areas exceeding 72 square inches (465 square centimeters). A 40 percent rating is assigned for scars encompassing an area or areas exceeding 144 square inches (929 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2007). Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1) (2007). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2) (2007). Diagnostic Code 7802 provided the rating criteria for scars, other than head, face, or neck, that are superficial and that do not cause limited motion. A 10 percent rating is assigned for scars encompassing an area or areas of 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2007). Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. 38 C.F.R. § 4.118, Diagnostic Code 7802, Note (1) (2007). A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802, Note (2) (2007). Under Diagnostic Code 7803, a 10 percent rating is assigned for superficial, unstable scars. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2007). An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7803, Note (1) (2007). A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7803, Note (2) (2007). Under Diagnostic Code 7804, a 10 percent rating is assigned for superficial scars that are painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007). A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1) (2007). Under Diagnostic Code 7805, other scars are rated on limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2007). Prior to July 3, 2008 Prior to July 3, 2008, the Veteran's service-connected right knee scars were rated as part of the Veteran's service-connected right knee disability. However, because the scars are a separate manifestation of this disability, the Board will consider the scars as a separate and distinct disability and consider whether an increased rating is warranted under any relevant Diagnostic Codes during the pendency of this claim. The evidence for the relevant period consists of the August 2005 VA examination. The Veteran's scars were reported to be flat, well-healed, non-tender, and non-adhering. The Veteran had full range of motion of the right knee at that time. The only rating available under Diagnostic Code 7804 provides for a 10 percent rating for superficial scars that are painful on examination. 38 C.F.R. § 4.118. However, the VA examination revealed that the scars were described as nontender. Consequently, an increased rating is not warranted under Diagnostic Code 7804. As for other potentially applicable codes, the Veteran's scars are not of the head, face or neck (Diagnostic Code 7800). There was no limit in the range of motion or function caused by the scar noted by the VA examiner (Diagnostic Code 7805). They were not reported to be deep or of a size (144 square inches) that would warrant a compensable rating. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802 (2007). The scar was not described as unstable which would allow for a compensable rating under Diagnostic Code 7803. Consequently, the Board finds that the Veteran's service-connected right knee scar did not warrant a compensable rating prior to July 3, 2008. As of July 3, 2008 As of July 3, 2008, the Veteran's service-connected scars of the knee were rated as 10 percent disabling using the criteria found at Diagnostic Code 7804, superficial scars that are painful on examination. As of December 10, 2012, the rating was decreased to 0 percent. 38 C.F.R. § 4.118. The only rating available under Diagnostic Code 7804 is the presently assigned 10 percent, and a higher rating is therefore not warranted under that code. While the December 2012 VA examination did not note any tender or painful scars, the Board finds that the Veteran has credibly reported painful scars and those scars were found to be tender at the August 2010 examination. Therefore, the Board finds that the 10 percent rating for painful scars should be continued as of December 10, 2012. However, no higher rating is warranted under Diagnostic Code 7804. As for other potentially applicable codes, the Veteran's scars are not of the head, face or neck (Diagnostic Code 7800). Additionally, none of the examiners of record have indicted that the Veteran's right knee scars limit the range of motion of the Veteran's right knee (Diagnostic Code 7805). Although the all scars were reported to be deep at the time of the December 2012 VA examination, the examiner specifically indicated that none of the scars had a total area measuring greater than 39 square centimeters (6 square inches). Consequently, a compensable rating is not warranted under Diagnostic Code 7801. Additionally, while the scars have at times been described as superficial scars which do not limit the Veteran's right knee range of motion, none of the scars had a total area measuring greater than 39 square centimeters (6 square inches). Consequently, a compensable rating is not warranted under Diagnostic Code 7802. Finally, at no time have the Veteran's right knee scars been described as unstable to warrant any increased or separate rating under Diagnostic Code 7803. In the absence of manifestations required for a higher rating, the Board finds that, resolving reasonable doubt in favor of the Veteran, a rating of 10 percent, but not higher, is warranted as of July 3, 2008. However, the weight of the evidence is against the assignment of a higher schedular rating for right knee surgical scars at any time since July 3, 2008. Extraschedular Consideration The Board has considered whether referral for consideration of an extraschedular rating is warranted. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993); 38 C.F.R. § 3.321(b)(1) (2013). Factors for consideration in determining whether referral for an extraschedular rating is necessary include marked interference with employment or frequent periods of hospitalization that indicate that application of the regular schedular standards would be impracticable. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1) (2013). The Board finds that referral is not warranted in this case. The evidence of record does not show that the Veteran's service-connected scars markedly interfered with employment, beyond that contemplated in the assigned rating, or cause frequent periods of hospitalization. None of the examiners of record concluded that the Veteran's scars markedly interfered with his ability to maintain employment at any time during the relevant appeal period. Moreover, the service-connected scars did not required frequent periods of hospitalization. Consequently, the Board finds that the evidence does not show that the criteria for referral are met because marked interference with employment and frequent hospitalizations are not shown and the schedular rating criteria are not shown to be inadequate. The schedular rating criteria provide for higher ratings for more severe symptomatology, which is not shown. 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher or separate ratings for the service-connected scars at any time during the pendency of appeal than 0 percent prior to July 3, 2008, and 10 percent as of July 3, 2008, and the claim for any other increase is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU The Board may dismiss any appeal which fails to allege specific error of fact or law in the decision being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2013). Withdrawal may be made by the appellant or by the authorized representative. 38 C.F.R. § 20.204 (2013). In a September 2013 communication, the appellant's representative, at his request, has withdrawn the appeal for the issue of entitlement to a TDIU. There remain no allegations of errors of fact or law for appellate consideration with regard to that issue. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. ORDER Entitlement to an initial compensable ratings for right knee scarring rated prior to July 3, 2008, is denied. Entitlement to a 10 percent rating, but not higher, for right knee scarring rated as of July 3, 2008, is granted. The appeal of the issue of entitlement to a TDIU is dismissed. REMAND A review of the claims file reveals that a remand is necessary before a decision on the merits of the claim for an increased rating for right knee instability and limitation of motion. The Veteran was last provided a VA examination to assess his service-connected right knee disabilities in December 2012. At that time he was noted to have last undergone an ACL repair in July 2011. He was generally functioning well at that time. However, VA outpatient treatment reports show that the Veteran was seen in the emergency room for right knee pain and instability in April 2013. X-rays of the right knee revealed mild degenerative changes of the patellofemoral and medial compartment. He was seen again in May 2013 and reported giving way of the right knee and a feeling of instability. He was assessed with continued pain and instability after his third failed ACL reconstruction. In July 2013, the Veteran was noted to have failed his currently available procedures and would need a total knee arthroplasty (TKA) at some point although the examiner noted that procedure should be delayed for as long as possible. Steroid injections were recommended until that time. Where there is evidence that a service-connected disability has worsened since the last examination, a new examination may be required to evaluate the current degree of impairment, particularly if there is no additional medical evidence that addresses the level of impairment of the disability since the previous examination. Snuffer v. Gober, 10 Vet. App. 400 (1997). In this case, there is medical evidence that the Veteran's service-connected right knee disabilities have increased in severity since the time of the most recent examination in December 2012. Consequently, another VA examination is necessary in order to ascertain the current severity of the service-connected right knee disabilities. VA outpatient treatment reports dated through July 2013 have been associated with the claims file. Because there may be outstanding VA medical records that contain information pertinent to the Veteran's claims, an attempt to obtain such records should be made. 38 C.F.R. § 3.159(c)(2) (2013); Bell v. Derwinski, 2 Vet. App. 611 (1992). Any treatment records dated since July 2013 should be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Obtain any VA treatment records dated since July 2013 and associate them with the claims file. 2. After obtaining the above records, schedule the Veteran for a VA examination to determine the current severity of his service-connected right knee disability. The examiner must review the claims file and note that review in the report. The examiner should specifically address the following: a) All necessary tests and studies, including range of motion studies, should be conducted. b) Discuss any weakened movement, excess fatigability with use, incoordination, painful motion, or pain with use or on flare-up, and provide an opinion as to how those factors result in any additional limitation of function. The examiner should specifically address the Veteran's functional loss due to flare ups and offer an opinion as to whether there are additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. c) State whether there is recurrent lateral instability or subluxation and state the severity if found. d) State what impact, if any, the Veteran's right knee disability has on his activities of daily living, including his ability to obtain and maintain employment. 3. Then, readjudicate the issue on appeal. If action remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs