Citation Nr: 1541611 Decision Date: 09/25/15 Archive Date: 10/02/15 DOCKET NO. 11-32 876 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to an increased rating for patellofemoral syndrome of the left knee, evaluated as noncompensably disabling for the period prior to February 11, 2015, and 10 percent disabling on and after February 11, 2015. 3. Entitlement to a 10 percent rating for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 (2014) for the period prior to February 11, 2015. 4. Entitlement to a 10 percent rating for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 (2014) for the period on and after February 11, 2015. REPRESENTATION Appellant represented by: Jan Dils, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION This appeal was processed using the Veteran's Benefits Management System (VBMS). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. In addition to the VBMS file, there is a Virtual VA paperless claims file associated with the claim. The Veteran served on active duty from March 1984 to May 1995. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina, which continued the noncompensable disability rating assigned for patellofemoral syndrome of the left knee, denied entitlement to service connection for hypertension, and denied a 10 percent rating for multiple noncompensable service-connected disabilities under 38 C.F.R. § 3.324. In an April 2015 rating decision, the RO increased the disability rating for the service-connected left knee disability to 10 percent, effective February 11, 2015. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (where evidence indicates that the degree of disability increased or decreased during appeal period following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found). The Veteran has not expressed satisfaction with the ratings assigned for this disorder. Accordingly, this issue will remain in appellate status for the entire appeal period. AB v. Brown, 6 Vet. App. 35 (in which the United States Court of Appeals for Veterans Claims (Court) stipulated that, unless a veteran expresses a desire for a specific rating for a service-connected disability, he/she is presumed to be seeking the maximum benefit permitted under the regulations). At the beginning of the appeal, the Veteran was represented by the North Carolina Division of Veterans' Affairs. In a February 2013 VA Form 21-22a, the Veteran appointed Jan Dills, Attorney at Law, as his representative, thereby revoking the earlier power of attorney. See 38 C.F.R. § 14.631(f)(1). The Veteran presented testimony before the undersigned Veterans Law Judge in March 2013 via videoconference. A copy of the transcript has been associated with the record of evidence. This matter was previously before the Board in May 2014 at which time it was remanded for additional development. It is now returned to the Board. As will be discussed further herein, as to the issue being decided herein, the Board finds that the agency of original jurisdiction substantially complied with the remand orders, and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The issue of entitlement to a 10 percent rating for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 (2014) for the period prior to February 11, 2015 is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. On May 26, 2015, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran's authorized representative that he wished to withdraw from appellate review his appeal of his claims seeking service connection for hypertension. 2. For the period prior to February 11, 2015, the Veteran's patellofemoral syndrome of the left knee has been manifested by normal extension and limitation of flexion to no worse than 135 degrees, even taking into account his complaints of pain; nor has he been shown to have any ankylosis; slight recurrent subluxation or lateral instability; removal of semilunar cartilage or dislocated semilunar cartilage with episodes of "locking," pain and effusion into the joint; and/or impairment of the tibia and fibula with slight left knee or ankle disability. 3. From February 11, 2015, the Veteran's patellofemoral syndrome of the left knee has been manifested by normal extension, limitation of flexion no worse than 115 degrees, even taking into account his complaints of pain; nor has he been shown to have any ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage with episodes of "locking," pain and effusion into the joint; and/or impairment of the tibia and fibula with moderate left knee or ankle disability. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal of the claim for entitlement to service connection for hypertension have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2014). 2. The criteria for a compensable rating for patellofemoral syndrome, left knee, for the period prior to February 11, 2015 have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7 , 4.59, 4.71a, Diagnostic Codes 5256 to 5262 (2014). 3. The criteria for a schedular rating in excess of 10 percent for patellofemoral syndrome, left knee, on and after February 11, 2015 have not been met. 38 U.S.C.A. §§ 1155 , 5107 (West 2015); 38 C.F.R. §§ 4.7 , 4.59, 4.71a, Diagnostic Codes 5256 to 5262 (2014). 4. For the period on and after February 11, 2015, there is no legal entitlement to a 10 percent disability evaluation for multiple noncompensable service-connected disabilities under 38 C.F.R. § 3.324 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it 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 that claimant is expected to provide. Further, in Dingess v. Nicholson, 19 Vet. Ap. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for benefits, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish the benefit sought and must inform him that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. In the January 2010 letter, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b)(1) (2014). In addition, the RO advised the Veteran of the additional notification requirements imposed by the Court in Dingess/Hartmen v. Nicholson, 19 Vet. App. 473 (2006). In particular, the January 2010 correspondence informed the Veteran of the need for evidence of a worsening of his service-connected disorder. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. See also Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action with respect to the issues decided herein. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2014). His service treatment records as well as all identified and available private and VA treatment records pertinent to the years after service and the issues at hand are in the claims file and were reviewed by both the RO and the Board in connection with the claims adjudicated herein. Pursuant to the May 2014 Board remand, the AOJ attempted to obtain medical records issued by the Veteran's private physician, Dr. Taylor, dated soon after the Veteran's discharge from service. In a July 2014 letter, the AOJ asked the Veteran to complete the VA Form 21-4142 Authorization and Consent to Release Information forms for this physician. It does not appear that the Veteran completed the necessary forms. If there is additional available evidence to help substantiate the Veteran's claim, the RO cannot obtain these records without further assistance from the Veteran. VA is only required to seek pertinent records that are adequately identified and for which necessary releases are furnished. 38 U.S.C.A. § 5103A(b); See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street"); 38 C.F.R. §§ 3.159(c)(1)(i), (c)(2)(i) (requiring a claimant to cooperate fully with VA's efforts to obtain federal and non-federal records). As the Veteran did not submit an additional VA Form 21-4142 for treatment received with Dr. Taylor, and did not otherwise respond to the July 2014 letter, any further efforts to obtain treatment records from this physician would be futile. 38 C.F.R. § 3.159(c)(2). The Veteran has also been afforded VA medical examinations for his left knee disorder on several occasions, most recently in February 2015. There is no objective evidence indicating that there has been a material change in the severity of his service-connected left knee disorder since the Veteran was last examined. See 38 C.F.R. § 3.327(a) (2014). The duty to assist does not require that a claim be remanded solely because of the passage of time since otherwise adequate VA examinations were conducted. See VAOPGCPREC 11-95. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the Board finds that the VA examinations obtained in this case are adequate, as they were predicated on examinations of the Veteran, as well as consideration of the medical records in the Veteran's claims file and the Veteran's reported history. The opinions consider all of the pertinent evidence of record, to include statements given by the Veteran at the time of the VA examinations, and provide a complete rationale for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claims decided herein has been met. 38 C.F.R. § 3.159(c)(4). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Withdrawal of Claim for Service Connection for Hypertension A veteran may withdraw his or her appeal in writing at any time before the Board promulgates a final decision. 38 C.F.R. § 20.204 (2014). When a veteran does so, the withdrawal effectively creates a situation in which an allegation of error of fact or law no longer exists. In such an instance, the Board does not have jurisdiction to review the appeal, and a dismissal is then appropriate. 38 U.S.C.A. § 7105(d) (West 2014); 38 C.F.R. §§ 20.101, 20.202 (2014). As previously noted above, in the August 2010 rating decision, the RO denied the Veteran's claim of entitlement to service connection for hypertension. In the November 2011 VA Form 9, the Veteran perfected a timely appeal of this issue. Following the May 2014 Board remand and additional development conducted pursuant to the remand instructions, in a May 2015 statement, the Veteran's authorized representative indicated that the Veteran wished to withdraw from appellate review his appeal seeking entitlement to service connection for hypertension. In view of the Veteran's expressed desire, the Board concludes that further action with regard to his claim of entitlement to service connection for hypertension is not appropriate. 38 U.S.C.A. § 7105(d) (West 2014); 38 C.F.R. § 20.204 (2014). The Board does not have jurisdiction over this withdrawn issue and, as such, must dismiss the appeal of this claim. See 38 U.S.C.A. § 7105(d) (West 2014); 38 C.F.R. §§ 20.101, 20.202, 20.204 (2014). Multiple Noncompensable Service-Connected Disabilities Whenever a Veteran is suffering from two or more separate permanent service- connected disabilities of such character as to clearly interfere with normal employability, even though none of the disabilities may be of compensable degree under the Rating Schedule, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324 . The provisions of 38 C.F.R. § 3.324 are predicated on the existence solely of non-compensable service-connected disabilities. As such, once a compensable evaluation for any service-connected disability has been awarded, the applicability of 38 C.F.R. § 3.324 is rendered moot. See Butts v. Brown, 5 Vet. App. 532, 541 (1993). In this regard, the April 2015 rating decision increased the disability rating for the Veteran's service-connected patellofemoral syndrome, left knee, to 10 percent, effective February 11, 2015. Therefore, the Veteran's claim for compensation under 38 C.F.R. § 3.324 is rendered moot for the period on and after February 11, 2015. Accordingly, the claim must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive the Board should deny the claim on the ground of the lack of legal merit or the lack of entitlement under the law). Increased Rating Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings will be applied, the higher rating will be assigned if the disability picture more closely approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2. As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use). See 38 C.F.R. §§ 4.40, 4.45 (2014); DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In VA Fast Letter 06-25 (November 29, 2006), VA's Compensation and Pension Service noted that to properly evaluate any functional loss due to pain, examiners, at the very least, should undertake repetitive testing (to include at least three repetitions) of the joint's range of motion, if feasible. It was determined that such testing should yield sufficient information on any functional loss due to an orthopedic disability. VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA General Counsel has stated that compensating a claimant for separate functional impairment under DC 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 (July 1, 1997). VA General Counsel held in VAOPGCPREC 23-97 that a veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under DC 5257, the Veteran must also have limitation of motion under DC 5260 or 5261 in order to obtain a separate rating for arthritis. If the Veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also held that, if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under DC 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent x-ray findings of arthritis, limitation of motion should be considered under DCs 5260 and 5261. Painful motion may add to the actual limitation of motion so as to warrant a rating under DCs 5260 or 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under DCs 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under DC 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. In addition, the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). Also, VA General Counsel has held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and under Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September, 2004). DC 5010 states that traumatic arthritis is to be rated as degenerative arthritis under DC 5003, which in turn, states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected, which in this case would be DCs 5260 (limitation of flexion of the leg) and 5261 (limitation of extension of the leg). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71(a), DC 5003. The Veteran was originally granted service connection for his left knee disability in the November 1995 rating decision. A noncompensable evaluation was assigned for the left knee injury with history of retropatellar pain syndrome pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257, effective as of May 26, 1995. In January 2010, VA received a claim from the Veteran seeking a higher disability evaluation. In the August 2010 rating decision, the RO recharacterized the issue to patellofemoral syndrome of the left knee, continued the noncompensable disability rating assigned for the left knee, and determined that the Veteran should be evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5260. When an unlisted disease, injury, or residual is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows. The first two digits will be selected from that part of the schedule most closely identifying the part or system of the body involved. The last two digits will be "99" for all unlisted conditions. 38 C.F.R. §§ 4.20 , 4.27 (2014). Here, the Veteran's disability is not specifically listed in the rating schedule and is therefore rated analogous to a disability in which not only the functions are affected, but the anatomical location and symptoms are closely related. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 60 degrees warrants a noncompensable evaluation; flexion limited to 45 degrees warrants a 10 percent evaluation; flexion limited to 30 degrees warrants a 20 percent evaluation; and flexion limited to 15 degrees warrants a 30 percent evaluation. 38 C.F.R. § 4.71a , Diagnostic Code 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 5 degrees warrants a noncompensable evaluation; extension limited to 10 degrees warrants a 10 percent evaluation; extension limited to 15 degrees warrants a 20 percent evaluation; extension limited to 20 degrees warrants a 30 percent evaluation; extension limited to 30 degrees warrants a 40 percent evaluation; and extension limited to 45 degrees warrants a 50 percent evaluation. 38 C.F.R. § 4.71a , Diagnostic Code 5261. Under DC 5262, impairment of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating. A 20 percent disability evaluation is warranted for moderate disability, and a 30 percent evaluation is warranted for marked disability. Under DC 5256, a 30 percent disability evaluation is assigned for ankylosis of the knee, favorable angle in full extension, or in slight flexion between 0 and 10 degrees. Under DC 5257, a 10 percent disability evaluation is assigned for slight recurrent subluxation or lateral instability. A 20 percent disability evaluation is contemplated when such impairment is moderate. A 30 percent disability evaluation is contemplated when such impairment is severe. Under DC 5258, a 20 percent disability evaluation is assigned for dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint. Normal range of motion for the knee is defined as follows: flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. A. For the period prior to February 11, 2015 The Veteran contends that he is entitled to a compensable rating for his patellofemoral syndrome of the left knee for the period prior to February 11, 2015. Private medical records issued at OrthoCarolina, and dated in December 2000, reflect the Veteran's complaints of giving way in the left knee when walking. The Veteran reported to feel a popping sensation in his knee while driving, and noted that the knee locked up on him making it difficult for him to place any weight on it. According to the Veteran, he had undergone several injections in the left knee with only minimal relief. On physical examination, the examiner observed no warmth, erythema or laxity in the left knee. The Veteran was diagnosed with having internal derangement of the left knee with possible underlying meniscal tear. He was thereafter scheduled for a magnetic resonance imaging (MRI) of the left knee, and the results produced showed a chronic anterior cruciate ligament tear, as well as a lateral meniscus tear. A March 2001 operative note reflects that the Veteran had pre-operative diagnoses of left knee chronic ACL tear and bucket handle of the meniscus tear, and subsequently underwent a left knee arthroscopy, partial medial meniscectomy and hamstring ACL reconstruction. Subsequent records reflect that his wounds were well-healed and x-rays revealed good alignment of his hardware. It was noted that the Veteran could return to work but should refrain from bending, kneeling, stooping, squatting, twisting, and standing for longer than 4 to 6 hours a day. A July 2001 post-operative note reflects that the Veteran was doing "extremely well" four months after his surgery. The Veteran denied any pain and the physician gave him permission to return to his previous activities. During a January 2010 VA pain assessment visit, the Veteran reported to experience pain, cramping and an aching sensation in the left knee, which on a scale of one to ten (with one being the least level of pain and ten being the highest) he rated at a seven. During the history and physical portion of the evaluation, the Veteran reported a history of left knee pain of two to three years duration that was worse in the morning, and added that crawling and kneeling, which are sometimes required for his work, serve to worsen the pain. The Veteran further indicated that he underwent a left knee arthroscopy and a partial medial meniscectomy and hamstring anterior cruciate ligament (ACL) reconstruction procedure in March 2001. On physical examination, the Veteran's left knee was tender to palpation in the lateral aspect with no signs of crepitus. The Veteran displayed good stability, and his motor strength was shown to be 5/5 and symmetrical in all major muscle groups in the lower extremities. The VA physician noted that the Veteran's gait and posture were normal for his age. It was further noted that the Veteran's level of function and range of motion in the lower extremities appeared normal for his age and general condition in the lower extremities. Based on her evaluation of the Veteran, the VA physician assessed the Veteran with chronic left knee pain, and prescribed him with non-steroidal anti-inflammatory drugs (NSAIDs). A March 2010 VA consultation report reflects that the Veteran was referred to a Rehabilitation Physician for evaluation of his left knee and to determine whether he should undergo a possible steroid injection to help alleviate his symptoms. Although the VA physician described the Veteran as overweight, he noted that the Veteran was doing fine and actively working. The left knee was clear any signs of effusion or patellar floating and the leg and feet muscles were described as fine. The Veteran was assessed with having arthralgia to his left knee status-post repair surgery to his anterior cruciate ligament. It was recommended that he follow up with his primary care physician and potentially undergo steroid injections. A subsequent informed consent form dated on the same day reflects that the Veteran consented to undergoing an aspiration and/or injection of his knee joint. During a May 2010 VA primary care visit, the Veteran reported having lost 26 lbs since his last visit. He also reported improvement in his knee pain since undergoing local injections. The treatment provider assessed him with chronic left knee pain that had improved with local injections and also likely from significant weight loss. The Veteran was afforded a VA examination for his left knee disorder in July 2010, during which time he reported anterior knee pain just below the patella and occasional pain over the last aspect. The Veteran described a sensation of instability without frank giving way, and noted that the pain did not radiate throughout his lower extremities. The Veteran denied any locking, fatigability, decrease in endurance, swelling, stiffness or weakness. He noted that he had undergone one steroid injection which provided some improvement, and he was currently taking 400 milligrams (mg) of etodolac twice a day, which the examiner described as efficacious without adverse reaction to either. The Veteran further noted to utilize an off the shelf brace on occasion which is efficacious. According to the Veteran, he experiences flare-ups in the form of increasing pain and stiffness during the cold weather months that subsides when the weather warms up. The examiner observed no additional limitations as a result of the Veteran's left knee disability. According to the VA examiner, the Veteran exhibited no signs of dislocation or subluxation and no inflammatory arthropathy. The Veteran reported to work in the heating, ventilation and air conditioning (HVAC) industry, and described discomfort in his knee when crawling under the house. The Veteran reported to be independent with activities of daily living and denied any periods of incapacitation under the orders of his health care provider as a result of his left knee disability. The examiner observed no evidence of pain, edema, effusion, instability, weakness, tenderness to palpation, heat, redness, abnormal movement or guarding. The Veteran's gait was normal, and he did not have any functional limitations when standing. He did report to have pain in the left knee when walking downhill. The examiner observed no abnormal callosity of the feet. On physical examination, the Veteran was shown to have flexion to 135 degrees with no objective evidence of pain and no additional limitation of motion upon repetitive motion. The Veteran also had extension to 0 degrees actively and passively without pain and his lateral collateral and medial collateral ligaments were intact with 30 degrees of flexion and to varus/valgus stress. According to the examiner the anterior cruciate and posterior cruciate ligaments were also intact with Lachman's maneuver and McMurray's maneuver. The January 2010 x-ray findings were significant only for evidence of ACL reconstruction, and otherwise normal. Subsequent VA treatment records dated from 2011 to 2015 confirm the Veteran's history of left knee surgery in 2001. Although the Veteran reported symptoms of chronic left knee pain during the March 2011 visit, the remaining VA treatment records are absent any complaints of, or treatment for the left knee. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that a compensable evaluation for the service-connected left knee disorder for the period prior to February 11, 2015, is not warranted. In this regard, under Diagnostic Code 5260, the Veteran has not been shown to have limitation of flexion to 45 degrees to warrant a compensable disability rating for this period. Additionally, the Veteran is not entitled to a separate compensable rating under Diagnostic Code 5261, which governs limitation of extension in the leg. The Board notes that the Veteran has not been shown to have limitation of extension to 10 degrees. Report of the July 2010 VA examination showed the Veteran's range of motion in his left knee to be 0 to 135 degrees, with no limitation or reduction of range of motion upon repetition. Accordingly, a compensable rating is not warranted under Diagnostic Code 5260 or 5261. See 38 C.F.R. § 4.71a, Diagnostic codes 5260-5261. Moreover, there was no objective evidence of pain found during the July 2010 examination. As such, there was no painful limitation of motion shown and a compensable rating is not warranted under Diagnostic Codes 5003. In addition, the Board has considered whether the Veteran is entitled to a compensable evaluation under Diagnostic Code 5257. As previously noted, the Veteran displayed good stability in the knee, and his motor strength was shown to be 5/5 and symmetrical in all major muscle groups in the lower extremities during the January 2010 VA treatment visit. In addition, the Veteran's left knee was clear any signs of effusion or patellar floating and the leg muscles were absent any abnormalities at the March 2010 VA consultation. Although the Veteran reported a sensation of instability in the left knee, upon physical examination, the July 2010 VA examiner did not observe any sign of instability, and described the Veteran's lateral collateral, medial collateral, anterior cruciate and posterior cruciate ligaments as intact. The examiner detected no evidence of dislocation or subluxation in the left knee joint, and noted that the Veteran displayed normal strength to varus/valgus pressure, and the Lachman and McMurray tests both produced negative results. In addition, the examiner described the Veteran's gait as normal and noted no functional limitations in the left knee joint while he was standing. As such, a compensable rating for instability of the right knee cannot be granted. The Board has also considered a functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, a compensable evaluation for the Veteran's service-connected left knee disorder is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are contemplated by the noncompensable disability rating already assigned. In this regard, the Board observes that the Veteran has complained of pain, cramping and aching in his knee. However, he reported no difficulty conducting his activities of daily living independently, and the July 2010 VA examiner observed no evidence of pain, effusion, instability, weakness, tenderness to palpation, heat, redness, abnormal movement or guarding in the left knee. In addition, the July 2010 VA examiner noted that there was no objective evidence of limited or reduced range of motion following repetitive motion. Furthermore, the examiner observed no gait or functional limitations upon standing or walking as a result of the left knee condition. Thus, the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. The Board finds that the effect of this symptomatology is contemplated in the currently assigned noncompensable disability evaluation. Additionally, the Board has also considered whether an increased evaluation would be in order under other relevant diagnostic codes for the knee. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). In this regard, Diagnostic Code 5256 is not for application as ankylosis was not shown. Diagnostic Code 5262 is not for application as impairment of the tibia and fibula was not shown and Diagnostic Code 5263 is not for application as recurvatum was not shown. The Board has also carefully considered whether a compensable rating is warranted pursuant to Diagnostic Code 5259, which provides a 10 percent rating for symptomatic removal of semilunar cartilage. The Veteran did undergo a partial medial meniscectomy in March 2001, and he did experience left knee symptoms during the period prior to February 11, 2015. However, given that it was a partial meniscectomy, a rating is not warranted under Diagnostic Code 5259 which would require removal of the meniscus. Diagnostic Code 5258 assigns a 20 percent rating for a symptomatic meniscus, but this rating requires pain (which the Veteran has), as well as frequent episodes of locking and effusion which are not present here, as noted by the July 2010 VA examiner. Thus, as the criteria for a compensable evaluation for the Veteran's service-connected left knee disorder for the period prior to February 11, 2015 have not been met, this portion of the Veteran's appeal is denied. In essence, the preponderance of the evidence is against a compensable disability evaluation for the Veteran's left knee disorder for the period prior to February 11, 2015. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. As such, entitlement to a compensable evaluation for service-connected patellofemoral syndrome of the left knee for the period prior to February 11, 2015 must be denied. B. On and after February 11, 2015 Following a review of the relevant evidence, the Board finds that the record does not contain evidence showing that the Veteran is entitled to an evaluation in excess of 10 percent as of February 11, 2015. The Veteran was afforded a more recent VA examination in connection to his left knee disorder in February 2015, at which time he provided his military history and reported a sensation of instability and antero-lateral pain. The Veteran denied experiencing any functional loss or impairment of the left knee and noted that flare-ups do not impact the function of the left knee. On physical examination, the Veteran was shown to have flexion to 115 degrees with pain, and extension to 0 degrees. The examiner noted that the pain during flexion does not result in/cause functional loss. The examiner also observed no objective evidence of pain with weight bearing but did note mild tenderness to palpation in the lateral joint line. According to the examiner, the Veteran was capable of performing repetitive motion and there was no additional functional loss or limitation of motion following repetitive motion. With regard to repeated use over time, the Veteran was examined immediately following repetitive use testing, and the examiner noted no limitation in the Veteran's functional ability with repeated use over a period of time due to pain, weakness, fatigability or incoordination. The Veteran did not exhibit or report any flare-up during the evaluation. When asked whether pain, weakness, fatigability or incoordination significantly limit his functional ability with flare-ups, the examiner marked that it did not. In addition, muscle strength test findings revealed the Veteran's strength to be 5/5 in the left knee during flexion and extension with no reduction in muscle strength. During the joint stability test portion, the Veteran denied a history of recurrent subluxation, lateral instability, or recurrent effusion in the left knee. The examiner found no sign of joint instability in the left knee and noted that the Veteran displayed normal strength to valgus/varus pressure and that the Lachman and Posterior drawer tests produced normal results. The examiner observed that the Veteran had a meniscal tear in the left knee, and had undergone a meniscectomy of the left knee in March 2001 which left a residual scar on the anterior knee that was 1 centimeter (cm) long and 1 cm wide. The examiner noted that the Veteran did not use any assistive devices as a normal mode of location. It was further noted that prior diagnostic test findings were absent findings of degenerative or traumatic arthritis but did reveal signs of the ALC reconstruction. According to the examiner, there was no evidence of crepitus in the left knee. When asked whether the Veteran's left knee disability impacts his ability to perform his occupational duties, the examiner marked that it did not. As noted above, in the April 2015 rating decision, the RO increased the disability rating for the left knee disability to 10 percent, effective February 11, 2015. However, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent for the service-connected patellofemoral syndrome of the left knee for the period on and after February 11, 2015. Indeed, the 10 percent rating was assigned in light of the February 2015 VA examination report which reflected objective evidence of pain on movement during flexion. As detailed, his limitation of motion in the left knee is noncompensable, but the 10 percent ratings is for application in light of findings of painful movement. In this regard, the Board notes the Veteran has not been shown to have limitation of flexion to 30 degrees in the left knee to warrant a disability rating in excess of 10 percent. As noted above, the Veteran was shown to have limitation of flexion to no worse than 115 degrees with no additional limitation of motion following repetitive movement. As such, for the period from February 11, 2015, a rating in excess of 10 percent for limitation of flexion of the left knee cannot be granted. Additionally, the Veteran is not entitled to a separate compensable rating under DC 5261, which governs limitation of extension in the leg. Indeed, the Veteran's limitation of extension in the left leg was no worse than 0 degrees at the February 2015 VA examination. Accordingly, a separate compensable rating is not warranted under DC 5261 for the period on and after February 11, 2015. See 38 C.F.R. § 4.71a, DC 5260. Also, from February 11, 2015, instability or subluxation was not shown in the left knee. The February 2015 VA examiner noted there to be no evidence or history of recurrent subluxation, lateral instability or recurrent effusion in the left knee. In addition, the Lachman and Posterior drawer tests were both shown to be normal, and the Veteran displayed normal strength to valgus and varus pressure. Moreover, results from muscle strength tests were shown to be normal during left knee flexion and extension, and there were no objective findings during this time frame indicative of instability or subluxation in the left knee. As such, a separate compensable rating under Diagnostic Code 5257 is not warranted. The Board has also considered whether the Veteran would be entitled to a higher evaluation for his left knee disorder under Diagnostic Codes 5010 and 5003. The Veteran's range of motion in his left knee has been shown to be no worse than extension to 0 degrees and flexion to 115 degrees. Therefore, the Veteran's limitation of flexion and extension are both noncompensable under Diagnostic Codes 5260 and 5261. As previously discussed, the January 2010 diagnostic test results was significant only for evidence of ACL reconstruction. Indeed, there are no X-ray findings of degenerative arthritis. Furthermore, the Veteran has never been noted to display any symptoms of crepitance, locking, swelling or effusion. He has only exhibited symptoms of painful motion and stiffness as a result of his disability, symptoms which are contemplated by the 10 percent evaluation already assigned. Therefore, assigning a separate rating under Diagnostic Codes 5010 and 5003 for the pain caused by arthritis would violate the rule against pyramiding. 38 C.F.R. § 4.414 (2014). In addition, the evidence of record is absent any findings of arthritis. The Board acknowledges that both VA examiners identified residuals scars on the Veteran's left knee as a result of his previous arthroscopic procedures. However, the Veteran has already been service-connected and separately evaluated for residual scars associated with patellofemoral syndrome of the left knee for the entire duration of the appeal. See August 2010 rating decision. Thus, a separate compensable rating for such residuals is not warranted. The Board has also considered a functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, an increased evaluation for the Veteran's service-connected left knee disorder is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran's symptoms are contemplated by the10 percent disability rating already assigned. In this regard, the Board observes that the Veteran has complained of ongoing pain and discomfort left knee. However, the February 2014 VA examiner noted that painful movement did not result in or or cause functional loss. The VA examiner further observed no additional functional loss or limitation of motion following repetitive motion. In addition, it was noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability following repetitive movement. Thus, the Veteran's complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. The Board finds that the effect of this symptomatology is contemplated in the currently assigned 10 percent disability evaluation. Additionally, the Board has also considered whether an increased evaluation would be in order under other relevant diagnostic codes for the knee. In this regard, Diagnostic Code 5256 is not for application as ankylosis was not shown. Furthermore, the Veteran may not be rated by analogy to this code as he has not suffered functional immobility of the knees. Likewise, Diagnostic Code 5259 does not provide for higher disability ratings, and is inapplicable. Diagnostic Code 5258 is not for application. As noted above, the 20 percent rating under Diagnostic Code 5258 requires pain (which the Veteran has), as well as frequent episodes of locking and effusion which are currently not present as noted by the February 2015 VA examiner. Additionally, there are no objective findings of impairment of the tibia and fibula, thus there is no basis for disability ratings under Diagnostic Code 5262. Finally, Diagnostic Code 5263 is not for application as recurvatum was not shown. In reaching this conclusion, the Board has also considered the testimony and assertions by the Veteran pertaining to his left knee. He is competent and credible to attest to the exhibited symptoms in his left knee. However, the objective evidence of record is more probative and persuasive than the descriptions of his symptoms. The objective findings do not support a higher rating based on the schedular criteria. The Veteran's symptoms do not more nearly approximate the criteria for the assignment of a higher rating in any regard. Therefore, to the extent that a disability evaluation in excess of 10 percent for the Veteran's service-connected left knee disability is warranted on and after February 11, 2015, the appeal is denied. Extraschedular Consideration Consideration has also been given to whether the schedular evaluations are inadequate, thus requiring that the AOJ refer a claim to the Under Secretary for Benefits or the Director, Compensation 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); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). 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. Id. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular 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 evaluations in this case are not inadequate. An evaluation in excess of the assigned ratings is provided for certain manifestations of the service-connected left knee disorder, but the evidence reflects that those manifestations are not present in this case. As noted above, the Veteran primarily complains that his left knee is manifested by pain on use, limited range of motion, stiffness and instability. His symptoms and the type of resulting functional impairment described by him are contemplated in the rating criteria. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Further, there are no additional symptoms that have not been attributed to a specific service-connected condition. The Board notes that under Johnson v. McDonald, 362 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual condition fails to capture all the service-connected disabilities experienced. However, in this case, there are no additional service-connected symptoms that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Lastly, the Court has held that a request for a total disability based on individual unemployability (TDIU), whether expressly raised by Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. It has not been shown or suggested that gainful employment is precluded due to the Veteran's left knee disability. Likewise, the February 2015 VA examiner determined that the Veteran's left knee disability did not impact his ability to work. The Board does not find that a claim for a TDIU has been reasonably raised by the record with regard to his increased rating claim for the left knee disability, and thus the Board finds it unnecessary to consider entitlement at this juncture. ORDER The appeal of entitlement to service connection for hypertension is dismissed. Entitlement to a compensable evaluation for patellofemoral syndrome of the left knee for the period prior to February 11, 2015 is denied. Entitlement to an evaluation in excess of 10 percent for patellofemoral syndrome of the left knee, on and after February 11, 2015, is denied. For the period on and after February 11, 2015, entitlement to a 10 percent disability rating for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 is denied. REMAND The Board notes that following the April 2015 rating decision which increased the disability rating for patellofemoral syndrome of the left knee to 10 percent effective February 11, 2015, the RO determined that the claim for entitlement to a 10 percent evaluation for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 was rendered moot. See April 2015 Supplemental Statement of the Case. Although this claim was rendered moot as of February 11, 2015, it is not rendered moot for the period prior to February 11, 2015. The VA has a duty to address all issues raised during the course of an appeal. Therefore, in order to protect the Veteran's right to due process, the claim for entitlement to a 10 percent evaluation for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 for the period prior to February 11, 2015, must be returned to the RO in order to afford them the initial opportunity to consider the claim for entitlement to a 10 percent evaluation for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324(2014) for the period prior to February 11, 2015. Martin v. Derwinski, 1 Vet. App. 411, 413 (1991); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: After reviewing all the records on the VBMS and Virtual VA claims files, readjudicate the claim for entitlement to a 10 percent evaluation for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 (2014). If the claim remains denied, furnish the Veteran and his attorney an appropriate SSOC that addresses this issue and afford them the requisite opportunity to respond. The claim should then be returned to the Board for further appellate action. 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 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 2014). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs