Citation Nr: 1610898 Decision Date: 03/17/16 Archive Date: 03/23/16 DOCKET NO. 09-29 874 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased disability rating in excess of 10 percent for a right knee strain. 2. Entitlement to service connection for sleep apnea, to include as due to service-connected cervical spine disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. Gordon, Associate Counsel INTRODUCTION The Veteran had active military service from September 1982 to August 1984, December 1990 to July 1991, and February 2003 to April 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which continued a noncompensable disability rating for the Veteran's service-connected right knee strain. The Veteran submitted a Notice of Disagreement (NOD) with this determination in June 2008, and timely perfected his appeal in August 2009. Subsequently, in an April 2010 rating decision, the RO increased the Veteran's disability for a right knee strain to 10 percent, effective September 27, 2006. In November 2013, the Board remanded this matter for further evidentiary development. The Board also notes that in an August 2015 rating decision, the RO granted the Veteran a separate evaluation for right knee subluxation and assigned a 20 percent disability rating effective December 15, 2014. As evidenced by the claims file, the Veteran has not expressed disagreement with either the assigned disability rating or effective date. Accordingly, that issue is not in appellate status and will be discussed no further herein. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) [pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA]. The Board informs the Veteran that should he desire to appeal either the assigned disability rating or effective date of the right knee subluxation disability, he must do so within one year from the date the August 2015 rating decision was mailed. 38 C.F.R. § 20.302 (2014). This appeal was processed using VBMS (the Veterans Benefits Management System) and the Virtual VA paperless processing system. Accordingly, any future consideration of this Veteran's case shall take into consideration the existence of these electronic records. The issue of entitlement to service connection for sleep apnea, to include as due to service-connected cervical spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's service-connected right knee strain is currently manifested by pain and minimal limitation of motion; the evidence does not show flexion limited to 45 degrees or less; extension limited to 10 degrees or more; locking; ankylosis; or impairment of the tibia and fibula associated with the Veteran's right knee. CONCLUSION OF LAW The criteria for an increased disability rating in excess of the currently assigned 10 percent for the service-connected right knee strain have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION I. VCAA 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. § 3.129(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice 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 the claimant is expected to provide. Further, in Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 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 service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. The claims for a higher disability rating are "downstream" issues in that they arose from an initial grant of service connection. In such cases, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regarding the duty to assist, the RO obtained the Veteran's service treatment records, post-service VA treatment records, VA examinations and medical opinions, and lay statements. The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims file. In addition, the RO's actions on remand complied with the November 2013 remand orders by affording the Veteran a June 2015 VA examination. That examination contained adequate findings to assess the current nature and severity of his right knee. Also, all current VA treatment records were associated with the claims file. Accordingly, the Board finds that there is substantial compliance with the Board's November 2013 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Analysis Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2014). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2014). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2014). A request for an increased rating must be viewed in light of the entire relevant medical history. See 38 C.F.R. § 4.1 (2014); see also Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). However, where entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "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." The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10 (2014). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40 (2014). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2014). The Veteran seeks entitlement to an increased rating for his service-connected right knee strain, which is currently evaluated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5261. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2014). The additional DC, shown after the hyphen, represents the basis for the rating, while the primary DC indicates the underlying source of the disability. The hyphenated diagnostic code in this case indicates that degenerative arthritis under Diagnostic Code 5003 is the service-connected disorder and limitation of leg extension under Diagnostic Code 5261 is a residual condition. These disabilities can be rated under various diagnostic codes located in 38 C.F.R. § 4.71a. 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, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Diagnostic Code 5257 contemplates recurrent subluxation or lateral instability of the knee. As discussed above, the Veteran was awarded a separate 10 percent rating for right knee subluxation under Diagnostic Code 5257 in the August 2015 rating decision effective December 15, 2014 and he has not disagreed with either the assigned disability rating or effective date. The Board additionally notes that there is no evidence of ankylosis, locking of the knee, disability caused by cartilage removal, or malunion or nonunion of the tibia and fibula. Thus, Diagnostic Codes 5256, 5258, 5259, and 5262 do not apply in this case. The medical evidence of record demonstrates that the Veteran's right knee disability is manifested by joint pain and limited range of motion. This symptomatology is congruent with the criteria set out in Diagnostic Codes 5260 [limitation of flexion] and 5261 [limitation of extension]. Accordingly, the Board finds that rating the Veteran under Diagnostic Codes 5260 and 5261 is appropriate in this case. Moreover, a veteran may receive separate ratings for limitations in both flexion and extension under Diagnostic Codes 5260 and 5261. See VAOPGCPREC 9-2004. Arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2014). The medical evidence of record indicates a diagnosis of right knee osteoarthritis. See December 2013 VA examination report. As such, because the evidence of record indicates arthritis of the Veteran's right knee, the Board finds that Diagnostic Code 5003 [arthritis], with further consideration of Diagnostic Codes 5260 and 5261 [limitation of leg motion], are for application. Under 38 C.F.R. § 4.71a, Diagnostic Codes 5003, arthritis of a major joint is to be rated under the criteria for limitation of motion of the affected joint. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2014). For the purpose of rating disabilities due to arthritis, the knee is considered a major joint. See 38 C.F.R. § 4.45 (2014). Where limitation of motion of the joint is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2014). Under Diagnostic Code 5260, limitation of flexion of the leg provides a noncompensable rating if flexion is limited to 60 degrees, a 10 percent rating where flexion is limited to 45 degrees, a 20 percent rating where flexion is limited to 30 degrees, and a maximum 30 percent rating if flexion is limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg provides a noncompensable rating if extension is limited to five degrees, a 10 percent rating if limited to 10 degrees, a 20 percent rating if limited to 15 degrees, a 30 percent rating if limited to 20 degrees, a 40 percent rating if limited to 30 degrees, and a 50 percent rating if limited to 45 degrees. Upon VA examination in August 2007, the Veteran reported that he had daily pain in his right knee. He believed that his right knee was "[slipping out]" and causing him to fall. He took Aleve as needed. He reported that his right knee flared up whenever it would slip out. He did not report additional treatment with flare-up in his right knee. He used ice on his right knee with flare-up as needed because his right knee swelled with flare-up. He also reported additional limitation in his right knee for four hours with flare-up and avoided any activity that would cause him to bend his right knee. He did not see a doctor for treatment of flare-up in his right knee. He had not had a recent injection into his knee either. The Veteran also did not wear a brace and was able to walk without assistive devices. He did not identify any restrictions on how far or long he could walk and believed he was able to walk two miles. If he stood for more than 30 minutes, both knees would hurt and he would have to sit down. He avoided any activity that would cause him to do "deep squats" because of pain in both knees. He also avoided high impact activities, such as sports and running, because of the pain in his knees. He also stated that he was very careful with his "dance moves" because of his knee pain. Physical examination revealed full extension in the right knee without pain. Flexion was 140 in the right knee without pain. The right knee was stable. There was no additional limitation with repetitive motion. X-rays were ordered, but were not done. A March 2008 MRI of the right knee without contrast showed axial T2 images of small joint effusion. Sagittal and coronal views revealed no evidence of meniscal tear. The anterior cruciate ligament was poorly delineated and appeared to be detached from its femoral attachment. The posterior cruciate ligament appeared to be intact. The quadriceps and patellar tendons appeared to be intact with no abnormal signal focus. Marrow signal appeared normal in the bony structure. Impression results were small joint effusion and possible old anterior cruciate tear. The Veteran was diagnosed with chronic right anterior cruciate ligament tear. The Veteran was afforded another VA examination in October 2009. The Veteran reported that he had intermittent once weekly pain which could last all day and was precipitated by certain positions or jogging. Walking was okay. He reported instability and slipping of the right knee, as well as, fatigability and lack of endurance. He denied the use of assistive aids. He further denied frank dislocation or recurrent subluxation. There was no history of inflammatory arthritis. His bilateral knee condition caused pain, decreased mobility, decreased stamina, endurance, inability to lift or carry, and decreased weakness of lower extremities in the work place. Such had a moderate impact on chores and shopping and exercise, a moderate to severe impact when playing sports, a mild impact on recreation and travel, and no impact on feeding, showering, dressing, toileting or grooming. The Veteran reported being able to stand for 15 minutes and being able to walk nearly two miles. Physical examination revealed that the Veteran was pleasant and appeared younger than his stated age. He had upright posture and a mildly antalgic gait favoring the right knee. He was in moderate distress of that knee. The right knee was nontender to examination and without deformity, effusion, or edema. The anterior drawer test was equivocal. There was grinding throughout right knee. Range of motion testing revealed flexion to 135 degrees and extension to 10 degrees both without pain. There was no loss of motion with repetitive testing of the right knee times three. There was "1+" bilateral upper and lower extremity deep tendon reflexes. There was 5/5 bilateral upper and lower extremity muscle strength other than 4/5 for the bilateral knee flexors and extensors due to joint rather than muscle conditions. There was "2+" bilateral upper and lower extremities soft touch and pain sensation. X-rays of the right knee revealed minimal patellofemoral and the medial compartment of the femorotibial degenerative changes. There was a small suprapatellar bursa pouch effusion. A June 2013 VA treatment record shows complaints of chronic right knee pain. Pursuant to the November 2013 Board remand, the Veteran was underwent VA examination of his right knee in December 2013. The VA examiner noted that the Veteran's claims file was reviewed. He was diagnosed with osteoarthritis and a meniscal tear of the right knee. The Veteran reported that flare-ups impacted the function of his knee as he had difficulty walking for extended periods. He also had occasional instability resulting in near falls. He had no flare-ups resulting in decreased range of motion. Range of motion testing revealed flexion to 120 degrees and normal extension to 0 degrees. There was objective evidence of pain on range of motion testing. The Veteran did not have additional limitation in range of motion testing of the knee and lower leg following repetitive-use testing. There was functional loss and/or functional impairment of the knee and lower leg due to pain on movement. There was tenderness or pain to palpation for joint line or soft tissues of the right knee. Muscle strength testing was normal. All joint stability testing was normal. There was no evidence of patellar subluxation/dislocation. The Veteran's history of meniscal tear was noted, which resulted in frequent episodes of joint "locking" and joint pain. He did not report the use of any assistive devices. The Veteran's right knee disability was noted to have caused difficulty when climbing and standing as frequently required by his job as a mechanic. In January 2014, an addendum opinion was provided by a VA orthopedic surgeon. He opined that the Veteran was experiencing mild right knee disability and that it was less likely as not that there would be any increased disability after repetitive motion in future flare-ups due to pain, weakness, fatigue, or incoordination. There did not appear to be any signs or symptoms of recurrent subluxation or lateral instability of the right knee. There appeared to be no symptoms secondary to removal of the meniscus. There was no impairment of the right tibia and fibula on x-ray or examination. There was also no evidence of the Veteran having frequent episodes of locking, pain, and effusions or episodes of dislocation of the semilunar cartilage. In June 2015, the RO afforded the Veteran another VA examination after receiving his reports of worsening of his right knee. At the examination, the Veteran reported wearing a knee brace to support his knee. He stated that he had intense pain intermittently inside the right knee joint, which occurred randomly when he was weight-bearing and went to put his weight on his right leg or knee. He stated that this particular symptom happened "a few times a day" and was brief or transient without changing the overall function of the right knee. He further reported mechanical symptoms and denied swelling or surgery on his right knee. The Veteran did not report flare-ups of his right knee. He reported having functional loss or functional impairment due to pain and loss motion. Range of motion testing of the right knee was considered abnormal or outside of the normal range with flexion to 120 degrees and extension to 0 degrees. The examiner explained that the Veteran's abnormal range of motion contributed to functional loss due to restricted motion. Pain was noted on the examination that caused functional loss. Flexion range of motion testing exhibited pain. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, specifically lower peripatellar tenderness. There was objective evidence of crepitus. He was able to perform repetitive use testing with at least three repetitions. There was no additional functional loss or range of motion after three repetitions. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion after three repetitions. The Veteran was not being examined immediately after repetitive use over time. Therefore, the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period of time. An additional contributing factor of disability was subluxation evident on x-ray and it was the most likely cause of the intermittent severe pains in the knee with ambulation. Muscle strength was normal and there was no atrophy or ankylosis. The examiner noted a recurrent history of moderate subluxation and no history of lateral instability. There was also no history of recurrent effusion. All joint stability testing was normal. McMurray's sign testing was negative. The Veteran indicated use of a brace as an assistive device. X-rays revealed arthritis of the right knee. Bony structures were intact showing no fracture or arthritis. Apparent elongation of collateral ligaments was allowing the femur to have subluxation lateral to the tibia. This was causing loss of cartilage space in the medial knee joint with early arthritis 2 articulations and minor medial degenerative osteophytes. The lateral view shows minor joint effusion in the suprapateller. The impression was that apparent elongation of collateral ligaments was allowing subluxation and developing minor arthritis in the medial knee joint. Mild effusion. The examiner stated that the Veteran's right knee did not impact his ability to perform any type of occupational task , such as walking, standing, lifting, sitting, etc. She continued to state that the Veteran's right knee subluxation and arthritis were at least as likely as not due to abnormal motion of the knee joint caused by the strain which lengthened the ligament allowing excess abnormal motion of the right knee joint. By way of an August 2015 rating decision, the RO continued the Veteran's 10 percent rating for his right knee, but separately awarded a 20 percent rating for subluxation of his right knee. The Veteran's service-connected right knee strain has been assigned a 10 percent disability rating pursuant to the criteria set forth in 38 C.F.R. § 4.71a , Diagnostic Code 5003-5261. Upon careful review of the evidence of the record, the Board finds that the objective evidence throughout the record overwhelmingly indicates that the disability picture in question is consistent with the currently assigned 10 percent evaluation for the right knee, as explained further below. The VA examination reports and VA treatment records do not reflect limitation of flexion or extension such as to warrant a compensable rating. To warrant a rating higher than 10 percent under Diagnostic 5260, the medical evidence must show flexion limited to 30 degrees or less. At worst, flexion of right knee was limited to 120 degrees with pain past this point on VA examination in June 2015, which is consistent with a noncompensable rating under Diagnostic Code 5260. Likewise, extension measurements are consistent with no more than a 0 percent (noncompensable) rating under Diagnostic Code 5261. For the reasons stated above, under Diagnostic Codes 5260 and 5261, respectively, the limitation of right knee movement exhibited by the Veteran is not so significantly impaired or limited as to indicate a compensable evaluation under either Diagnostic Code for either knee. Where x-ray evidence of arthritis is presented, but the loss of range of motion is noncompensable, a 10 percent disability rating will be assigned under Diagnostic Code 5003. So it is in this case. Further, a rating in excess of 10 percent contemplates X-ray evidence of involvement of two or more minor joint groups, with occasional incapacitating exacerbations. This case, however, involves only one major joint (the right knee). Accordingly, an increased disability rating is not warranted for arthritis. In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. § 4.40 and 4.45 (2014). See DeLuca, supra. The Board recognizes the Veteran's complaints of functional loss as a result of his right knee disability, notably his difficulty in walking for long periods of time as well as flare-ups. However, the Board places greater probative value on the objective clinical findings which do not support a rating in excess of 10 percent. In this regard, the competent medical evidence of record does not indicate any significant functional loss attributed to the Veteran's knee complaints sufficient to warrant a higher disability rating. Specifically, the record reflects that the Veteran has had pain with his right knee. The Board observes that, given the Veteran's painful, albeit noncompensable right knee motions, and other symptoms, the 10 percent ratings assigned appear to be consistent with Diagnostic Code 5003. 38 C.F.R. § 4.40, 4.45, and 4.59 (recognizing the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint). The medical evidence simply does not reflect any additional functional loss due to pain, weakness, excess fatigability, or incoordination that would be tantamount to a compensable disability based on flexion or extension. In light of the fact that the Veteran has repeatedly demonstrated nearly full flexion and extension, the Board is satisfied that any additional functional impairment occurring during flare ups would not be sufficient to establish his entitlement to a compensable rating for either limitation of extension or limitation of flexion. As such, the Board finds that the DeLuca factors (noted above) provide no basis for assignment of a rating in excess of 10 percent for the Veteran's right knee. See also Mitchell v. Shinseki, 25 Vet.App. 32, 44 (2011). In sum, pain alone does not demonstrate a loss of functionality as needed to support of higher evaluation based on limitation of motion. Based on this record, the Board is unable to identify any clinical findings that would warrant an evaluation in excess of 10 percent for the Veteran's right knee disability under 38 C.F.R. § 4.40 and 4.45 during the period under consideration. Moreover, in assigning the Veteran a 10 percent rating for his right knee disability, the AOJ contemplated functional loss due to the right knee disability. The current 10 percent rating therefore adequately compensates the Veteran for any functional impairment attributable to his service-connected right knee disability. See 38 C.F.R. §§ 4.41, 4.10 (2014). In sum, the Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran's service-connected right knee strain. In Hart, supra, the Court held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. In reaching its conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that timeframe. See 38 U.S.C.A. § 5110 (West 2014). After a careful review of the record, the Board can find no evidence to support a finding that the Veteran's right knee disability was more or less severe during the appeal period. Specifically, as discussed above, the August 2007, October 2009, December 2013, and June 2015 VA examination reports, as well as VA treatment records, indicate that the Veteran's right knee symptomatology remained relatively consistent throughout the period. As such, there is no basis for awarding the Veteran an increased disability rating for any time during the period under consideration. Extraschedular Consideration Next, the Board has considered whether referral for extra-schedular consideration is warranted. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular evaluation is made. 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the first Thun element is not satisfied here. The Veteran's service-connected right knee disability is manifested by signs and symptoms such as pain, fatigue, weakness, and occasional locking, which impairs his ability to stand and walk for long periods, dance in certain ways, and play high impact sports. These signs and symptoms, and their resulting impairment, are entirely contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the knee and leg provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 2560 and 5261 (providing ratings on the basis of limited flexion and extension). For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in standing, walking, and playing high impact sports. In short, there is nothing exceptional or unusual about the Veteran's right knee disability because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. Because the schedular rating criteria contemplate fully the Veteran's disability picture, application of the regular schedular standards is not rendered impractical. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Additionally, the 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 conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014). However, in this case, there are no additional symptoms that have not been attributed to a specific service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). 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. As discussed above, while there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected right knee strain, the evidence shows no distinct periods of time during the appeal period, when the Veteran's service-connected right knee strain varied to such an extent that ratings greater or less than those assigned would be warranted. See Hart, 21 Vet. App. at 509-10. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is part and parcel of an increased rating claim when such claim is raised by the record or the veteran. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, there is no evidence that the Veteran was unemployable due to his service-connected right knee strain during the appeal period. Thus, the Board finds that a TDIU claim has not been raised. See Id. ORDER A rating in excess of 10 percent for service-connected right knee strain is denied. REMAND With regards to the Veteran's service connection claim for sleep apnea, the Veteran requested a videoconference hearing on his VA Form 9, which was received at the RO in January 2016. To date, the Veteran has not been afforded an opportunity to appear before a Veterans Law Judge at a Board hearing. To ensure full compliance with due process requirements, a remand is required to schedule the Veteran for his requested hearing. See 38 U.S.C.A. § 7107 (West 2014); 38 C.F.R. §§ 19.75, 19.76, 20.700, 20.703, 20.704 (2014). In addition, the Veteran included a handwritten statement on his VA Form 9 by which he now contends that his sleep apnea is secondary to his service-connected cervical spine disability. The Board notes that the Veteran was afforded a VA examination regarding the issue of entitlement to service connection for sleep apnea in June 2015 and an addendum opinion was provided in August 2015. However, neither provided an opinion regarding secondary service connection. Thus, a remand for an addendum opinion addressing the Veteran's contention based on the alternative theory of entitlement to secondary service connection is necessary. Accordingly, the case is REMANDED for the following action: 1. The RO must place the Veteran's name on the docket for a videoconference hearing at the RO before the Board, according to the date of his request for such a hearing. 2. The RO should arrange for the record to be returned to the June 2015 VA examining physician for review and an addendum medical opinion, clarifying the opinion previously provided by responding to the following: (a) Is it at least as likely as not (a 50% or greater probability) that the Veteran's sleep apnea was incurred in, or was aggravated (increased in severity) due to, his service, or was caused or aggravated by his service-connected cervical spine disability. (b) If the opinion of the physician is that the sleep apnea was not incurred in/caused by service or caused by the service-connected cervical spine disability, but was aggravated by the cervical spine disability, the physician should specify, to the extent possible, the degree of sleep apnea that resulted from such aggravation (i.e., identify the baseline level of severity of the sleep apnea before the aggravation occurred, and the level of severity of the sleep apnea after aggravation was completed). The physician should explain the rationale for all opinions, citing to supporting factual data and medical literature as deemed appropriate. If after consideration of all pertinent factors it remains the physician's conclusion that the opinion sought cannot be provided without resort to mere speculation, it must be stated whether the need to speculate is caused by a deficiency in the state of general medical knowledge, or by a deficiency in the record, or the physician lacks the requisite knowledge or training. If the June 2015 VA examiner is unavailable or is unable to offer the addendum opinion sought, the record should be forwarded to another physician for review and the medical nexus opinion sought. 3. Following any additional indicated development, the originating agency should review the claims file and readjudicate the issue on appeal. If any benefit sought is not granted, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs