Citation Nr: 1619149 Decision Date: 05/11/16 Archive Date: 05/19/16 DOCKET NO. 10-28 424 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an increased rating for chondromalacia, left knee, with degenerative joint disease and semilunar cartilage removal, currently rated as 20 percent disabling. 2. Entitlement to a compensable rating for chondromalacia, left knee, with degenerative joint disease and limitation of flexion. 3. Entitlement to an increased rating for status post anterior cruciate ligament reconstruction, right knee with degenerative joint disease, currently rated as 10 percent disabling. 4. Entitlement to a compensable rating for right knee laxity. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Missouri Veterans Commission WITNESSES AT HEARING ON APPEAL Appellant, spouse ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in February 2013 for further development. The Board also remanded the issue of entitlement to service connection for a back disability secondary to service connected right and left knee disabilities. The RO issued a May 2013 rating decision in which it granted service connection for a lumbar strain. The grant of service connection constitutes a complete grant of the claim. Consequently, the issue is not before the Board. The May 2013 RO rating decision also granted a separate (noncompensable rating for right knee laxity). The RO also issued a February 2014 rating decision in which it granted a temporary 100 percent rating based on surgical or other treatment necessitating convalescence for the left knee. The 100 percent rating was effective June 28, 2013 and it was returned to a 20 percent rating effective January 1, 2014. The RO also issued a January 2016 rating decision in which it granted a separate (noncompensable) rating for left knee limitation of flexion effective March 3, 2015. It also granted service connection (and noncompensable ratings) for post surgical scarring to the right and left knees effective November 17, 1999 and June 28, 2013 respectively. These ratings are considered part and parcel with the perfected appeal. The issues of entitlement to an increased rating with respect to the left knee and entitlement to a total disability rating based on individual unemployability (TDIU) are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's status post anterior cruciate ligament reconstruction, right knee with degenerative joint disease is not manifested by leg flexion limited to 30 degrees; leg extension limited to 15 degrees; ankylosis; malunion of the tibia and fibula; or dislocation of the semilunar cartilage. 2. Effective April 9, 2013, the Veteran's right knee laxity is manifested by slight subluxation or lateral instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability evaluation in excess of 10 percent for the Veteran's service-connected status post anterior cruciate ligament reconstruction, right knee with degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including § 4.7 and Codes 5260-5261 (2015). 2. Effective April 9, 2013, the criteria for entitlement to a disability evaluation of 10 percent, but no higher, for the Veteran's service-connected right knee laxity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. Part 4, including § 4.7 and Code 5257 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In a June 2009 letter, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b) (2015). The RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that he was expected to provide. The Veteran was informed of the process by which initial disability ratings and effective dates are assigned, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2015). VA has done everything reasonably possible to assist the Veteran with respect to the claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2014) and 38 C.F.R. § 3.159(c) (2015). Relevant service treatment and other medical records have been associated with the claims file. The Veteran was given VA examinations in August 2009, May 2011, April 2013, and March 2015, which are fully adequate. The examiners reviewed the claims file in conjunction with the examinations and they addressed the relevant rating criteria. The duties to notify and to assist have been met. Further regarding the duty to assist, the United States Court of Appeals for Veterans Claims (Court) has held that that provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). At the Veteran's hearing the undersigned identified the issue, sought information as to treatment to determine whether all relevant records had been obtained, and sought information as to any changes in the disability since the last examination. Ultimately the claim was remanded for a new examination. The Board thereby met the duties imposed by 38 C.F.R. § 3.103(c)(2) as interpreted in Bryant. Increased Ratings Disability evaluations 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 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. 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). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The arthritic component of the Veteran's right knee disability has been rated under the provisions of Diagnostic Codes 5260. Under Diagnostic Code 5260, a 10 percent rating is warranted for leg flexion limited to 45 degrees. A 20 percent rating is warranted for leg flexion limited to 30 degrees. A 30 percent rating is warranted for leg flexion limited to 15 degrees. Pursuant to Diagnostic Code 5261, a 10 percent rating is warranted for leg extension limited to 10 degrees. A 20 percent rating is warranted for leg extension limited to 15 degrees. A 30 percent rating is warranted for leg extension limited to 20 degrees. A 40 percent rating is warranted for leg extension limited to 30 degrees. A 50 percent rating is warranted for leg extension limited to 45 degrees. Separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension), both codified at 38 C.F.R. §4.71a, may be assigned for disability of the same joint. See VAOPGCPREC 9- 2004. Ankylosis of the knee will be rated as 60 percent disabling if at an extremely unfavorable angle, in flexion at an angle of 45 degrees or more. A 50 percent rating will be assigned if the knee is in flexion between 20 degrees and 45 degrees. The disability will be rated at 40 percent if it is in flexion between 10 degrees and 20 degrees. A 30 percent rating will be assigned if there is ankylosis at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Finally, impairment of the tibia and fibula will be rated as 40 percent disabling where there is a nonunion, with loose motion, requiring brace. A malunion of the tibia and fibula will be rated as 30 percent disabling if there is marked knee or ankle disability, 20 percent disabling if there is moderate knee or ankle disability, and 10 percent disabling if there is slight knee or ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5262. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2015). Additionally, the law permits separate ratings for arthritis and instability of a knee. Specifically, the VA General Counsel has held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257 because the arthritis would be considered an additional disability warranting a separate rating even if the limitation of motion was not compensable. See VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997). Likewise, the VA General Counsel has also held that, when x-ray findings of arthritis are present and a Veteran's knee disability is evaluated under Code 5257, the Veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98 (Aug. 14, 1998). In this case, a separate rating has already been assigned; the question for consideration is the propriety of the percentage and effective date chosen. Pursuant to 38 C.F.R. § 4.71a (Diagnostic Code 5257), a rating of 10 percent is warranted when the Veteran experiences slight subluxation or lateral instability. A rating of 20 percent is warranted when the Veteran experiences moderate subluxation or lateral instability. A rating of 30 percent is warranted when the Veteran experiences severe subluxation or lateral instability. Dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Removal of the semilunar cartilage, which is symptomatic, warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. The Veteran underwent a VA examination in August 2009. The examiner reviewed the claims file in conjunction with the examination. The Veteran denied pain in the right knee. There were also no symptoms noted (no deformity, giving way, instability, pain, stiffness, weakness, incoordination, decreased speed of motion, episodes of dislocation or subluxation, locking episodes, effusion, inflammation, affect on the motion of the joint, and no symptoms of arthritis). Upon examination, the Veteran's gait was normal. There was a well healed scar. The only symptom observed was clicks or snaps of the knee. There was no crepitation, no mass behind the knee, no instability, and no patellar or meniscus abnormality. The Veteran achieved full range of motion (flexion to 140 degrees and extension to 0 degrees). There was no objective evidence of pain with active range of motion. There was objective evidence of pain following repetitive motion. X-rays revealed some mild degenerative narrowing of medial joint compartment. In the Veteran's July 2010 substantive appeal (VA Form 9), he stated that "My right knee is awesome and very good - just this left knee is giving me bad times." The Veteran underwent a VA examination in May 2011. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported no other medical care visits or prescription medications from any doctor since 2009. He stated that he took nonprescription daily multivitamin and one aspirin. He denied other pain medications or analgesic rubs. He lived in a one-floor home with a basement. He denied difficulty or falls going up and down the basement stairs. He had five acres of mostly unimproved ground and did some walking over this rougher terrain. He was unemployed. He reported doing varied daily activities that included walking (sometimes) to a maximum of one mile (most recently three weeks prior to the examination). He was able to drive a car and shop through a large store without difficulty. He packed and carried luggage and heavier boxes from a recent driving vacation back to Arizona. He stated that he has never used a cane for knee problems. On this most recent vacation, he noticed that he had to stop, get out of the car, and walk briefly every 1.5-2.0 hours due to stiffness and soreness in both knees. He stated that in the past year, he had almost no pain or discomfort from the right knee. He reported that one month prior to the examination, he stepped off a curb and felt sudden pain with a feeling of "metal to metal." He was able to walk home and then rested the leg in elevation. He had swelling that evening with mild erythema, but no warmth or ecchymotic bruising. He stated that the right knee pain and swelling resolved gradually over the next two weeks. At the time of the examination, the Veteran reported that he felt normal function again with no pain. He denied locking or give way weakness on other occasions to the right knee. He had no pain with daily activities or at night in recent weeks. He denied stiffness in the right knee. He stated that until the aforementioned strain, the right knee had been no problem for many months. He stated that he did not use heat or ice or analgesic balms for either knee. Upon examination, the Veteran arose from the waiting room chair pushing lightly off by both arms. He then walked erect with a normal gait with no ataxia; he was not antalgic. He wore a left knee neoprene brace, but did not use a cane. He sat comfortably during the interview. He removed the left knee brace without difficulty. He stood without pushing off and demonstrated normal tiptoe and heel walk strength and stable tandem gait. He did three knee bends fully, but only by holding with both hands to furniture and pushing up some to assist arising. He complained of pain only in the medial left knee. He ascended the examination table with no difficulty and sat erect unsupported. Muscles above and below both knees were well developed with no atrophy. Both knee joints appeared symmetrical with no edema, erythema or effusions. Patellar mobility in relaxed extension was normal and pain free bilaterally with no ballottement. There was mild genu valgum deformity, measuring 5 degrees at the right knee while standing. The right knee had two, healed, linear, surgical scars, a 6.5 cm scar just proximal of the medial joint line and an 8 cm scar over the lower patella. They were flat, mobile, nontender, and hypopigmented. Varus, valgus, and drawer tests for instability were negative and pain free. Lachman testing with internal and external rotation caused mildly painful patellar pop, but no crepitus or joint line pain. Active range of motion in the right knee was is 0-130 degrees on 3 tries with no pain. There was no focal right knee tenderness upon palpation. Repetitive motion testing of the knees revealed no further impairments of function due to pain, fatigue, incoordination, or instability. X-rays revealed mild narrowing of the medial compartment and postoperative anterior cruciate ligament repair. The Veteran underwent a VA examination in April 2013. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that his right knee was "getting worse." He described swelling "off and on" depending upon the ambient temperature. He stated that severe cold or severe heat caused his right knee to swell. Swelling could also occur if he walked greater than 1/4 mile. He stated that he could stand between a half hour and an hour before he had to get off his feet because of knee pain. He also stated that after sitting for 1 hour his knees become stiff. He reported that his right knee pops with movement. He stated that for the past 7-9 years, he has had to walk stairs one at a time. He did not use a cane and he did not wear a brace on his right knee. He reported waking up frequently because of bilateral knee pain. He complained that the right knee tended to give way 2 or 3 times a week. He stated that he fell about a month prior to the examination. He had no history of locking. Upon examination, the Veteran stood with normal alignment of both knees. The examiner was unable to discern any visible varus deformity on the left knee (although this was evident on the standing x-ray). The Veteran had an antalgic limp favoring the left lower extremity. He was not asked to squat because of his bilateral knee conditions. The Veteran was able to achieve full extension of the right knee, and 115 degrees of flexion. Quadriceps and hamstring strength in the right knee was 5/5. There was no change in motion with repetition. With regards to the right knee, there was only minor pain, minor fatigability, no weakness, no lack of endurance, and no incoordination. There was no joint effusion. Medial joint line tenderness was present to the left knee; but not on the right. There was normal patellofemoral tracking in both knees. There was a 2+ positive Lachman test on the right with a firm endpoint, negative drawer sign, negative pivot shift with a 1+ valgus laxity of the right knee with the knee in 30 degrees of flexion. In June 2014, the Social Security Administration determined that the Veteran's disabilities have rendered him disabled. The Veteran underwent a VA examination in March 2015. The examiner reviewed the claims file in conjunction with the examination. The examiner noted that an April 2013 x-ray showed ACL repair screw intact, and medial compartment osteoarthritis. Orthopedics clinic care has since been focused on the left knee, as the right knee symptoms were "generally doing well" without bracing or any joint swelling. An August 2014 right knee x-ray described the same changes, but arthritis in all 3 compartments. The Veteran reported pain in the right knee periodically throughout the day, made worse by weight bearing, sitting, or driving more than an hour. He reported that the knee pops and has awakened him at night (though he stated that it is usually the left knee that awakens him). He denied swelling in the right knee. He stated that the knees (bilaterally) prevent jogging or complete stooping, squatting, or kneeling. He reported that he lived in the country on 5 acres. He stated that he uses a riding lawn mower but does not do anything by hand or on foot. He could not carry more than grocery sacks. He reported that he could walk 1/8 of a mile at most. He could push a cart through aisles at Walmart. He reported that he used the basement stairs occasionally, but must always lead up only with right leg. He could descend by either but only 1-step then both feet down before the next step. He reported that he holds the rail carefully. The Board notes that it was unclear how many of these limitations were due to the right knee only as the Veteran clearly favored his right leg. It appeared that most limitations were based on his more severe left knee disability. The Veteran denied flare-ups of the knee or lower leg. Upon examination, he achieved flexion from 0 to 110 degrees and extension from 110 to 0 degrees. Pain on flexion and extension caused functional loss, but repetitive movement did not reduce range of motion. 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, in relaxed full extension, passive manipulation of the patella was mildly painful without crepitus/subluxation felt or pain/effusion on direct compression. There was mild right tenderness palpating quadriceps and patellar tendons insertions. There was objective evidence of crepitus. 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 examiner was unable to state whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated used over a period of time. The examiner explained that flare-ups were not currently reported by the Veteran as affecting joint function. Therefore, it is not possible to state "whether pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups" or to specify degrees ROM loss, and no medical opinion can be provided. The examiner further explained that "repetitive use over a period of time" the joints function above may or may not develop "additional limitation due to pain, weakness, fatigability or incoordination." Finally, the examiner stated that the Veteran's history does not enable him to state, without resorting to mere speculation, "the degrees of additional ROM loss", if any, which might occur in that instance. The Veteran had 5/5 strength in the knee in both forward flexion and extension. There was no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing revealed normal findings. The examiner noted moderate pain expression with right knee varum/valgum stressing. The examiner noted that the Veteran underwent ACL reconstruction in 1999. The examiner also noted that right knee osteoarthritis has been present at least since April 2013 knee x-ray, and is an expected progressive change from the past ACL tendon repair; it is NOT a separately-ratable diagnosis or condition. Outpatient treatment reports dated September 2015 reflect that X-rays of the right knee showed no new changes (VBMS, 1/12/16 #1, p. 39). Analysis To warrant a rating in excess of 10 percent, the Veteran's right knee disability would have to be manifested by leg flexion limited to 30 degrees (Diagnostic Code 5260), leg extension limited to 15 degrees (Diagnostic Code 5261), ankylosis (Diagnostic Code 5256), or malunion of the tibia and fibula with a moderate knee or ankle disability (Diagnostic Code 5262). The Veteran underwent VA examinations in August 2009, May 2011, April 2013, and March 2015. He achieved leg flexion to 140 degrees, 130 degrees, 115 degrees, and 110 degrees respectively in the right knee. He achieved extension to 0 degrees at all four examinations. There was no evidence of ankylosis, malunion or nonunion of the tibia and fibula. Repetition of movement did not lead to additional functional loss commensurable with the next-higher evaluation. The medical evidence contains no findings that the Veteran's right leg flexion was limited to 30 degrees. Additionally, the Board notes that separate ratings for limitation of flexion and extension are not warranted insofar as the Veteran has been shown to have full extension. In regard to DeLuca criteria, the April 2013 VA examiner noted that there was no change in motion with repetition. He also noted that there was only minor pain, minor fatigability, no weakness, no lack of endurance, and no incoordination. The May 2015 VA examiner was unable to state whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated used over a period of time. There was no reduction in range of motion with repetitive movement and the Veteran did not endorse flare-ups. In sum, there is no medical evidence to show that there is any additional loss of motion of the right knee due to pain or flare-ups of pain, supported by objective findings, or due to excess fatigability, weakness or incoordination, to a degree that supports a rating in excess of 10 percent. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for a rating in excess of 10 percent for status post anterior cruciate ligament reconstruction, right knee with degenerative joint disease must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Instability Finally, the Board notes that the Veteran is currently in receipt of a noncompensable (0%) rating for right knee laxity. A 10 percent is warranted when the Veteran experiences slight subluxation or lateral instability. A rating of 20 percent is warranted when the Veteran experiences moderate subluxation or lateral instability. A rating of 30 percent is warranted when the Veteran experiences severe subluxation or lateral instability. At the Veteran's August 2009 and May 2011 VA examinations varus, valgus, and drawer tests for instability were negative and pain free. Likewise, the March 2015 VA examiner noted that joint stability testing revealed normal findings. However, the Board notes that at the Veteran's April 2013 VA examination, the examiner noted that there was a 2+ positive Lachman test on the right with a firm endpoint, negative drawer sign, negative pivot shift with a 1+ valgus laxity of the right knee with the knee in 30 degrees of flexion. Given this, and in light of his complaints of the knee giving way, as reported at the April 2013 examination, the Board finds that a rating of 10 percent for right knee laxity is warranted effective April 9, 2013. The Board notes that a rating is excess of 10 percent is not warranted insofar as the instability noted is no more than slight. Extraschedular Ratings Pursuant to 38 C.F.R. § 3.321(b)(1) (2015), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors are marked interference with employment and frequent periods of hospitalization). The rating criteria fully contemplate the Veteran's disability as noted above, his symptomatology has consisted of pain, limitation of motion, and (for a time) instability of the right knee. These symptoms are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is, therefore, not warranted. 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to a rating in excess of 10 percent for status post anterior cruciate ligament reconstruction, right knee with degenerative joint disease is denied. Effective April 9, 2013, a rating of 10 percent, but no greater, is granted for right knee laxity. REMAND Left knee Outpatient treatment reports dated September 2015 reflect that the Veteran reported chronic pain. He sought physical therapy, but it was not completed. He also wanted a knee replacement but knew that he was too young for it. X-rays of the left knee revealed arthritis and that one of the screws was broken (VBMS, 1/12/16 #1, pgs. 36-39). An October 2015 treatment report reflects that the left knee had skin intact, with no erythema peri-incisionally. The medial incision was moderately tender to palpation. There was no swelling over incisions. There was mild-moderate left knee effusion. There was 10 degree flexion contracture appreciate over the left knee. He could flex to 90 degrees, with significant pain obtaining passive/active flexion past 90 degrees. The knee was stable to varus/valgus stress at 0/30. There were no drawer signs, anterior/posterior (VBMS, 1/12/16 #1, p. 10). VA outpatient treatment reports reflect that the Veteran was scheduled to undergo surgery on February 12, 2016 (VBMS, 1/12/16 #1, pgs. 1-5). A more current VA examination is warranted to determine the severity of the Veteran's left knee post-surgery. TDIU The Veteran's claim for a TDIU is dependent on whether the Veteran's service connected disabilities render him unable to secure or follow a substantially gainful occupation. As such, the claim is inextricably intertwined with the issue of whether an increased rating is warranted for the Veteran's service connected left knee disability. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. The RO should make sure that the VA records are updated and in the claims folder. 2. The RO should schedule the Veteran for a VA orthopedic examination for the purpose of determining the current severity of the Veteran's left knee disability. It is imperative that the claims file be made available to the examiner for review in connection with the examination. The examiner should also comment on the functional impact of the Veteran's service connected disabilities on his ability to work. For each disability, the examiner should discuss the likely impairments imposed; for example, would the Veteran be precluded from prolonged standing, walking, lifting or other physical activity. Would sedentary work be possible? The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinion. 3. After completion of the above, the AMC should review the expanded record and determine if the benefits sought can be granted. If the claims remain denied, then the AMC should furnish the Veteran and his representative with a supplemental statement of the case, and afford a reasonable opportunity for response before returning the record to the Board for further review. 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). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs