Citation Nr: 1621959 Decision Date: 06/01/16 Archive Date: 06/13/16 DOCKET NO. 12-14 515A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE 1. Entitlement to an increased rating (or evaluation) in excess of 20 percent for the service-connected left knee degenerative joint disease (DJD), status-post arthroscopy. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION The Veteran is represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Tenney, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from June 1979 to June 1999. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision of the RO in St. Petersburg, Florida, which denied an increased rating (evaluation) for the service-connected left knee disability. This case was previously before the Board in December 2013, where the Board remanded the increased rating issue on appeal for additional development that included attempting to obtain a copy of any Social Security Administration (SSA) records, and for a new VA examination. In March 2013, VA received notice from SSA that SSA records for the Veteran did not exist. A January 2014 VA examination report reflects the VA examiner reviewed the record, conducted an in-person examination with appropriate testing, and rendered the requested opinions and rationale. As such, an additional remand to comply with the December 2013 Board remand directives is not required. Stegall v. West, 11 Vet. App. 268 (1998). The issue of a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT For the entire rating period on appeal from November 10, 2009, the service-connected left knee disability manifested left knee flexion to 90 degrees, left knee extension to 5 degrees, joint "locking," painful motion, and swelling. CONCLUSION OF LAW The criteria for a disability rating in excess of 20 percent for the service-connected left knee disability has not been met or more nearly approximated for any period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2015). In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Regarding the claim for an increased rating for the left knee disability, the duty to notify was satisfied through a November 2009 letter to the Veteran that addressed all notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the Veteran of the evidence required to substantiate the claim and of the Veteran's and VA's respective duties for obtaining evidence, as well as effective dates. The Veteran was additionally given specific notice regarding disability rating codes. See Vazquez-Flores, 580 F.3d 1270. Regarding the duty to assist in this case, the Veteran received VA examinations in February 2010, April 2010, and January 2014. The VA examination reports are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination reports reflect that the VA examiners reviewed the record, conducted an in-person examination, and rendered the requested opinions, including as to functional impairment. All relevant documentation, including VA treatment records, has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the issue on appeal. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Any duties imposed on VA, including the duties to assist and to provide notification, have been met as set forth above. Increased Rating in Excess of 20 Percent for Left Knee Disability Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2015). Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2015). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2015). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran is in receipt of a 20 percent disability rating, for the entire rating period on appeal, for the service-connected left knee disability under 38 C.F.R. § 4.71a., Diagnostic Codes 5010-5258. Hyphenated Diagnostic Codes are used when a rating under one Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2015). The additional Code, shown after the hyphen, represents the basis for the rating, while the primary Code indicates the underlying source of the disability. In this case, Diagnostic Code 5010 is used for rating traumatic arthritis, while Diagnostic Code 5258 would indicate the schedular rating criteria for a (single and maximum) 20 percent disability rating for dislocation of semilunar cartilage with frequent episodes of joint "locking," pain, and effusion. VA General Counsel has interpreted that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Code 5003, or limitation of motion codes (Diagnostic Codes 5260, 5261), and 5257. See VAOPGCPREC 23-97. VA General Counsel has also interpreted that, when X-ray findings of arthritis are present and a veteran's knee disability is evaluated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable evaluation under DC 5003 if the arthritis results in limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Furthermore, to warrant a separate rating from Diagnostic Code 5257, for arthritis based on X-ray findings and limited motion under Diagnostic Code 5260 or 5261, the limited motion need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on X-ray findings of arthritis and painful motion under 38 C.F.R. § 4.59. Diagnostic Code 5010 represents arthritis due to trauma, substantiated by x-ray findings, which in turn is to be rated under Diagnostic Code 5003 as degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id., Diagnostic Code 5003. Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Id., Diagnostic Code 5003, Notes (1) and (2). The Diagnostic Codes that rate on the basis of limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. For disabilities of the musculoskeletal system, the Board also considers whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling, and pain on movement. 38 C.F.R. § 4.45. Additionally, painful motion is an important factor of disability, and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Throughout the course of this appeal, the Veteran has contended that the service-connected left knee disability has been manifested by more severe symptoms than contemplated by the 20 percent disability rating assigned. In a March 2010 notice of disagreement, the Veteran wrote that the left knee disability had not improved after undergoing an arthroscopy, and that the pain was "more pronounced than ever before." The Veteran also wrote that he was unable to stand for more than one hour and walked with a pronounced limp. See March 2010 notice of disagreement. In an October 2012 statement, the Veteran advanced that the left knee disability had significantly worsened since the February 2010 VA examination, and should be rated as 30 percent disabling. In a March 2013 statement, the Veteran wrote that since retirement both knees had worsened in severity, and that a private physician had suggested a knee replacement. An August 2009 private MRI reflects a private exminater assed a complex tear of the body and posterior horn of the medial meniscus, a radial tear of the posterior horn of the lateral meniscus, and a tear of the anterior horn of the lateral meniscus. A September 2009 private examination report reflects full extension and left knee flexion to approximately 95 degrees. The September 2009 private examiner noted the knee was limited by pain and swelling. Private treatment records from September 2009 to November 2009 reflect pain and swelling of the left knee, and a recommendation for knee replacement. A November 2009 private treatment record reflects a left knee arthroscopy was performed. A subsequent November 2009 private treatment record reflects the Veteran was discharged after the left knee arthroscopy, was given instructions regarding care of the left knee, and was prescribed pain medication. In February 2010 the Veteran underwent a VA examination for the service-connected left knee disability. At the February 2010 VA examination, the Veteran reported left knee pain, stiffness, weakness, incoordination, use of a cane, and severe flare-ups every one to two months. The Veteran also reported undergoing a left knee arthroscopy for a meniscus tear in November 2009. Upon physical examination, the VA examiner noted an antalgic gait, tenderness, guarding of movement, crepitation, and grinding. The VA examiner did not discern weakness or ankylosis. Range of motion testing reflected left knee flexion to 95 degrees and extension to 5 degrees, each with objective evidence of painful motion. The Veteran underwent another VA examination in April 2010. At the April 2010 examination, the Veteran reported chronic pain, instability, stiffness, weakness, incoordination, and weekly flare-ups. Upon physical examination, the April 2010 VA examiner noted crepitus, tenderness, pain, grinding, an antalgic gait, and a meniscus abnormality. The April 2010 VA examiner did not discern instability. Range of motion testing reflected flexion to 110 degrees, with pain beginning at 90 degrees, and normal extension (0 degrees). An August 2012 private treatment record reflects treatment for left knee pain. The private examiner noted moderate swelling, tenderness, pain on range of motion, and crepitus. The Veteran underwent another VA examination in January 2014. At the January 2014 examination, the Veteran reported experiencing pain, locking, clicking, and flare-ups. The Veteran did not report instability and denied currently experiencing a flare-up. Upon physical examination, the VA examiner noted no patellar subluxation/dislocation and a November 2009 meniscectomy, which produced a scar less than 39 square centimeters. Range of motion testing reflected flexion to 110 degrees with pain beginning at 100 degrees, and extension to 5 degrees with no objective evidence of painful motion. Initially, the Board notes that the Veteran is currently in receipt of the maximum disability rating provided under Diagnostic Code 5258 based on semilunar cartilage dislocation with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. No higher rating than 20 percent is provided. Accordingly, the Board finds that the left knee disability is rated at the highest rating under Diagnostic Code 5258; therefore, an increased rating under Diagnostic Code 5258 is not available. Nevertheless, the Veteran contends that a disability rating in excess of 20 percent is warranted based on left knee pain. See March 2010 notice of disagreement. The Veteran may not be assigned separate ratings under both Diagnostic Code 5003 and Diagnostic Code 5258 for disability of the same knee for any period because to do so would involve prohibited pyramiding by twice rating overlapping symptoms. The Veteran's knee disability has been manifested by arthritis, joint "locking," painful motion, weakness, stiffness, swelling, incoordination, and functional impairment including use of a cane and an inability to stand for prolonged periods. Both Diagnostic Codes 5003 and 5258 overlap in rating based on pain and locking as forms of limitation of motion; therefore, assigning separate ratings under both Diagnostic Code 5003 and Diagnostic Code 5258 would violate the prohibition against pyramiding. 38 C.F.R. § 4.14; Esteban at 261 (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition); see also Arthur J. Helfet, Clinical Features of Injuries to the Semilunar Cartilages, in Disorders of the Knee 110 (Arthur J. Helfet ed., 2d ed. 1982) (removal of the semilunar cartilage may resolve restriction of movement caused by tears and displacements of the menisci). On review of all the evidence, lay and medical, the Board finds that for the entire rating period on appeal from November 10, 2009, the service-connected left knee disability manifested left knee flexion to 90 degrees, left knee extension to 5 degrees, joint "locking," painful motion, and swelling. The Board also finds that the criteria for an increased disability rating in excess of 20 percent under Diagnostic Code 5260 or 5261 for the service-connected left knee disability has not been met or more nearly approximated for any period. 38 C.F.R. §§ 4.3, 4.7, 4.71a. A rating in excess of 20 percent (30 percent) under Diagnostic Code 5260 for limitation of motion requires flexion limited to 15 degrees or less. Id. A 30 percent rating under Diagnostic Code 5261 requires limitation of extension of the leg to 20 degrees. Id. For the entire rating period on appeal, the limitation of motion of the left knee did not more nearly approximate flexion limited to 15 degrees or less, or extension limited to 20 degrees or more, as needed for a 30 percent disability rating, even with consideration of the additional limitation due to pain and swelling. The evidence demonstrates, at worst, left knee flexion to 90 degrees and extension to 5 degrees, to include any additional limitation of motion due to pain or the other symptoms listed above. See April 2010 VA examination report (demonstrating left knee flexion to 90 degrees); see also January 2014 VA examination report (demonstrating left knee extension to 5 degrees). The Board has considered the Veteran's assertion of flare-ups of pain, and the fact that at the April 2010 VA examination left knee flexion was to 90 degrees. This is 75 degrees better than limited range of flexion warranting a 30 percent disability rating (15 degrees or less), such that even additional flare-ups would not limit flexion to 15 degrees or less. Based on the evidence above, an increased rating in excess of 20 percent based on limitation of flexion under Diagnostic Code 5260 or limitation of extension under Diagnostic Code 5261 is not warranted. The Board has considered whether an increased rating for the left knee disability is warranted on the basis of functional loss due to the pain, joint "locking," and swelling shown by the evidence. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. As shown in the February 2010 VA examination report and other VA and private treatment records, the Veteran has reported functional impairment including use of a cane and the inability to stand for prolonged periods. Each of these examples of functional impairment incorporates pain and limited or painful motion. The Board finds that this functional impairment does not warrant an increased rating in excess of 20 percent under Diagnostic Code 5260 or 5261. The Board has also considered whether an increased or separate disability rating is warranted under any of the other diagnostic codes pertaining to the knee for any part of the rating period. There is no lay or medical evidence of ankylosis; therefore, the Board finds that Diagnostic Code 5256 does not apply. There is no lay or medical evidence that the Veteran underwent a knee replacement of either knee joint; therefore, Diagnostic Code 5055 is inapplicable. The evidence does not show recurrent subluxation or lateral instability of the left knee for any period. Although the Veteran reported instability during the April 2010 VA examination, the Board finds that, in the context of the other specific findings, which include clinical observation of no left knee subluxation or instability, this lay report of instability more closely resembles weakness in the knee rather than actual instability. See Dorland's Illustrated Medical Dictionary 958 (31st ed. 2007) (defining instability as a "lack of steadiness or stability" and functional instability as the "inability of a joint to maintain support during use"). As such, a separate rating under Diagnostic Code 5257 is not warranted. As discussed above, consideration of left knee weakness was included in the 20 percent disability rating assigned under Diagnostic Code 5258; therefore, a separate rating for left knee instability under the facts of this case would constitute impermissible pyramiding. 38 C.F.R. § 4.14. Diagnostic Code 5262 does not apply, as the evidence does not show impairment of the tibia or fibula in the left knee. Diagnostic Code 5263 assigns a single 10 percent disability rating for genu recurvatum that is acquired, traumatic, and with weakness and insecurity in weight-bearing objectively demonstrated. As the evidence of record does not reflect that the Veteran has genu recurvatum of the left knee, Diagnostic Code 5263 does not apply. Additionally, the Board finds that a separate disability rating under Diagnostic Code 5259 is not warranted. The rating criteria under Diagnostic Codes 5258 and 5259 differ from each other only in that the semilunar cartilage is dislocated in Diagnostic Code 5258 and surgically absent in Diagnostic Code 5259. Diagnostic Code 5258 requires dislocation of the semilunar cartilage with symptoms of frequent joint "locking," pain, and effusion and Diagnostic Code 5259 requires removal of the semilunar cartilage that is symptomatic; therefore, Diagnostic Codes 5258 and 5259 overlap with each other in symptoms of pain, effusion, and locking, but not as to dislocation or surgical absence. Esteban at 261 (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). Granting a separate rating for the same overlapping manifestations, specifically pain and locking, of the Veteran's left knee disability under Diagnostic Code 5259 would constitute impermissible pyramiding. 38 C.F.R. § 4.14. Moreover, the highest available rating under Diagnostic Code 5259 in this case is 10 percent; thus, Diagnostic Code 5259 does not allow for a higher rating than Diagnostic Code 5258 (which provides a single, maximum rating of 20 percent). Finally, for the entire rating period, the evidence of record does not show any scar associated with the left knee disability that is greater than 39 square centimeters, nor has the Veteran asserted otherwise; therefore, the Board finds that the Veteran is not entitled to a separate compensable rating for scars under Diagnostic Codes 7800 through 7805 for the left knee disability. 38 C.F.R. § 4.118 (2015). Extraschedular Consideration The Board has considered whether referral for an extraschedular rating would have been warranted for the left knee under 38 C.F.R. § 3.321(b)(1) (2015). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that 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. 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet App 111 (2008). Turning to the first step of the extraschedular analysis, the Board finds that the schedular criteria are adequate to rate the Veteran's left knee disability. Over the course of the entire rating period from November 10, 2009, the left knee disability has, at various times, manifested symptoms and impairment including limited motion, pain, swelling, weakness, stiffness, incoordination, locking, and functional impairment including use of a cane, and an inability to stand for prolonged periods. The schedular rating criteria specifically provide ratings based on limitation of motion (Diagnostic Codes 5260 and 5261), including motion limited by factors such as pain, weakness, and stiffness (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), and for symptoms such as "locking" and pain associated with semilunar cartilage removal or dislocation, as shown in this case (Diagnostic Code 5258 and 5259). With respect to functional impairment with prolonged walking and standing, interference with standing and weight-bearing (walking necessarily involves weight-bearing) is considered as part of the schedular rating criteria under 38 C.F.R. § 4.45. To the extent that prolonged standing or walking causes incidental knee pain, such pain is considered as part of the rating criteria, to include as due to orthopedic (DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59) factors such as weakness, incoordination, and fatigability, which are incorporated into the schedular rating criteria. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Burton v. Shinseki, 25 Vet. App. 1, 4 (2011); Sowers v. McDonald, No. 14-0217 (Vet. App. Feb. 12, 2016). The Board notes that, according to Johnson v. McDonald 762 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 rating of the individual disabilities fails to capture all the service-connected disabilities experienced. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. The Veteran's service-connected disabilities include a left knee disability, a right knee disability, a right shoulder disability, a back disability, and tinnitus. ORDER An increased disability rating in excess of 20 percent for a left knee disability is denied. REMAND TDIU In February 2016, the Veteran submitted a timely notice of disagreement (NOD) to the January 2016 rating decision, which, in pertinent part, denied a TDIU. To date, no statement of the case (SOC) has been issued as to the issue of a TDIU. The Court has directed that, where a veteran has submitted a timely NOD with an adverse decision and the RO has not subsequently issued a SOC addressing the issue, the Board should remand the issue to the RO for issuance of a SOC. Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Accordingly, the issue of a TDIU is REMANDED for the following action: Issue a SOC which addresses the issue of a TDIU. The Veteran should be given the appropriate opportunity to respond to the SOC. The RO should advise the Veteran that the claims file will not be returned to the Board for appellate consideration of the issue following the issuance of the SOC unless he perfects his appeal. The Veteran 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 or Court 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. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs