Citation Nr: 1622207 Decision Date: 06/02/16 Archive Date: 06/13/16 DOCKET NO. 09-09 247 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Sioux Falls, South Dakota THE ISSUES 1. Entitlement to a rating in excess of 20 percent for patellofemoral syndrome with degenerative joint disease, right knee, prior to August 18, 2009. 2. Entitlement to a rating in excess of 30 percent for patellofemoral syndrome with degenerative joint disease, right knee, status post total knee arthroplasty, from October 1, 2010. 3. Entitlement to a rating in excess of 10 percent for patellofemoral syndrome with degenerative arthritis of the left knee, prior to January 18, 2016. 4. Entitlement to a rating in excess of 30 percent for left knee total arthroplasty, from January 18, 2016. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Suzie Gaston, Counsel INTRODUCTION The Veteran served on active duty from February 1986 to August 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the St Louis, Missouri, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the claims for a rating in excess of 20 percent for patellofemoral syndrome with degenerative joint disease of the right knee, and a rating in excess of 10 percent for patellofemoral syndrome with degenerative arthritis of the left knee. The claim was subsequently transferred to the RO in Sioux Falls, South Dakota which, in a June 2008 rating decision, confirmed the previous denial of the claims for increased rating for the right and left knee disorders. By a rating action in September 2009, the RO assigned a temporary 100 percent rating for the right knee effective August 18, 2009, and a 30 percent rating was assigned, effective from October 1, 2010. In July 2012, the Board remanded the case to the RO via the Appeals Management Center (AMC) for further evidentiary development. Following the requested development, a supplemental statement of the case (SSOC) was issued in January 2013. In an August 2013 decision, the Board denied the claims of entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome with arthritis, entitlement to a rating in excess of 20 percent for the right knee prior to August 18, 2009, and entitlement to a rating in excess of 30 percent for the right knee from October 1, 2010. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2014 Order, the Court vacated the August 2013 decision of the Board, pursuant to the recommendation of a contemporaneous Joint Motion for Remand (JMR), and remanded the matter for action consistent with the terms of the JMR. In the JMR, the Parties agreed that a new VA opinion was required and must follow review of all relevant evidence of record by the examiner. In February 2014 the Veteran submitted updated private physical therapy records accompanied by a waiver of review by the agency of original jurisdiction (AOJ). In July 2014, the Board remanded the case for further evidentiary development. The AMC completed the requested development and issued an SSOC in November 2014. In March 2015, the Board again remanded the case for still further evidentiary development. Following the requested development, another SSOC was issued in December 2015. A review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). During the course of the appeal, on two separate occasions, the RO granted a temporary 100 percent disability rating based on convalescence following the Veteran's two surgeries on his right knee. And, recently, the RO granted a temporary 100 percent disability rating based on convalescence following surgery on the left knee in January 2016. However, as higher disability ratings are available for the Veteran's knees, both before and after each convalescent period, the claim for higher disability ratings for the right and left knee disabilities remain viable on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board has thus re-characterized the issues as shown on the title page. The issue of entitlement to a rating in excess of 30 percent for left knee total arthroplasty, from January 18, 2016 and the issue of entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals AMC, in Washington, DC. FINDINGS OF FACT 1. Prior to August 18, 2009, patellofemoral syndrome with degenerative joint disease of the right knee was manifested by pain and limitation of flexion; remaining function was better than flexion to 30 degrees. 2. Since October 1, 2010, the Veteran's right knee, status post total knee replacement, has been manifested by intermediate degrees of residual weakness, pain or limitation of motion. 3. Prior to January 18, 2016, the Veteran's left knee disability was manifested by subjective complaints of pain, and objective clinical findings of tenderness and x-ray findings of arthritis. The Veteran had flexion to 100 degrees, at worst, and extension to 0 degrees; and she does not have left knee fatigue, weakness, lack of endurance, subluxation or instability. CONCLUSIONS OF LAW 1. Prior to August 18, 2009, the criteria for a rating in excess of 20 percent for patellofemoral syndrome with degenerative joint disease, right knee, were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260 (2015). 2. Since October 1, 2010, the criteria for a rating in excess of 30 percent, for patellofemoral syndrome with degenerative joint disease, right knee, status post total knee arthroplasty, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, Diagnostic Code 5055 (2015). 3. The criteria for a rating in excess of 10 percent for patellofemoral syndrome of the left knee, prior to January 18, 2016, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, Diagnostic Code 5260 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist. VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See eg. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). In the instant case, VA provided adequate notice in a letter sent to the Veteran in November 2007. Additional letters were sent in July 2008, July 2012, February 2014, October 2015, and November 2015. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). All obtainable evidence identified by the Veteran relative to her claim has been obtained and associated with the claims file, and that neither she nor her representative has identified any other pertinent evidence not already of record that would need to be obtained for a proper disposition of this appeal. It is therefore the Board's conclusion that the Veteran has been provided with every opportunity to submit evidence and argument in support of her claim, and to respond to VA notice. VA provided adequate examinations in this case, as discussed in the Merits section of this decision. Accordingly, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising her as to the evidence needed, and in obtaining evidence under the VCAA. II. Factual background. By a rating action, dated in February 1999, the RO granted service connection for patellofemoral syndrome of the right and left knee, each evaluated as 0 percent disabling, effective September 29, 1998. Subsequently, a February 2005 rating decision increased the rating for the right and left knee disorders from 0 percent to 10 percent, each, effective September 1, 2003. In a statement dated in December 2007, the Veteran indicated that she was seeking increased ratings for her bilateral knee disabilities. In conjunction with the claim, the Veteran was afforded a VA examination in January 2008. At that time, she reported having had surgery on the right knee in August 2003 to remove a bone cyst on the anterior tibia. She states since her last rating examination in 2004 she has had gradual worsening of the medial joint line pain. She states that the right knee feels unstable and weak but has not given out on her. She has had to use a cane because of the right knee symptoms for the past three years. She started wearing an elastic knee brace on a daily basis for the past three months. She states that although the knee feels unstable it has not actually given way on her. It does pop when she walks and she has had problems with chronic swelling but no locking. She had had cortisone injections to the knee within the past month. She has not missed any -work because of the knee problems because her employers have accommodated her knee problems by giving her a desk job. Her usual level of pain in the right knee is 7/10 in severity but she gets flare ups to 9 5-10/10 occurring three to four times a week and lasting anywhere from a few hours to two days. The Veteran related that these flare-ups are usually triggered by walking more than one half block standing for more than five minutes at a time or climbing one half a flight of stairs. She noted that she treats the flare-ups with rest, elevation, brace, Icy Hot, heating pad and Aleve. She takes two Aleve tablets every four to six hours as needed for knee pain. She has had no further surgery on the knee since 2003. She stated that, during flare-ups, she is still able to perform all of her own activities of daily living independently but has to do them slowly. She denied any significant impact on her work activities since she has been given a light duty position. With respect to the left knee, the veteran reported that, since her last examination in 2004, she has had gradually worsening pain over the anterior left knee under the kneecap and at the tibial femoral joint lines on either side of the kneecap. The Veteran reported that the left knee swells fairly frequently and pops when she walks; however, it does not lock up on her and has not given way. It does feel slightly unstable but she states this is less noticeable than on the right knee. She does not wear a brace on the left knee and has not had to use a cane because of the left knee problems. She reported the usual severity of pain on the left knee was 5/10 with flare ups to 7/10 occurring three times a week and lasting for 2 to 3 hours at a time. They are usually brought on by being on her feet a lot or standing for more than seven minutes at any one time. She treats the flare-ups with rest elevation Icy Hot heat pad and Aleve and occasionally will wrap the left knee in an Ace bandage She has not had any joint injections to the left knee. She has not had any surgery on the left knee She has not missed any work because of the left knee flare-ups. She stated that the left knee problems slow down her activities of daily living but she is still able to perform them all independently. She denied any significant impact on her occupation. Examination of the right knee, without the elastic brace, revealed no redness, no increased warmth, and no palpable effusion. The knee was tender over the medial patellofemoral point line and over a 3.5 cm linear surgical scar on the anterior tibia just lateral to the midline. There was a palpable bony depression under that scar but no evidence of fluxuance or infection. There was mild crepitation of the patella during excursion with otherwise normal tracking. Range of motion is limited to 0 to 115 out of 140 degrees. The limitation is due to pain and stiffness as well as some obesity of the thigh and calf. Repetitive testing was not possible due to the veteran experiencing severe pain in the knee with the initial range of motion test. Anterior and posterior drawer signs were negative. There was no varus or valgus instability on testing of the collateral ligaments. McMurray's test was negative for meniscal damage. There was no varus or valgus angulation of the knee on standing. Examination of the left knee revealed no redness or warmth or increased effusion. There were no scars on the knee. There was mild tenderness to palpation on the infrapatellar margin. There was moderate crepitation of the patella with otherwise normal excursion. Range of motion was limited to 0 to 110 out of 140 degrees due to pain and stiffness. Repetitive testing was not possible due to pain in the knee. Anterior and posterior drawer signs were negative. Varus and valgus stressing of the collateral ligaments was negative, and McMurray's test was negative tor meniscal damage. There was no evidence of popliteal cyst. There was normal popliteal pulse. There was no evidence of varus or valgus angulation of the knee on standing. The Veterans gait was noted to be limping favoring the right knee and with the use of a cane in the left hand. X-ray study of the left knee revealed mild degenerative joint disease; and, there was a finding of degenerative joint disease in the right knee. The pertinent diagnoses were patellofemoral syndrome with moderate degenerative joint disease of the right knee; and patellofemoral syndrome with mild degenerative arthritis of the left knee. Received in February 2008 were private treatment notes from Dr. Denise Hooks-Anderson, dated from December 2007 to January 2008. These records show that the Veteran received follow up evaluation for her service-connected bilateral knee disorder. During a clinical visit in January 2008, it was noted that the Veteran was having symptoms in the knee without locking She does note recurrent swelling She is not having any giving way. It was noted that the Veteran had a small effusion with crepitance on range of motion. There was no gross instability. No cords and no adenopathy were noted. The impression was degenerative arthritis with reactive synovitis. Received in May 2008 were reports of x-ray study of the knee, dated in April 2008. The report noted impressions of cartilage narrowing involving the medial compartment on the Right, and a large benign appearing calcification located in the center of the tibial plateau anteriorly. It was noted that no abnormality was found on the study of the left knee. Also received in May 2008 were VA progress notes dated from March 2008 to May 2008. Follow up evaluation and treatment for her bilateral knee disorder. An orthopedic consult note, dated in April 2008, indicated that the Veteran seen today for right knee pain, status post injury while in service and had arthrotomy now with increasing pain, with no swelling. It was noted that she had a good rom and the knee was stable. X-rays revealed advancing DJD right knee, especially with medial joint line and pat/fern joint. It was noted that the Veteran was starting a new job. Received in October 2008 were VA progress notes dated from July 2008 to October 2008 which show that the Veteran received clinical attention and treatment for her bilateral knee disorder as well as a psychiatric disorder, diagnosed as depression. Received in May 2009 were VA progress notes dated from January 2009 to May 2009 indicating that the Veteran received follow up evaluation for symptoms associated with degenerative joint disease of the right knee. A January 2009 treatment note reported that the Veteran had been to orthopedics to receive injections in the knee. A radiology report, dated in April 2009, noted findings of osteoarthritic changes in both knees, which were described as severe in the right, and mild to moderate on the left. When seen in May 2009, the Veteran reported that she was scheduled for knee replacement of the right knee. The Veteran was afforded a VA examination in May 2009, at which time it was noted that her chief complaint was edema and pain in both knees, right being worse than the left. She also reported having a popping sensation in the knee. The Veteran indicated that the pain was over the anterior medial aspect of the joint line. She felt like the knee was weak and somewhat unstable, but she denied any actual giving way of the knee. It was noted that the Veteran used a cane for the last few years, and she stated that she used it all the time. She denied heat, redness or locking in the knee. She had been treated with multiple medications as well as Synvisc and cortisone shots to the right knee and VA had offered her TKAs. It was noted that aggravating factors are walking and stairs. The examiner also noted that the Veteran uses a strap brace occasionally although it seems to fall off. It was reported that the Veteran was been unemployed since November 2008. It was noted that the only effects of her knee disability on her ADLs is that she has adaptive equipment at home such as a raised toilet seat and rails in the bath and a bench in the bath and a Rollator. It was noted that she had surgery on the right knee in June 2003; she had a partial right medial meniscectomy chondroplasty removal of a loose body and an open biopsy removal of a proximal tibial tumor. She stated that her only symptom is pain, which she rates as 7-8 with aggravating factors already listed as stairs and walking. No history of dislocation. The only other effect on ADLs is that she has someone come in and help clean; otherwise, she dresses and bathes herself and drive. The Veteran reported that same symptoms in the left knee, just to a slightly lesser extent although her pain scale was the same. She has not had any surgery on the left knee. On examination, the examiner observed that the Veteran walked with a cane in her right hand with a very slight limp favoring the right knee. She was not wearing a brace on the day of the examination. Examination of the right knee revealed no obvious effusion, no redness, and no other gross deformity. She had a slight 3.5 cm scar in a vertical fashion over the anterior tibia proximally. There was no adherence or pain over the scar. She had very mild crepitus with flexion. There was negative anterior grind test, negative McMurray's, negative anterior drawer sign, and negative Luckman's. No signs of medial collateral instability were noted. Range of motion was from 0 degrees to 115 degrees. After 3 repetitive motions, there was no further loss of motion or objective signs of pain. The examiner noted that motion was limited due to the obesity of the thigh. The Veteran stated that she was unable to perform a squat. Muscle strength was normal; and neurovascular status of the extremities was intact. Inspection of the left knee was unremarkable. There is no effusion no heat or redness. There was mild joint line tenderness over the medial joint line and mild crepitus with motion. Negative anterior drawer sign negative Lockman's negative McMurray's. No signs of a lateral medial collateral instability. Range of motion was 0-115 degrees. After 3 repetitive motions, there is no further loss of motion or objective signs of pain. Additional functional impairment due to pain, repetitive use, fatigue, weakness, lack of endurance, or incoordination could not be specified as to degree of loss of motion without resorting to mere speculation regarding both knees. Muscle strength was 5/5. Neurovascular status of the extremities was intact. X-ray examination of the knees, dated in April 2009, revealed severe osteoarthritic changes on the right and mild to moderate osteoarthritic changes on the left. The impression was osteoarthritis of the bilateral knees. Of record is an operation report, dated in August 2009, indicating that the Veteran presented for right knee arthroplasty because of ongoing pain and disability. Extensive arthritic changes were noted in the knee. The finding of the surgery was advanced arthritis of the right knee. The Veteran was afforded a VA examination in August 2012. It was noted that the Veteran walked with a right sided limp. It was reported that she underwent a right total knee arthroplasty procedure because of advanced arthritis of the right knee on August 18, 2009. She had had ongoing pain and disability. The Veteran stated that it took her a while to recover from the surgery. Now, she has quite a bit of swelling of her right knee and she feels like it locks up and then is very painful. She had pain in her left knee as well. The Veteran indicated that there were times that she gets sharp pain which comes and goes. She still used a cane all of the time. The Veteran also reported sporadic pain in her left knee; she noted that the knee pain is more severe during the winter months. The Veteran stated that the pain rating in the right knee on the average is 6.5 out of 10 and is pretty much constant but she had periodic non-incapacitating pain in her right knee. Her left knee pain was also constant at a 6/10. She reported having occasional flare-ups, and flares up with sharp pain 8-9/10. She got sharp pain in the left knee once in a while and it was unpredictable. She was unemployed as of November 2008. The Veteran stated that she is able to put in an eight hour work day, but has to stand up periodically to stretch her knee. She reported that she could sit for 1.5 hours, and then has to change positions. The examiner noted that the Veteran used a cane in her right arm. It was reported that her prolonged standing was limited to 10-15 minutes; she was able to sit for 1.5 hours, but then she has to stand and stretch. The Veteran reported that walking was limited; however, the examiner noted that her subjective limitations seemed greater than her objective and radiologic findings. Range of motion in the right knee revealed a flexion to 110 degrees, with painful motion beginning at 110 degrees. Extension was to 0 degrees, with no objective evidence of painful motion. Range of motion in the left knee was from 0 degrees to 125 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions. There was no change in the range of motion after repetitive use testing. The examiner stated that the Veteran had less movement than normal in both knees, with pain on movement of the right knee. The Veteran had tenderness to palpation in the left knee. Muscle strength testing was 5/5 in both knees with flexion and extension. Lachman's and posterior drawer tests were normal. There was no history of recurrent patellar subluxation or dislocation in the knees. The examiner noted that the Veteran had a total right knee replacement in August 2009, and now had intermediate degrees of residual weakness, pain and limitation of motion. It was noted that the Veteran used a cane on a constant basis. The examiner stated that the Veteran's knees do not impact her ability to work, and that she is capable of doing some light lifting and sedentary work. The examiner noted that, on examination of the left knee, X-rays show mild degenerative changes; range of motion was not painful from normal full extension to 125 degrees flexion, and no change with repetitive movements. There was no evidence of effusion. She had mild tenderness across the front of the left knee. There were no problems with the tibial and fibula, no nonunion, and no instability demonstrated by knee exam with anterior/posterior drawer's signs, Lachman's and valgus and varus stress. There were no gross bony deformities. No muscle weakness or atrophy was noted. There was no dislocation of the semilunar cartilage. No demonstrable locking or subluxation was noted. The level of disability in regards to intermittent sharp pain was to a mild nature. No history or plans for a left knee arthroplasty as evidenced by review of the chart. With respect to the right knee, it was noted that she was recovering with normal residuals of a right knee arthroplasty, with a stable knee. There was no effusion. Full extension without pain and flexion to 110 degrees with only mild pain at 110 degrees of flexion. The chronic residuals have stabilized and not worsened. Recent X-ray of right knee shows a normal right total knee arthroplasty without loosening of the components. Pain on range of motion testing was considered mild and certainly not severely painful and without weakness of the extremity. Her knee flexion and extension was 5/5. Received in February 2014 were treatment reports from Sanford Medical Center, dated from September 2013 to November 2013. These records show that the Veteran received follow up evaluation and physical therapy for low back pain, secondary to the right knee disorder. During a clinical visit in September 2013 for evaluation of low back pain, the Veteran complained of pain and swelling in the right knee. She stated that she had difficulty with stairs. On the occasion of a VA examination in February 2014, the Veteran indicated that she had her right knee replaced in Sioux Falls in 2009 and she still gets daily right knee pains. The Veteran indicated that she gets flare-ups with activity and walking. Range of motion in the right knee was 0 degrees of extension to 85 degrees of flexion. The examiner noted that the Veteran was able to perform repetitive-use testing with 3 repetitions; following repetitive use testing, range of motion in the right knee was 0 degrees to 90 degrees. There was no additional limitation of motion following repetitive-use testing. Muscle strength was 4/5 with flexion, and 5/5 with extension. No instability was noted. There was no evidence or history of recurrent subluxation or dislocation. It was noted that the Veteran had intermediate degrees of residual weakness, pain or limitation of motion. It was noted that the Veteran required regular use of a cane; she also reported using a brace on the knee in the past. The Veteran indicated that she also experiences swelling of the knee. The Veteran reported that she had missed work in the past due to her bilateral knee and hip conditions; she last worked in December 2013 doing temp work. The examiner noted that pain and weakness could significantly limit functional ability during flare-ups, or when the joint or spine is used repeatedly over a period of time. The examiner stated that additional limitation due to pain and weakness and fatigability and incoordination was feasible and likely to occur; however, he also stated that it is not possible to determine actual degrees of additional range of motion loss due to pain and weakness on use or fatigability or incoordination during flare-ups as an examiner must be present to objectively and clearly determine these additional losses, if present. Received in August 2014 were VA progress notes dated from November 2012 to July 2014, which show that the Veteran received follow up evaluation for bilateral knee disorder. An orthopedic note, dated in November 2012, indicates that the Veteran was seen for evaluation of bilateral knee pain. On examination, she had mild swelling in the right knee; no effusion was noted as such. Range of motion was from 0 degrees to 100 degrees. No synovial thickening and no specific tenderness was noted. A primary care note, dated in July 2014, indicates that the Veteran called to talk about her knee giving way. The Veteran was afforded a VA examination in August 2014. With respect to the left knee, the Veteran stated that, as time has progressed, She states as time has progressed she thinks this is bone on bone and notes that this has been giving her significant problems. She stated that when she stands up "it is hard to straighten" and she has quite a bit of pain in the knee. She describes pain on the anterior knee area as well as stiffness. She also notes stiffness behind the knee and demonstrates this area with holding the left leg straight out in the chair. She states that the left knee "feels the same as the right knee before the surgery". The Veteran denied giving out or locking up of the knee. She stated that she is having a harder time with balance and this examiner notes that this can be multifactorial in nature. She has had an injection in the left knee prior without relief. She reported that occasionally she will use the straight leg brace she was given for the right knee on the left knee when it is hurting worse. Regarding the right knee, the Veteran indicated that she has had 2 prior surgeries, with the last in 2009 and she reports ongoing pain since then and states that it took "about a year for the surgical pain to go away". She reported that the knee does not catch, lock up or give out either. She stated that it is just slow to straighten it. The Veteran stated that flare-ups impact the function of her knees. She noted that the right knee was impacted by cold and moisture, and the left knee was impacted by cold air and weightbearing. Range of motion in the right knee was 0 degrees of extension and 120 degrees of flexion, with no objective evidence of pain; range of motion in the left knee was 0 degrees of extension to 100 degrees of flexion, with no objective evidence of pain. It was noted that the Veteran was able to perform repetitive-use testing with 3 repetitions. There was no additional limitation of motion following repetitive-use testing. It was noted that the Veteran's bilateral knee disorder caused functional impairment with less movement than normal, incoordination, impaired ability to execute skilled movements smoothly, and disturbance of locomotion. It was also noted that the Veteran had tenderness to palpation in the left knee. Muscle strength testing was 5/5. Lachman's and posterior drawer tests were normal. There was no history of recurrent patellar subluxation or dislocation. Examination of the right knee revealed a well-healed midline scar. Throughout the right knee, there was no heat, warmth, edema or crepitus noted. Strength was 5/5 and no Baker's cyst noted. Her gait was antalgic and she took a moment when first standing to gain balance, which the examiner stated could by multifactorial. Examination of the left knee revealed medial and lateral as well as lower patellar tenderness but no other heat, warmth or edema and strength was 5/5. No crepitus or Baker's cyst noted. It was noted that the Veteran used a brace occasionally and crutches constantly. Right knee x-ray noted that prosthesis was in place from the prior surgery in 2009 for degenerative joint disease. She was currently not working. The examiner stated that it is hard to get up and out of bed at times and could not clean the house like she would like to and takes longer to get dressed and daughter and son-in-law have moved in to help. She reported using a heating pad at night. Gait was antalgic and she used a cane. As noted below that there was no further loss of ROM noted on the exam after 4 repetitions and this examiner would have to merely speculate on any further loss of range of motion with flare-ups as there is no documented further loss of flare-ups noted in the clinical records reviewed. The Veteran did not describe instability or locking up of either knee, but described that they are stiff and it takes time to move the knees. There was no additional limitation of motion by pain, fatigue, weakness or lack of endurance following repetitive motion and no functional loss compared to baseline as noted. This examiner would have to resort to mere speculation in regards to further loss of range of motion with flare-ups as there is no documented further loss of range of motion with flare-ups noted in the clinical records. Received in November 2014 were VA progress notes dated from January 2013 to October 2014, which show that the Veteran received ongoing clinical attention and treatment for her bilateral knee disorder. Received in April 2015 were VA progress notes dated from November 2014 to April 2015 reflecting ongoing treatment for several disabilities, including the knees. Subsequently received in May 2015 were private treatment reports. These records indicate that the Veteran was seen in July 2014, with complaints of acute/chronic bilateral knee pain, right greater than left. She has not fallen, denies any type of injury. She was walking tonight when her right knee "gave out", she did not fall. She has a past history of right total knee replacement many years ago. She was currently on Tramadol, Flexeril, Neurontin, and Mobic for her ongoing knee pains. She denies fever, no numbness or tingling of her lower extremities. Examination of the extremities revealed acute and chronic bilateral knee pain, right greater than left. She had no calf pain or tenderness, no numbness or tingling of bilateral lower extremities. The assessment was bilateral knee pain. Received in January 2016 was an operative report, indicating that the Veteran was admitted to Sioux Falls Specialty Hospital on January 18, 2016 with a diagnosis of left knee degenerative joint disease. She underwent a left total knee arthroplasty. III. Legal Analysis. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Diagnostic Code 5010 addresses the issue of arthritis due to trauma, substantiated by x-ray findings, which is to be rated as degenerative arthritis under Diagnostic Code 5003. See 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2014). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved (here, Diagnostic Codes 5260 and 5261). If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5260, a 10 percent is warranted where flexion was limited to 45 degrees. A rating of 20 percent is warranted where flexion was limited to 30 degrees and a rating of 30 percent is warranted were flexion was limited to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 10 percent rating is warranted where extension was limited to 10 degrees and a 20 percent rating is warranted where extension was limited to 15 degrees. A rating of 30 percent is warranted where extension was limited to 20 degrees while a 40 percent rating is warranted where extension was limited to 30 degrees. A 50 percent is warranted where extension was limited to 45 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5257 addresses recurrent subluxation or lateral instability of a knee, and assigns a 10 percent disabling for a slight impairment, 20 percent disabling for a moderate impairment, and 30 percent disabling for a severe impairment. 38 C.F.R. § 4.71a Replacement of the knee joint with a prosthesis warrants assignment of a 100 percent evaluation for a period of one year following implantation of the prosthesis. 38 C.F.R. § 4.71a, Diagnostic Code 5055. This period commences at the conclusion of the initial grant of a total rating for one month following discharge from the hospital under the provisions of 38 C.F.R. § 4.30. 38 C.F.R. § 4.71a, Prosthetic Implants, Note (1). Thereafter, a minimum 30 percent disability evaluation will be assigned. A 60 percent evaluation will be assigned for chronic residuals consisting of severely painful motion or severe weakness in the affected lower extremity. Intermediate degrees of residual weakness, pain, or limitation of motion will be evaluated by analogy under 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Standard range of knee motion is from zero degrees (on extension) to 140 degrees (on flexion). See 38 C.F.R. § 4.71, Plate II. The Board has also considered other diagnostic codes to determine if a higher evaluation is warranted. However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, dislocated semilunar cartilage with frequent locking and effusion into the joint, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5258, 5262, and 5263 do not apply. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5262, 5263. A. Rating in excess of 20 percent for right knee, prior to August 18, 2009. Historically, the Veteran's right knee disability has been characterized as degenerative joint disease with patellofemoral syndrome and the rating has been assigned under Diagnostic Codes 5010-5260, the diagnostic codes for degenerative arthritis and limitation of flexion. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. After reviewing all of the clinical evidence and subjective complaints noted during his medical treatment during the period prior to August 18, 2009, the Board finds that the preponderance of the evidence shows that a disability rating in excess of 20 percent for limitation of flexion of the right knee is not warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5260. In this respect, the Veteran's flexion of the right knee was noted to be, at its worst, limited to 115 degrees. See May 2009 VA Examination. In order to be entitled to the next higher rating it must be shown that flexion is limited to 15 degrees or worse. Here, even considering the Veteran's reports of pain, the 115 degrees of flexion is compelling evidence that a higher rating is not warranted. The Board has not ignored the explanation that repetitive testing was not possible due to pain and the Veteran's reports of increased pain during flare ups. However, the fact that additional testing did not occur is not in itself sufficient to find that a higher rating is warranted. To receive disability compensation, however, for painful motion, that pain must result in functional loss, i.e., limitation in the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination or endurance." See 38 C.F.R. § 4.40; see also Mitchell, 25 Vet. App. at 38. In other words, "although pain may cause functional loss, pain itself does not constitute functional loss" that is compensable for VA benefit purposes. Mitchell, 25 Vet. App. at 37. Here, given the Veteran's ability to perform physical tasks and her overall range of motion on subsequent examinations, the Boards finds that the preponderance of the evidence is against entitlement to a rating in excess of 20 percent for the right knee, to include due to pain and during flare ups. Consequently, while the Veteran had complaints of pain and stiffness, the evidence reflects right knee flexion was, at most, limited to 115 degrees with pain, with no additional limitation in of motion of the knee and lower leg following repetitive-use testing. As the evidence does not show limitation of flexion to 15 degrees or less, even when considering Deluca factors, a higher rating for limitation of right knee flexion is not warranted. See 38 C.F.R. § 4.7; see also 38 C.F.R. §§ 4.40, 4.45, 4.59 as applied under DeLuca, 8 Vet. App. at 204-08; 38 C.F.R. § 4.71a, Diagnostic Codes 5260. Additionally, as the record does not show extension limited to 10 degrees or greater, a separate compensable evaluation based on limitation of extension under Diagnostic Code 5261 is also not warranted for the right knee. The Veteran has reported using a knee braces and requiring the assistance of a cane for ambulation. On VA examination in May 2009, the examiner noted that the Veteran was not wearing a brace on the day of the examination. He also noted that there was negative anterior grind test, negative McMurray's sign, negative Lachman's sign, and negative anterior drawer sign. No signs of medial collateral instability were noted. As the medical findings showed no laxity and no objective evidence of subluxation, the Board concludes that a separate disability rating under Diagnostic Code 5257 is not warranted for the right knee. While the Veteran is competent to report that her disabilities are worse than presently evaluated, whether a disability has worsened sufficiently to meet the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the Veteran's complaints coupled with the medical evidence. Although the Veteran believes she meets the criteria for higher and/or separate disability ratings, her complaints and the medical findings do not support a finding that she meets the schedular requirements for a rating in excess of 20 percent prior to August 18, 2009. As the preponderance of the evidence is against the claim for a rating in excess of 20 percent prior to August 18, 2009, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Rating in excess of 30 percent for right knee, from October 1, 2010. In this case, the RO has evaluated the Veteran's status post total right knee arthroplasty as 30 percent disabling under Diagnostic Code 5055 which rates knee replacements (prosthesis). In considering the evidence of record under the laws and regulations set forth above, the Board concludes that the Veteran is not entitled to a rating in excess of 30 percent for her patellofemoral syndrome with degenerative joint disease, right knee, status post total knee arthroplasty, from October 1, 2010. As an initial matter, the Board has considered entitlement to a higher rating under Diagnostic Codes 5256, 5261, and 5262, as directed by Diagnostic Code 5055. The Board notes her residuals of a total right knee arthroplasty are not characterized by nonunion of the tibia and fibula with loose motion requiring a brace; while the record indicates that the Veteran still uses a cane, the examiner described the knee as stable in August 2012. Specifically, the examiner stated that she was recovering from right knee arthroplasty with normal residuals and a stable knee; there was no effusion, full extension without pain and flexion to 110 degrees with only mild pain at 110 degrees. The examiner also noted that the chronic residuals have stabilized and not worsened. He further noted that pain on range of motion was considered mild. The Veteran, therefore, is not entitled to a compensable rating, much less a rating in excess of 30 percent, pursuant to Diagnostic Code 5262 for impairment of the tibia and fibula. The Veteran's range of motion of the right knee measured flexion to 120 degrees, according to the most recent August 2014 VA examination. Such does not warrant a compensable rating under Diagnostic Code 5260 for limitation of flexion. The earlier VA examination and treatment records also reflect noncompensble measurements for flexion. Even though the most severe limitation of motion was recorded in a May 2012 VA examination with painful flexion from 0 to 110 degree, this still does not warrant a 10 percent rating. The Veteran's limitation of extension of the right knee likewise is shown to be noncompensable, measuring 0 degrees on all VA examinations of record. As such, the Veteran's right knee does not warrant a 10 percent rating under Diagnostic Code 5261. At present, she is in receipt of the minimum 30 percent rating under Diagnostic Code 5055, so she is in a more favorable position currently than if she were rated by analogy to Diagnostic Code 5256, 5261, or 5262. Regarding consideration under Diagnostic Codes 5260 for limited flexion and 5257 for knee impairment with recurrent subluxation or lateral instability, the Veteran is already in receipt of the maximum allowable rating contemplated by these Diagnostic Codes, and the evidence fails to show symptoms that would meet even a zero percent rating under either Diagnostic Code. The Board observes that the Veteran has complained of pain in the right knee as well as stiffness, weakness, and swelling. She has also reported difficulty with prolonged walking or standing, as well problems sitting for too long. This caused disturbance of locomotion, and interference with sitting, standing and weight bearing as reported in the August 2012 VA examination. The August 2014 VA examination likewise showed functional loss was less movement than normal, incoordination, impaired ability to execute skilled movements smoothly, and disturbance of locomotion. However, while the above discussed VA examination reports have shown objective evidence of pain with active and repetitive limited range of motion, and even with limitations due to repetitive use, the motion remains at a noncompensable level on flexion and extension. There is not instability shown and his muscle weakness alternates between 5/5 and at worst, 4/5. The Board finds that this minimal functional impairment does not rise to the level of "chronic residuals consisting of severe painful motion or weakness in the knee" necessary to establish a higher rating under Diagnostic Code 5055. Similarly, although the Veteran has reported flare-ups, the other findings as well as her description of the flare-ups lead the Board to the conclusion that even during a flare-up, her disability does approximate the criteria for a higher rating. In consequence, a higher rating based on pain and the other DeLuca factors is not warranted in this appeal. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In light of the above, the Board finds that a preponderance of the evidence is against the claim of entitlement to an increased disability rating for patellofemoral syndrome with right knee TKA in this case. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). C. Rating in excess of 10 percent for left knee prior to January 18, 2016. Prior to January 18, 2016, the Veteran's left knee disorder was evaluated as 10 percent disabling under Diagnostic Code 5099-5010. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2014). The Veteran is seeking a higher rating. Having reviewed the evidence of record, the Board concludes that the Veteran's left knee disability was no more than 10 percent disabling prior to January 18, 2016. Such an evaluation contemplates periarticular pathology productive of painful motion and/or flexion limited to 45 degrees. The Board notes that the evidence does not show such limitation. In order to warrant a higher evaluation for limitation of flexion, the evidence must demonstrate flexion limited 30 degrees or the functional equivalent of limitation of flexion to 30 degrees due to such factors as painful motion, less movement than normal, weakened movement, excess fatigability, or incoordination. Applying the pertinent legal criteria to the facts of this case, the Board concludes that the probative evidence of record is against the Veteran's claim of entitlement to a disability rating in excess of 10 percent for patellofemoral syndrome of the left knee prior to January 18, 2016. Significantly, during the December 2007 VA examination, range of motion in the left knee was from 0 degrees to 110 degrees; it was noted that repetitive testing was not possible due to pain. In May 2009, range of motion was from 0 degrees to 115 degrees. The examiner noted that, after 3 repetitive motions, there was no further loss of motion or objective sings of pain. In August 2012, range of motion in the left knee was from 0 degrees to 125 degrees. And, in August 2014, range of motion in the Veteran's left knee was from zero to 100 degrees. The examiner stated that there was no additional limitation of motion by pain, fatigue, weakness or lack of endurance following repetitive motion and no functional loss compared to baseline as noted. This examiner would have to resort to mere speculation in regards to further loss of ROM with flare-ups as there is no documented further loss of ROM with flare-ups noted in the clinical records. In light of these findings, the Board finds that the range of motion findings as noted above would not entitle the Veteran to a compensable evaluation under Diagnostic Code 5260 (limitation of flexion of the knee). Diagnostic Code 5261 is inapplicable because there is no limitation of extension of the right knee. As such, no more than the currently assigned 10 percent rating under Diagnostic Code 5003 is warranted. The appropriate rating for limitation of motion is determined after consideration of functional loss due to flare-ups, fatigability, incoordination, weakness, and pain on movement. See DeLuca, 8 Vet. App. at 202; Mitchell v Shinseki, 25 Vet. App. 32 (2011); 38 C.F.R. §§ 4.40, 4.45. However, as noted above, the August 2014 examination revealed that repetitive testing did not result in any additional limitation of function or motion in the left knee to a compensable degree. Thus, assignment of a compensable rating for limitation of flexion under DC 5260 is not warranted. Assignment of a separate rating for limitation of extension under DC 5261 is also not warranted as the Veteran has demonstrated full extension in the left knee. Also, as for flare-ups, the 2014 VA examiner indicated that it is not feasible to render an opinion on any additional limitation in function or motion in terms of specific degrees as making this determination would require mere speculation and would be void of any objective observation. The Board finds that the VA examiner's opinion complies with Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011) and DeLuca v. Brown, 8 Vet. App. 202, 205-6 (1995). The VA examiner has clearly articulated why it is not feasible for the examiner to portray any additional functional impairment the Veteran experiences during flare-ups in terms of the degrees of additional loss in range of motion. VA does not have to demand a conclusive opinion from the examiner. See Jones v. Shinseki, 23 Vet. App. 382, 391 (2010) ("While VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence."). Indeed, a higher rating cannot be based on medical speculation and certainly not lay speculation. 38 C.F.R. § 3.102 (2015). Neither the Veteran nor the Board can speculate and arbitrarily pick a disability rating; there must be a basis in fact for the assigned rating. Id. The Board further finds that assignment of a separate rating under DC 5257 for instability is not warranted. VA examinations found no objective evidence of instability of the left knee. More recently, in August 2014, it was noted that Lachman's and posterior drawer tests were normal; and, there was no evidence of recurrent patellar subluxation or dislocation. The Veteran is competent to report symptoms capable of lay observation, such as feelings of weakness and instability in her left knee. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, her subjective reports of instability are given less probative weight than the VA examination reports, which objectively noted no knee instability or subluxation after undergoing testing to specifically determine if instability was clinically present. The Board has also considered the Veteran's lay statements that her left knee disability is worse than currently evaluated. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran is competent to report symptoms of pain and weakness because this requires only personal knowledge as it comes to her through her senses; however, she is not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's left knee disability has been provided by the medical personnel who have examined her during the appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. For the foregoing reasons, the Board finds that an evaluation in excess of 10 percent for patellofemoral syndrome of the left knee is not warranted prior to January 18, 2016; there is no doubt to be resolved; and the Veteran's claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). D. Extraschedular Consideration Also considered by the Board is whether referral is warranted for a rating outside of the schedule. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b). The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. Also considered by the Board is whether the collective effect of his other service connected disability warrants referral for extraschedular consideration. See Johnson v. Shinseki, 762 F.3d 1362 (Fed. Cir. 2014). If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. All symptoms and the level of disability resulting from the Veterans bilateral knee disabilities are addressed by criteria found in the rating schedule. The Veteran's symptoms are essentially pain and fatigability and she has reported the knee giving out. The criteria for limitation motion and instability contemplate all of her reported symptoms in kind. As higher ratings are available for disability greater than that suffered by the Veteran, for her reported symptoms, it cannot be said that the schedular criteria does not contemplate her level of disability. Her service connected disabilities are limited to those of her knees and bursitis of each hip. The bilateral factor has been assigned. There is no combined effect of her service connected disabilities that makes her disability picture and unusual or exceptional one. For these reasons, the Board declines to remand this case for referral for extraschedular consideration. ORDER Entitlement to a rating in excess of 20 percent for patellofemoral syndrome with degenerative joint disease, right knee, prior to August 18, 2009, is denied. Entitlement to a rating in excess of 30 percent for patellofemoral syndrome with degenerative joint disease, right knee, status post total knee arthroplasty, from October 1, 2010, is denied. Entitlement to a rating in excess of 10 percent for patellofemoral syndrome with degenerative arthritis of the left knee, prior to January 18, 2016, is denied. REMAND After a review of the record, the Board finds that further development is required prior to adjudicating the Veteran's claim of entitlement to a rating in excess of 30 percent for left knee total arthroplasty from January 18, 2016 and to adjudicate the TDIU part of this case. As noted above, the Veteran was afforded a VA examination of her left knee for compensation purposes in August 2014. However, a review of the electronic files on the VBMS processing system reflects that the Veteran underwent a left total knee arthroplasty in January 2016; the procedure was performed at the Sioux Falls Specialty Hospital in Sioux Falls, South Dakota. This surgery renders the August 2014 VA examination no longer reflective of the current status of the disability; hence, a contemporaneous examination to address the current severity of the left knee disability following the January 2016 arthroplasty surgery is necessary. The Veteran raised the question of whether TDIU is warranted in a December 2015 correspondence and filed a VA Form 21-8940, Application for Increased Compensation Based on Unemployability in March 2016. In that application she stated that she had been too disabled to work since January 2016 and stated that chronic knee pain was the reason. As entitlement to TDIU has been raised in the course of the claim and appeal for an increased rating, it is part of the claim and the Board has jurisdiction over it. Because, it is unclear what the proper rating for the left knee should be following the arthroplasty, it would be premature for the Board to adjudicate the TDIU aspect at this time. For the aforementioned reasons, the case is REMANDED to the agency of original jurisdiction (AOJ) for the following actions: 1. Ensure that the Veteran is scheduled for a VA examination of her left knee to assess the current level of severity. The examiner must review the entire file in conjunction with the examination. 4. Thereafter, readjudicate the Veteran's claim that is the subject of this Remand, including whether TDIU is warranted. If any benefit sought remains denied, furnish to the Veteran and her representative a supplemental statement of the case and allow an appropriate opportunity to respond thereto before returning the case to the Board, if otherwise in order. 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 is remanded by the Board 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). ____________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs