Citation Nr: 1750185 Decision Date: 11/06/17 Archive Date: 11/17/17 DOCKET NO. 10-08 898 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an evaluation for degenerative changes of the right knee, status post total knee replacement (right knee disability), in excess of 10 percent prior to April 8, 2010, and in excess of 30 percent from June 1, 2011. 2. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G. Johnson, Associate Counsel INTRODUCTION The Veteran had honorable active service in the United States Army from November 1974 to November 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In June 2007, in pertinent part, the RO denied an increased rating in excess of 10 percent for the Veteran's right knee degenerative changes. In March 2008, the Veteran submitted a statement that he wanted to file an increase for his right knee disability, which, in effect, indicated his desire to continue with the increased rating claim for a right knee disability, even though he did not specifically state that he was intending to disagree with the June 2007 rating decision. Additional relevant evidence was also added to the record in May 2008, suggesting a reasonable possibility of an increase in severity of his right knee disability. As the Veteran submitted statements that, in effect, indicated his desire to continue with these claims, and new and material evidence pertaining to the right knee disability was submitted within one year of the June 2007 rating decision, the Board determines that the June 2007 rating decision remained pending as it pertained to the increased rating claim for a right knee disability. Courts have held that 38 C.F.R. § 3.156(b) requires that VA evaluate submissions received during the year following notice of a rating decision to determine whether they contain new and material evidence, even if the new submission may support a new claim. See Bond v. Shinseki, 659 F.3d 1362, 1367-1368 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-252 (2010). In July 2010, the RO increased the Veteran's rating to 100 percent effective April 8, 2010, based on surgical treatment necessitating convalescence. The RO assigned a 10 percent rating from June 1, 2011. In December 2010, the RO increased the Veteran's rating to 30 percent effective June 1, 2011. Because the increase in evaluation of the Veteran's degenerative changes of the right knee, status post total knee replacement does not represent the maximum evaluation available for the condition, the Veteran's claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In January 2011, the Veteran testified at a Travel Board hearing before a Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. The case was previously before the Board in September 2011, at which time, the Board remanded the issue of a right knee disability to the Agency of Original Jurisdiction (AOJ) for additional development, including, a VA examination to determine the severity of the Veteran's right knee disability and to obtain relevant VA treatment records. There has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In December 2012, the Board notified the Veteran that the VLJ who conducted the Board hearing was no longer employed at the Board. In January 2013, the Veteran submitted a request for a Travel Board hearing. In June 2013 the Board remanded the issue of right knee disability to the Agency of Original Jurisdiction (AOJ) for additional development, including, scheduling a Travel Board Hearing. There has been substantial compliance with the remand directives. See Stegall. supra.. In January 2016, the Veteran withdrew his request for a Travel Board hearing. In September 2016, the Veteran's representative asserted that the Veteran stated that he no longer wanted a Board hearing to address his right knee disability. Therefore, the Veteran's hearing request is deemed withdrawn. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to April 8, 2010, the Veteran's degenerative changes of the right knee, has been productive of painful motion with flexion limited to no less than 100 degrees, including on repetition, and extension limited to 0 degrees, without ankylosis, recurrent subluxation or instability, dislocated or removed cartilage, impairment of tibia or fibula, or genu recurvatum. 2. From June 1, 2011, the Veteran's degenerative changes of the right knee, status post total knee replacement is manifested by chronic residuals consisting of severe painful motion and weakness. CONCLUSIONS OF LAW 1. Prior to April 8, 2010, the criteria for the assignment of a rating in excess of 10 percent for degenerative changes of the right knee have not been met 38 U.S.C.A. § 1155 (West 2016); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260 (2017). 2. From June 1, 2011, the criteria for a 60 percent evaluation for degenerative changes, status post right total knee replacement are met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.326(a). In light of the favorable disposition of the claim for an increased rating for degenerative changes of the right knee, status post total knee replacement, the Board finds that any deficiencies with regard to the duty to notify or assist is non prejudicial, and thus, no further discussion of VA's duties to notify and assist is necessary. II. Increased Rating for Right Knee Disability The Veteran seeks a rating in excess of 10 percent for his service connected degenerative changes of the right knee, status post total knee replacement prior to April 8, 2010, and in excess of 30 percent from June 1, 2011. The Veteran testified that prior to his knee replacement surgery, he had instability of the right knee where he would have to catch himself before falling, and as a result, he had to leave work early twice a week to go to water therapy. He testified that the right knee would lock up on him at least three or four times a day when he was getting into trucks and his knees would swell at least twice a week. The Veteran testified that he continued to have instability of his right knee after surgery, and he would have instability approximately every 15 to 20 steps. He also testified that his right knee continued to lock up on him, that he had limited range of motion, and that his right knee was always swollen. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Although the Veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994), see also 38 C.F.R. § 4.1. The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. Service connection for degenerative changes, right knee with an evaluation of 10 percent was granted in a March 2004 rating decision, effective July 25, 2003. Rating decisions issued in July 2004 and July 2006 continued the 10 percent rating. The Veteran filed a claim for increased rating in September 2006. A rating decision issued in June 2007 continued the 10 percent rating. A rating decision issued in February 2009 continued the 10 percent rating for degenerative changes, right knee. A rating decision issued in July 2010 increased the disability rating to 100 percent effective April 2010, and 10 percent from June 2011. A December 2010 rating decision increased the disability rating to 30 percent from June 2011. The Veteran's degenerative changes of the right knee, status post total knee replacement is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5055. The Board will consider whether the Veteran can receive higher ratings for his right knee under all applicable diagnostic codes. Under Diagnostic Code 5055, for one year after a prosthetic replacement of the knee joint, the knee is rated at 100 percent. Thereafter, a 60 percent rating is assignable for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion are rated under Diagnostic Codes 5256 (ankylosis), 5261 (limitation of extension) and 5262 (impairment of the tibia and fibula). The minimum rating after a knee replacement is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Under Diagnostic Code 5256, ankylosis of the knee in a favorable angle in full extension, or in slight flexion between 0 and 10 degrees warrants a 30 percent rating. Ankylosis of the knee in flexion between 10 and 20 degrees warrants a 40 percent rating. Ankylosis of the knee in flexion between 20 and 45 degrees warrants a 50 percent rating. Extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more warrants a 60 percent rating. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 28th edition, p. 86. Under Diagnostic Code 5257, knee impairment with recurrent subluxation or lateral instability is rated at 10 percent when slight, 20 percent when moderate, and a maximum 30 percent when severe. 38 C.F.R. § 4.71a. When semilunar cartilage is dislocated with frequent episodes of locking, pain and effusion into the joint a 20 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5258. When semilunar cartilage has been removed, but remains symptomatic, a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Diagnostic Code 5260 pertains to limitation of flexion. A 10 percent evaluation is assignable when flexion is limited to 45 degrees. A 20 percent evaluation is assignable where flexion is limited to 30 degrees. An evaluation of 30 percent is assignable when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 applies to limitation of extension of the leg. A 10 percent evaluation is assignable for extension limited to 10 degrees. A 20 percent evaluation is assignable for extension limited to 15 degrees. A 30 percent evaluation is assignable for extension limited to 20 degrees. A 40 percent evaluation is assignable for extension limited to 30 degrees. A 50 percent evaluation is assignable when extension is limited to 50 degrees. 38 C.F.R. § 4.71a. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The VA General Counsel has also directed that separate ratings are available if a particular knee disability causes both compensable (10 percent) limitation of extension (Diagnostic Code 5261) and compensable limitation of flexion (Diagnostic Code 5260) of the same joint. Specifically, where a Veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-2004. Diagnostic Codes 5262 and 5263 provide ratings for impairment of tibia and fibula and genu recurvatum, respectively. Diagnostic Code 5010 provides that arthritis, due to trauma, substantiated by x-ray findings are to be rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis is rated according to Diagnostic Code 5003. Degenerative arthritis established by x-ray findings is to be evaluated based on limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, an evaluation of 10 percent 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 evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups. A 20 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a. In VAOPGCPREC 23-97, the VA General Counsel interpreted that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that, if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. When assigning ratings, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were an amputation were to be performed. 38 C.F.R. § 4.68. Amputation not improvable by prosthesis controlled by natural knee action warrants a 60 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5165. When evaluating joint disabilities rated based on limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 207 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. See id. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, that is established by x-ray, is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). The Court has held that the provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The Court has also issued the opinion of Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016), which clarifies additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. The Board has carefully reviewed the evidence of record and finds the evidence in this case does not warrant a rating in excess of 10 percent prior to April 8, 2010, for right knee degenerative changes, but from June 1, 2011, a 60 percent rating for chronic residuals following total knee replacement is warranted. Post service treatment records reflect a diagnosis of degenerative changes, right knee from January 2007. In March 2006, a VA physical therapist noted that physical examination of the Veteran's right knee reflected active range of motion flexion to 120, passive range of motion flexion to 126, and extension was within normal limits. The treatment provider noted that the Veteran did not use any assistance to walk, and he could walk 1,000 feet without rest. The Veteran was afforded a VA examination in April 2006. Physical examination of the Veteran's right knee reflects flexion to 140 degrees and extension to 0 degrees without pain. Physical examination of the Veteran's left knee reflects flexion to 80 degrees with pain, and extension to 10 degrees. The examiner noted that the Veteran's right knee was not limited by pain, fatigue, weakness, lack of endurance, or incoordination. The examiner opined that the Veteran's condition affected the Veteran's usual activities by not being able to run, jump, or do prolonged walking or standing. The examiner opined that it did not affect the Veteran's usual occupation because he had been working in the post office for the past 20 years. In January 2007, the Veteran was afforded a VA examination, which reflected a diagnosis of degenerative changes right knee. The Veteran reported that he did not have any particular trauma to his right knee, but because he began favoring his left knee, he started developing problems in his right knee, which became more pronounced in 2004. The Veteran reported that it felt like it gave out at times, and he had pain just on the front of the right knee area. The examiner noted that physical examination of the right knee revealed abnormal appearance, as there were osteoarthritic changes to a mild degree. There was no heat, redness, swelling, effusion, drainage or abnormal movement of the right knee. There was tenderness on the lateral joint line. The examiner noted that there was no medial and lateral instability noted. There was crepitus on flexion of the right knee. The Veteran had flexion of the right knee to 130 degrees with pain and extension to 0 degrees with no pain. The range of motion of the right knee was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use or during flare-ups. There was no ankylosis of the right knee. He had flexion of the left knee to 90 degrees with pain, and extension to 0 degrees with no pain. The Veteran was afforded a VA examination in June 2008, which reflected a diagnosis of degenerative changes right knee. The examiner noted that the Veteran's right knee disability developed in 2006, when the Veteran was compensating for his left knee, left hip and back disabilities. The Veteran reported that he had weakness, stiffness, swelling, giving way, lack of endurance, fatigability of the right knee with intermittent pain 10 to 20 times a day, lasting for 1 to 2 hours each time. The Veteran reported that the pain would travel down to the right calf like a crushing, aching, squeezing, cramping, burning, sharp pain with severity of 10 out of 10, and was worsened with walking, resting, or driving. To treat the pain, the Veteran would apply ice, heat and rest, and sometimes complete bedrest. The examiner noted that the Veteran did not have a prosthetic implant. The examiner noted that the functional impairment resulting from the Veteran's right knee condition was that the Veteran could not run, he would miss a lot of work because of his knee pain, he could not drive too long with stiffness, and he had aching and swelling of the right knee. Physical examination revealed guarding of movement and weakness of both knees. There was crepitus on both knees without locking pain. There was no ankylosis. The Veteran had flexion of both knees to 110 degrees with pain, and extension to 0 degrees with no pain. The examiner noted that there was fatigue, weakness, lack of endurance, and incoordination of both knees. After repetitive use of both knees, there was an additional 10 degrees limitation of motion with pain, fatigue, weakness, lack of endurance and incoordination with pain having the major impact on function. The Veteran had normal stability tests bilaterally. The examiner noted that the Veteran required a cane to walk. VA treatment records reflect that the Veteran underwent a right total arthroplasty in April 2010. The treatment records reflect a diagnosis of right knee degenerative joint disease. The treatment provider noted that the Veteran had a longstanding history of right knee pain secondary to degenerative joint disease. The treatment provider noted that the Veteran failed conservative management and elected to have total knee replacement. A May 2010 VA examination reflects a diagnosis of degenerative changes, right knee status post knee replacement with residual of inability to move and pain. Physical examination of the right knee reflected ankylosis. The examiner noted that there was ankylosis at 20 degrees of the right knee joint flexion, which is an unfavorable position, and ankylosis at 20 degrees of the right knee joint extension, which is an unfavorable position. The examiner did not perform range of motion of the right knee because the joint was ankylosed, and the Veteran was unable to perform stability tests for the right knee because he had just had surgery. The examiner noted that the Veteran's right knee was unstable and painful. There was no subluxation on the right knee. The examiner opined that the effect of the condition on the Veteran's daily activity was a complete inability to perform any activities of daily living or normal recreational activities. The examiner opined that the Veteran's right knee was expected to improve within three months. The Veteran was afforded a VA examination in October 2011. Physical examination of the Veteran reflected that his right knee deep tendon reflexes were absent, and his left knee deep tendon reflexes were hypoactive. The Veteran's right knee muscle strength reflected active movement against gravity, and his left knee muscle strength reflected no muscle movement. The Veteran was afforded a VA examination for his left knee arthritis in April 2015. Physical examination of the Veteran's right knee reflected flexion to 110 degrees with pain, and extension to 0 degrees. The examiner noted that pain was noted on the examination, but it did not result in or cause functional loss. The Veteran's left knee reflected flexion to 130 degrees with pain, and extension to 0 degrees. The Veteran was able to perform repetitive use testing with at least three repetitions, but there was no additional functional loss or range of motion after three repetitions. The examiner noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Physical examination of the right knee reflected normal strength on forward flexion and extension. The examiner noted that there was no ankylosis, no history of lateral instability, no history of recurrent effusion. The examiner did not test joint stability of the right knee. The examiner opined that following total knee joint replacement of the right knee, the Veteran had chronic residuals consisting of severe painful motion or weakness. The Veteran used a cane to walk due to the pain in his hips and knees. The examiner opined that the Veteran's conditions did not impact his ability to perform any type of occupational task. The Board notes, that the Veteran currently has a 10 percent evaluation for right knee degenerative changes prior to April 8, 2010. This is presumably based on demonstrated painful flexion. See Lichtenfels, supra. The Veteran was afforded VA examinations in April 2006, January 2007 and June 2008, which reflect that the Veteran's flexion was limited to at most 100 degrees. Based on these measurements, the Veteran's flexion has not been limited to a compensable level under Diagnostic Code 5260 prior to April 8, 2010. Likewise, the examinations reflect that extension was 0 degrees, with no objective evidence of painful motion. However, as noted, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. See id. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Thus, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, that is established by x-ray, is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual compensable limitation of motion under Diagnostic Codes 5260 or 5261. The examiner noted that functional loss was present in the right knee, manifesting as limitation of motion with pain, fatigue, weakness, lack of endurance, and incoordination. The examiner also noted crepitus without locking pain. The normal range of motion for the knee is 140 degrees flexion and 0 degrees extension. 38 C.F.R. § 4.71, Plate II. Compensation for pain is limited to a single 10 percent disability rating per joint when there is "no actual or compensable limitation of motion." See Mitchell v. Shinseki, 25 Vet. App. 32, 36 (2011). The Veteran's flexion is limited to at most 100 degrees, and there is less movement than normal, but this functional loss due to painful motion is otherwise not compensable under the rating criteria. Thus, the Board finds that the Veteran is entitled to the minimum rating of 10 percent for limitation of flexion due to pain as currently assigned. The Board has considered whether it may be appropriate to rate the Veteran's right knee disability under other diagnostic codes, but finds that no higher or additional evaluations are warranted, prior to April 8, 2010. The evidence during this period does not reflect findings of favorable ankylosis of the right knee in a favorable angle in full extension, or in slight flexion between 0 and 10 degrees, which would warrant a higher rating. There is no objective evidence of instability or subluxation, and there is no evidence of a torn or removed cartilage. Further, the evidence during this period does not reflect findings of impairment of the tibia and fibula, or genu recurvatum, or hyperextension, prior to April 8, 2010. From June 1, 2011, the Board finds that the criteria for a disability rating of 60 percent are met. The evidence during this period reflects that the Veteran underwent total knee replacement surgery in April 2010. Therefore, the Veteran's right knee disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board observes that the evidence during this period does not reflect findings of limitation of extension to 30 degrees; or favorable ankylosis of the right knee in a favorable angle in full extension, or in slight flexion between 0 and 10 degrees, which would warrant a higher rating; or impairment of the tibia and fibula manifested by nonunion. However, based upon the April 2015 VA examination, the Board finds that there was evidence of chronic residuals consisting of severe painful motion and weakness. The Board finds that overall the evidence indicates that the evidence in this case from June 1, 2011 more nearly approximates the 60 percent rating that contemplates chronic residuals consisting of severe painful motion and weakness. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In this case, a preponderance of the evidence is against a finding that a disability evaluation in excess of 10 percent is warranted for degenerative changes of the right knee prior to April 8, 2010; however, the Board finds that the residuals of the Veteran's total right knee replacement do warrant a 60 percent disability evaluation from June 1, 2011. The Board finds that it is not necessary to defer adjudication of the extraschedular issue while the TDIU claim is further developed pursuant to the remand instructions below. Brambley v. Principi, 17 Vet. App. 20(2003) (noting the inextricably intertwined nature of a decision on extraschedular consideration and a TDIU claim). In Brambley, the determining factor for the extraschedular rating was marked interference with employment. In this case, the initial element of the analysis is not met as the Board finds that the schedular criteria are not inadequate as they contemplate all of the Veteran's symptomatology as outlined above; therefore, an analysis of whether there is marked interference with employment is not required. Thus, meaningful effect of Brambley does not apply to the Veteran's case. ORDER Entitlement to a rating in excess of 10 percent prior to April 8, 2010 for degenerative changes of the right knee is denied. Entitlement to a 60 percent rating for degenerative changes of the right knee, status post total knee replacement from June 1, 2011, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The Veteran's claim for a total disability rating based upon individual unemployability due to service-connected disabilities must be remanded. A 100 percent combined schedular rating has been granted from February 21, 2013. However, the assignment of a 100 percent combined schedular rating does not necessarily render the issue of TDIU moot. There could be a situation where a Veteran has a schedular total rating for a particular service-connected disability, and nonetheless could establish entitlement to a TDIU for another service-connected disability in order to qualify for special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s) by having an "additional" disability of 60 percent or more ("housebound" rate). Bradley v. Peake, 22 Vet. App. 280, 293 (2008); see also 38 U.S.C.A. § 1114(s). Essentially, the Veteran might still be entitled to TDIU if one service-connected disability alone could constitute the basis for a grant of TDIU at any point during the appeal period. Thus, it is possible to be awarded a TDIU on the basis of a single disability, notwithstanding the combined 100 percent rating. Bradley v. Peake, 22 Vet. App. at 293-94. The Board notes further, that the 100 percent combined rating in this case is only effective from February 21, 2013. The Board observes that the Veteran reported that he last worked fulltime in 2009; the appeal period goes back to 2006. See, e.g. VA Form 21-8940, dated in February 2013. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA general medical examination in regard to his TDIU claim. The claims folder must be made available for the examiner to review. The VA examiner should provide an opinion as to the functional impairment caused solely by the Veteran's service-connected disabilities, either alone or in combination with each other, which include bilateral knee disabilities, bilateral hip disabilities, and a low back disability, given his education and occupational experience, which could impact either daily living or industrial capacity. The examiner should not consider the Veteran's age or any nonservice-connected disabilities. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 2. Thereafter, adjudicate the issue of entitlement to a TDIU, to include on an extraschedular basis for any applicable period during the course of this appeal. The AOJ should also consider whether a TDIU is warranted even for the period from February 21, 2013 for any particular service-connected disability even though a schedular 100-percent combined rating is already in effect in order to determine the Veteran's eligibility for SMC under section 1114(s). If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and afforded a reasonable period of time within which to respond thereto. 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112. S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs