Citation Nr: 1750737 Decision Date: 11/07/17 Archive Date: 11/17/17 DOCKET NO. 10-19 647 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for residuals of a right wrist fracture. 2. Entitlement to increases in the (10 percent prior to July 31, 2012 and 20 percent from that date to February 29, 2016) combined staged ratings assigned for left knee degenerative joint disease (DJD). 3. Entitlement to a rating in excess of 30 percent for post-total knee replacement (TKR) left knee disability from April 1, 2017. 4. Entitlement to a combined rating in excess of 20 percent for right elbow epicondylitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1983 to August 2001. These matters are before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the Montgomery, Alabama Regional Office (RO) of the Department of Veterans Affairs (VA). In November 2016, the case was remanded for additional development. An interim (June 2017) rating decision assigned a total schedular rating for the left knee disability from February 29, 2016 to April 1, 2017 (and that period of time is not for consideration), and a 30 percent rating from that date, and also granted a separate 10 percent rating for limitation of left knee extension for the period from July 31, 2012 to February 29, 2016. The matters of the ratings for right elbow epicondylitis are being REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action on his part is required. FINDINGS OF FACT 1. A chronic right wrist disability, residual of a right wrist fracture in service, was not manifested in service; arthritis of the right wrist was not manifested within one year after the Veteran's separation from service; and no current right wrist disability is shown to be related to his service, to include as a residual of a fracture therein. 2. It is reasonably shown that the Veteran's left knee DJD was manifested by limitation of extension at 10 degrees throughout (from April 23, 2008 to February 29, 2016), but at no time was shown to have been manifested by limitation and 15 degrees, even with consideration of functional impairment on use; at no time prior to February 29, 2016 is it shown to have been manifested by flexion limited to 30 degrees, even with consideration of functional impairment on use. 3. At no time from April 1, 2017, is the Veteran's post-TKR left knee disability shown to have been manifested by chronic residuals of severe painful motion or weakness; by ankylosis or limitations of motion warranting a combined rating in excess of 30 percent; or by nonunion of tibia or fibula or malunion marked knee disability. CONCLUSIONS OF LAW 1. Service connection for residuals of a right wrist fracture is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2016). 2. The Veteran's left knee DJD warrants a combined 20 percent (but no higher) rating throughout prior to February 29, 2016, from (the earlier effective date of) April 23, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (Codes) 5003, 5260, 5261 (2016). 3. A rating in excess of 30 percent for post-TKR left knee disability is not warranted for any period of time from April 1, 2017. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Codes 5055, 5256, 5261, 5262 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. VA's duty to notify was satisfied by correspondence in May 2008 and October 2008. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159. The Veteran has not raised any other issues with respect to the duties to notify and assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) ("the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence that is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection for residuals of a right wrist fracture Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders first diagnosed after discharge may be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic diseases (to include arthritis), may be service connected on a presumptive basis if manifested to a compensable degree within a specified period of time postservice (one year for arthritis). 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a). For diseases listed in 38 C.F.R. § 3.309(a), a nexus to service may be established by showing continuity of symptomatology following service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Veteran contends that he has current chronic right wrist disability as a residual of a fracture sustained in service. He asserts that he fractured the right wrist in a fall in service and continued to have wrist pain throughout, and after, his service. His STRs show that he sustained a right wrist fracture his in March 1994, in a fall on asphalt while jogging. He was placed in a short arm cast for 3 weeks followed by a splint. In May 1994, the injury was noted to be healing with no further damage or complications. The remaining STRs are silent for findings, treatment, or diagnosis regarding the right wrist. On April 2001 service separation examination, the upper extremities were normal on clinical evaluation; the examiner noted the Veteran's report of a history of chronic right wrist pain. On February 2002 VA examination, the Veteran related that in March 1994 he broke his right wrist, which was casted for three weeks. He reported that he still experienced right wrist pain, inflammation, fatigue, and lack of endurance, with occasional (monthly) exacerbations from normal usage. An X-ray was negative, and there were no constitutional signs of arthritis. Following physical examination, it was noted that there was no pathology to render a diagnosis of a right wrist disorder. On January 2016 VA examination, it was noted that the Veteran sustained a right wrist fracture in 1994, and that follow-up notes indicate that the condition had resolved. He reported aching in the right wrist for the previous 6 years, with daily discomfort, and that he last saw a primary care physician regarding the wrist around 2010 (and there was no documentation of such visit). He reported that pain sometimes awakens him. He reported about twice weekly flare-ups (which occur spontaneously), with the pain level going to 9/10, and that he cannot do any heavy lifting. He had worked as a contractor from 2001 to 2010. Imaging studies of the wrist did not show degenerative or traumatic arthritis. Following physical examination, the diagnosis was right wrist strain. The examiner noted that the Veteran reported some right wrist pain on his May 2001 retirement examination and that a February 2002 right wrist X-ray was negative. The examiner opined that the right wrist strain was less likely than not (less than 50% probability) incurred in or caused by the claimed injury in service. The examiner noted that the Veteran sustained a wrist fracture on active duty in the mid-1990s, and reported he had problems with the wrist for about the past 6 years. The examiner opined that the current condition is unrelated to the 1994 healed fracture. In a February 2017 addendum, the 2016 VA examiner opined that the Veteran's current right wrist condition was less likely than not (less than 50% probability) incurred in or caused by the injury in service. The examiner noted that the Veteran sustained a right wrist fracture on active duty which had resolved, and opined that the Veteran does not suffer from a chronic non-healed fracture. The examiner noted that review of the record does not find any right wrist injury other than the resolved 1994 fracture. The examiner noted that the Veteran's 2001 retirement exam did list a report of some chronic right wrist pain; however, on 2016 examination, the Veteran indicated that he had problems with the wrist for only about 6 years. The examiner explained that the January 2016 opinion (indicating current right wrist disability was unrelated to a fracture in service) was provided based on the Veteran having been symptomatic for only 6 years; that he was able to function as a contractor from 2001 until 2010; that he had not seen a physician for his wrist since 2010; and that there was no documentation of treatment for the wrist. The examiner noted that the February 2002 examination report was reviewed and showed a normal right wrist, and that 2016 right wrist X-rays found no evidence of DJD. The examiner opined that the current right wrist condition is not likely related to military service. While a right wrist fracture (that resolved without residual pathology) in service is shown, a chronic right wrist disability in service is not. Although the Veteran reported a history of chronic right wrist pain on service separation examination, a right wrist disability was not then found. There is no evidence that the currently diagnosed right wrist strain was manifested in service or that right wrist arthritis was manifested in the first postservice year (and the Veteran does not allege otherwise). Consequently, service connection for residuals of a right wrist fracture on the basis that such disability became manifest in service and persisted, or on a presumptive basis (for right wrist arthritis as a chronic disease under 38 U.S.C.A. § 1112), is not warranted. The right wrist strain currently shown is not a chronic disease listed in 38 C.F.R. § 3.309(a), and continuity of symptoms is also not shown (as the Veteran's upper extremities were normal on April 2001 service separation examination, and in 2016 he reported only a 6 year history of wrist problems). Furthermore, the preponderance of the evidence is against a finding that a current right wrist disability may otherwise (i.e., other than based on onset in service or on a chronic disease presumptive basis or continuity) be related to his service. Whether in the absence of contemporaneous evidence of onset of a chronic disability in service and postservice continuity of related complaints a current chronic right wrist disability may be related to remote service/documented injury therein is a medical question. VA examiners have all opined that any current right wrist disability is unrelated to his right wrist fracture in service. On the dispositive question of whether the current right wrist strain is related to/a residual of the undisputed fracture in service the Board finds the report of the January 2016 examination (with February 2017 addendum) particularly probative, and persuasive. The providers reflect familiarity with the Veteran's records, and the rationale for the opinions cites accurately to supporting factual data. The provider acknowledged the history of right wrist pain noted in service, but observed that in 2016 the Veteran reported that his current right wrist problems were only 6 years in duration (i.e., beginning about 9 years after service). While the Veteran is competent to report (current and past) right wrist problems he has had, he is a layperson, and is not competent to, by his own opinion, establish that current right wrist pathology is related to (a residual of) a fracture that occurred in remote service. In light of the foregoing, the Board concludes that the preponderance of the evidence is against this claim, and that the appeal seeking service connection for residuals of a right wrist fracture must be denied. Left knee disability ratings Disability ratings are determined by applying the criteria set forth in 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. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. When evaluating a service-connected disability based on limitation of motion, the Board must take into consideration functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnson v. Brown, 9 Vet. App. 7 (1996). In DeLuca, the Court held that a diagnostic code based on limitation of motion does not subsume 38 C.F.R. §§ 4.40 and 4.45 and that the rule against pyramiding set forth in 38 C.F.R. § 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use, including use during flare-ups. Id. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Nonetheless, a rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). The criteria for rating the Veteran's left knee disability prior to February 29, 2016 are found in Codes 5256 to 5263. Under Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Codes for the specific joints involved. When the limitation of motion of the specific joints involved is noncompensable under the appropriate Codes, a 10 percent rating is warranted for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under Code 5260, limitation of knee flexion to 15 degrees warrants a 30 percent rating, to 30 degrees a 20 percent rating, to 45 degrees a 10 percent rating, and to 60 or more degrees a 0 percent rating. Under Code 5261, limitation of knee extension at 20 degrees warrants a 30 percent rating, at 15 degrees a 20 percent rating, at 10 degrees a 10 percent rating, and at 5 degrees (or less) a 0 percent rating. 38 C.F.R. § 4.71a. Post-TKR knee disability is rated under Code 5055. A 60 percent rating is warranted for chronic residuals of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion, are rated by analogy to Codes 5256, 5261, or 5262. 30 percent is the minimum rating under Code 5055. Consideration of other diagnostic codes for rating knee disability (5256, 5257, 5258, 5259, 5262, 5263) is inappropriate in this case as the Veteran's left knee disabilities do not include the pathology required in the criteria for those Codes (ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage, removal of symptomatic semilunar cartilage, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. On June 2008 VA examination, the Veteran reported left knee stiffness, swelling, giving way, lack of endurance and pain. He did not have weakness, heat, redness, locking, fatigability, or dislocation. He reported constant pain at the front of the knee on the inside, traveling to around the knee, described as burning, aching and sharp, and 9/10 in severity. The pain was elicited by physical activity and stress and relieved by rest and Motrin. He could function with medication at the time of pain. He reported tenderness in the front of the knee and below the knee cap sometimes becoming stiff and giving way. He reported being unable to use stairs or drive for over an hour most of the time. On physical examination, there was tenderness and guarding of left knee movement. There were no signs of edema, effusion, weakness, redness, heat, or subluxation. There was crepitus, but no genu recurvatum or locking pain. Flexion was to 60 degrees with pain occurring at 30 degrees, and extension was to 0 degrees. Joint function was additionally limited by pain after repetitive use; it was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. The examiner was unable to perform ligament stability tests because the Veteran was unable to bend the knee enough, due to pain. Neurological testing was normal. X-rays showed degenerative arthritic changes. The diagnosis was DJD, left knee, status post fracture, with subjective pain and stiffness and objectively decreased range of motion with pain and X-ray evidence of DJD. The examiner opined that the effect of the condition on the Veteran's daily activity was limited exercise and ambulatory capacity due to knee and low back conditions. On June 2010 treatment, the Veteran reported left knee pain that was aggravated by squatting and jogging, with associated swelling and stiffness. He was noted to have low grade chondromalacia in the medial and patellofemoral compartments. On physical examination, there was a moderate amount of patellofemoral crepitus of the knee, mild pain over the medial femoral condyle, and moderate tenderness over the patellofemoral articulation. There was pain with patellofemoral ballottement and no lateral compartment tenderness. The knee was stable. X-rays revealed only mild medial joint space narrowing and a small patellofemoral osteophyte; there were no fractures, dislocations, or bony lesions. In a July 31, 2012 statement, the Veteran stated that he could not flex his left knee and that the knee gave way. He stated that he has to go up the stairs one step at a time due to lack of flexibility in the left knee. On April 2014 treatment, the Veteran reported no significant changes in his symptoms, which included left knee pain that was moderate with a rating of 6/10 severity. He was treated with a cortisone/steroid injection in February 2014 with significant relief of the symptoms for 2 to 3 weeks. He complained of left knee pain over the anterior medial joint line that was worse with activity, with swelling. He reported that the pain limited his activity and bothered him daily. He reported that the knee would pop and grind. He reported undergoing left knee arthroscopy in July 2013. On physical examination, there was patellofemoral crepitation and no instability, redness or warmth. Motor and sensory function was intact. The knee was tender over the medial joint line. Range of motion was from 10 to 110 degrees. X-rays showed deformity from prior proximal tibia fracture, varus deformity at the joint line, medial loss of joint space, spurs noted in the patellofemoral compartment, lateral tracking of the left patella, and calcification of medial and lateral menisci. On September 2015 VA examination, the Veteran reported constant pain and arthritis in the left knee. He reported limited ability to walk or stand due to pain. He reported getting periodic injections which are of limited value. He reported being unable to stand for more than 10 minutes or walk for a quarter-mile at a time before he must stop due to knee pain. He did not report flare-ups. On physical examination, flexion was from 5 to 40 degrees, and extension was from 40 to 5 degrees. The examiner noted that the range of motion itself contributes to functional loss in that the Veteran is unable to bend his knee. Pain was noted on exam for flexion and extension and caused functional loss. There was evidence of pain with weight bearing. There was objective evidence of medial joint line tenderness on palpation of the joint. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional functional loss or range of motion after three repetitions. The examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner could not say without resort to mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time,. Additional contributing factors of disability included less movement than normal due to ankylosis, adhesions, etc.; disturbance of locomotion; and interference with standing. Muscle strength testing was 3/5 for forward flexion and 4/5 for extension, showing a reduction in muscle strength entirely due to the knee disability. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint instability was not found on testing; anterior instability (Lachman), posterior instability (posterior drawer), medial instability and lateral instability tests were all normal. The Veteran did not use any assistive device for normal locomotion. The examiner opined that the Veteran's left knee disability did not impact his ability to perform any type of occupational task. The diagnoses included proximal tibial fracture (1995) with DJD, and left knee traumatic arthritis. Based on this evidence, a February 2016 rating decision granted a separate 0 percent rating for limitation of left knee extension, effective April 23, 2008, and continued the 10 percent rating for joint disease of the left knee, residual of fracture. The Veteran submitted an operative report showing that he underwent a left knee TKR in February 29, 2016. On March 2017 VA examination, the Veteran was noted to be one year status post left total knee replacement. Flexion of the left knee was from 115 to 0 degrees and extension was from 0 to 115 degrees. Pain was noted on flexion but did not result in or cause functional loss. There was no evidence of pain with weight bearing. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the joint or associated soft tissue. On May 2017 VA examination, the Veteran reported constant moderate (6 to 7 out of 10) pain in the left knee. He reported intermittent feelings of giving way every other day but no locking. There were no dislocations or subluxation and no recurrent effusions. He used naproxen and a neoprene brace for the left knee, and he previously had physical therapy following left knee replacement in February 2016. He retired from the Army in 2001 and had worked as a defense contractor until 2010. He reported flare-ups of the knee that were worse with prolonged walking. He did not report any functional loss or impairment of the joint, including, but not limited to, with repeated use over time. On physical examination, flexion of the left knee was from 0 to 100 degrees and extension was from 100 to 0 degrees. The range of motion itself did not contribute to functional loss. Pain was noted on flexion and extension but did not result in, or cause, functional loss. The examiner opined that passive range of motion testing was not medically appropriate because attempts to perform passive range of motion and/or during weightbearing increase the risk of falls and injury, therefore it was not feasible. There was no evidence of pain with weight bearing, and there was no evidence of pain when the joint was used in non-weight bearing. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the knee or associated soft tissue. The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional functional loss or range of motion after three repetitions. The examination was neither medically inconsistent nor inconsistent with the Veteran's statements describing functional loss during flare-ups or with repetitive use over time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups or repeated use over a period of time. Muscle strength testing was 5/5 for flexion and extension, with no reduction in muscle strength. There was no atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint instability was not found on testing: anterior instability (Lachman), posterior instability (posterior drawer), medial instability and lateral instability tests were all normal. The Veteran reported residuals of left total knee joint replacement consisting of intermediate degrees of residual weakness, pain or limitation of motion. X-rays showed total knee arthroplasty in place with no obvious failure or loosening; that there may be slight narrowing of the femorotibial joint spaces; no acute fractures or dislocation; suggestion of a small joint effusion; mild degenerative change at the proximal tibiofibular articulation; and soft tissues unremarkable. The examiner opined that the Veteran's left knee disability impacts function in that it causes interference with prolonged standing and/or walking. A June 2017 rating decision assigned a schedular 100 percent rating (under Code 5055) for post-TKR left knee disability from February 29, 2016, and a 30 percent rating from April 1, 2017, and also granted a 10 percent rating for limitation of left knee extension from July 31, 2012 (the date of an informal claim for increase) to February 29, 2016 (when the TKR was performed). Rating prior to February 29, 2016 Significantly, on the June 2008 VA examination which was the basis for the 0 percent "stage" of the ratings assigned for limitation of extension by the AOJ, the Veteran reported left knee stiffness; he reported tenderness in the front of the knee and below the knee cap sometimes becoming stiff and giving way, and he reported being unable to use stairs. In the July 31, 2012 statement which was the basis for the 10 percent "stage" of the ratings assigned, he stated that he could not flex his left knee, that the knee gave way, and that he has to go up stairs one step at a time due to lack of flexibility in the left knee. The Board finds no reason to question the credibility of the Veteran's report on the June 2008 examination, and finds that it reasonably reflects that he had the symptoms reported in July 2012 throughout the period under consideration. As the symptoms described meet the schedular criteria for a 10 percent rating under Code 5003-5261 for limitation of left knee extension, the Board finds that such rating is warranted throughout (from April 23, 2008 to February 29, 2016). See 38 C.F.R. § 4.7. The analysis proceeds to consideration whether a rating in excess of 10 percent for limitation of extension is warranted for any period of time under consideration. The evidence of record does not include any records showing that the above-listed criteria for a 20 percent rating were met (or approximated) at any time during the evaluation period. A 20 percent rating under Code 5261 requires extension limited at 15 degrees; at no time prior to February 29, 2016 is the Veteran's left knee extension shown to have been limited to such degree. Consequently, the Board finds that a schedular 20 percent rating is not warranted for any period of time under consideration. The medical evidence does not show that at any time prior to February 29, 2016, the Veteran's left knee disability met the schedular criteria for a rating in excess of 10 percent under Code 5260 (for limitation of flexion). On June 2008 VA examination, there was crepitus of the knee and tenderness and guarding of movement of the knee, but flexion was to 60 degrees. On April 2014 treatment, the Veteran reported moderate left knee pain over the anterior medial joint line; flexion was to 110 degrees. On September 2015 VA examination, flexion was to 40 degrees, and pain was noted on examination, causing functional loss. The evidence does not reflect that during this time left knee flexion was limited to 30 degrees, even with the reported limitations regarding pain, weakness, stiffness, swelling, heat, redness, squatting, climbing, and weightbearing, so as to warrant a 20 percent rating under Code 5260. Therefore, such rating is not warranted. Rating for post-TKR left knee disability from April 1, 2017 From April 1, 2017, the only medical evidence regarding the status of the Veteran's left knee disability is in the report of the May 2017 VA examination. On that examination flexion of the left knee was to 100 degrees and extension was to 0 degrees (the knee was not ankylosed); pain was noted on flexion and extension but did not result in or cause functional loss. X-ray results showed total knee arthroplasty in place (with no obvious failure or loosening seen; there was no report of nonunion or malunion of tibia or fibula); there was a suggestion of a small joint effusion, and mild degenerative change at the proximal tibiofibular articulation was noted. It is not shown that at any time the post-TKR left knee disability had chronic residuals of severe painful motion or weakness in the affected extremity, so as to warrant a 60 percent rating under Code 5055. Regarding intermediate degrees of weakness, pain or limitation of motion considered by analogy to Codes 5256, 5261, or 5262, it is not shown at any time that left knee had manifestations analogous to fixation (ankylosis) limitations of flexion/extension that would warrant ratings combining to exceed 30 percent; or impairment analogous to nonunion requiring a brace (so as to warrant a 40 percent rating under Code 5262). Accordingly, a rating in excess of the minimum 30 percent post-TKR rating is not warranted. The ratings now assigned account for all left knee limitations shown during the periods under consideration. Hence, even with consideration of sections 4.40 and 4.45 and DeLuca, the record presents no basis for the assignment of higher ratings for the left knee under Codes 5003, 5055, 5260 and/or 5261. In summary, the Veteran's service connected left knee disability warrants a combined 20 percent (10 percent under Code 5260 and 10 percent under Code 5261), but no higher, rating throughout prior to February 29, 2016 (i.e., from the earlier effective date of April 23, 2008) and a rating no higher than 30 percent from April 1, 2017.. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Finally, the matter of a total disability rating based on individual unemployability due to service-connected disability (TDIU) is not asserted specifically or raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). ORDER Service connection for residuals of a right wrist fracture is denied. A 20 percent combined (10 percent under Code 5260 and 10 percent under Code 5261) rating is granted for the Veteran's left knee disability for throughout the period under consideration, i.e., from the earlier effective date of April 23, 2008, subject to the regulations governing payment of monetary awards. Ratings for the left knee disability in excess of 20 percent prior to February 29, 2016 and in excess of 30 percent from April 1, 2017 are denied. REMAND In November 2016, the Board remanded the matters of the ratings for the Veteran's right elbow disability pursuant to new precedential caselaw. The Board noted that in Correia v. McDonald, 28 Vet. App. 158 (2016) (regarding adequacy of range of motion testing 38 C.F.R. § 4.71a), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the range of motion testing described in the final sentence of § 4.59. The Board noted in the November 2016 remand that the September 2015 VA examination did not comply with Correia, and remanded the matters for a new examination to correct the deficiency. On March 2017 VA examination, although range of motion testing was performed, the Veteran's right elbow was not tested for pain on both active and passive motion, or in weight-bearing and nonweight-bearing positions, as instructed. There is no indication that the AOJ sought to have the Veteran re-examined. Further development for an adequate medical examination is necessary. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The action previously sought by the Board is necessary for a proper adjudication of the Veteran's appeal and there has not been substantial compliance with the remand instructions. Therefore, the matter must be remanded once again for compliance with the previous order/completion of the actions sought. See Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following: 1. The AOJ should arrange for an orthopedic examination of the Veteran to assess the current severity of his service-connected right elbow disability. (a) Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion testing for pain on BOTH active and passive motion AND in weight-bearing and nonweight-bearing. If the elbow cannot be tested on "weight-bearing," then the examiner must specifically indicate that such testing cannot be done (and explain why). (b) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups. The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If this is not feasible to determine without resort to speculation, the examiner must provide an explanation for why this is so. The examiner must include rationale with all opinions. 2. The AOJ should then review the record, ensure that the development sought is completed as requested, and readjudicate the matter remaining on appeal. If the benefit sought remains denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative opportunity to respond, and return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs