Citation Nr: 1751301 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 14-05 591 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to a higher initial rating for left knee patellofemoral syndrome, currently rated 10 percent disabling. 2. Entitlement to a higher initial rating for right knee patellofemoral syndrome, currently rated 10 percent disabling. 3. Entitlement to a separate initial rating for right knee instability. 4. Entitlement to an initial, compensable rating for hypertension, prior to April 1, 2015. 5. Entitlement to service connection for shin splints, right lower extremity. 6. Entitlement to service connection for obstructive sleep apnea, to include as due to an undiagnosed illness. 7. Entitlement to a total disability rating based on individual unemployability (TDIU), to include on an extraschedular basis, from January 1, 2015. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran served on active duty from October 1984 to October 1988 and February 2003 to August 2003. He had additional service in the Army National Guard. These matters come before the Board of Veterans' Appeals (Board) from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In that decision, the RO granted service connection for patellofemoral syndrome for each knee and hypertension and assigned initial ratings based upon limitation of motion. It denied service connection for shin split, right leg and sleep apnea. The Veteran timely appealed these determinations. In December 2014, the RO issued a decision severing service connection for hypertension from April 1, 2015. The Veteran did not appeal this decision and it is final. Thus, service connection for hypertension is no longer in effect from April 1, 2015. In June 2015, the Veteran was afforded a RO hearing and withdrew his Board hearing request. A RO hearing transcript is of record. At this hearing, the Veteran stated that he was now unemployed and that his service-connected bilateral knee disabilities interfered with employment. The Board finds that entitlement to TDIU is raised as part of the higher initial rating claims. Rice v. Shinseki, 22 Vet. App. 447 (2009) (TDIU must be considered when raised by the record in initial or increased rating claims). The issues of entitlement to service connection for shin splints of the right lower extremity, obstructive sleep apnea, and entitlement to TDIU from January 1, 2015 on an extraschedular basis are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the appeal period, limitation of motion of the left knee flexion more nearly approximated 30 degrees when considering additional functional loss; at no time did it more nearly approximate 15 degrees, to include consideration of additional functional loss. 2. Throughout the appeal period, limitation of motion of the right knee extension at more nearly approximated 15 degrees when considering additional functional loss; at no time did it more nearly approximate 20 degrees, to include consideration of additional functional loss during flare-ups. 3. The evidence is at least evenly balanced as to whether the Veteran's right knee disability more nearly approximates slight instability; at no time does the Veteran's right knee disability more nearly approximate moderate instability. 4. Prior to April 1, 2015, the Veteran's service-connected hypertension required the regular use of prescribed medications with a history of increased blood pressure readings; symptoms did not more nearly approximate predominant diastolic blood pressure of 110 or more, or a predominant systolic blood pressure of 200 or more. CONCLUSIONS OF LAW 1. The criteria for a 20 percent rating, but no higher, for limitation of left knee flexion are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260 (2017). 2. The criteria for a 20 percent rating, but no higher, for limitation of right knee extension are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261 (2017). 3. The criteria for a separate 10 percent rating, but no higher, for right knee instability are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2017). 4. Prior to April 1, 2015, the criteria for a disability rating in excess of 10 percent for service-connected hypertension have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1-4.7, 4.104, DC 7101 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The appeal for higher initial ratings arises from the Veteran's disagreement with the initial ratings assigned after the grants of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim of service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). In any event, the Veteran was appropriately notified in an October 2009 letter about the information and evidence needed to substantiate his claims, as well as the division of responsibilities in obtaining evidence. VA satisfied its duty to notify. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA obtained the Veteran's service treatment records (STRs), service personnel records, and all of the identified relevant post-service VA treatment records. In addition, he was afforded VA examinations to assess the severity of his service-connected knee and hypertension disabilities. To the extent that the knee examinations were inadequate with regard to estimated motion loss during flare-ups, the Board has remedied this inadequacy by itself estimating the degree of additional limitation of motion caused by flare-ups in a manner favorable to the Veteran. Cf. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (finding orthopedic examination inadequate with regard to flare-ups where the examination was the basis for a denial of a higher disability rating). The Board also notes that in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court interpreted 38 C.F.R. § 4.59 as to require expansive range of motion testing. The VA examination reports mostly address the Correia factors except for passive versus active motion. In this case, passive movement (i.e. assisted motion) would inherently reflect greater mobility than active movement, and the Veteran does not identify any specific problem with passive motion for either knee. See Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Consequently, any deficiency as now outlined by Correia, and is harmless error. Accordingly, there is adequate evidence of record to make a determination in this case. In June 2015, the Veteran testified at a hearing presided by a Decision Review Officer (DRO) at the RO. The hearing reflects that the DRO identified the issues and elicited pertinent testimony. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). Neither the Veteran, nor his representative, has asserted that VA failed to comply with these duties; they have not identified any prejudice in the conduct of the hearing. The Board, therefore, concludes that the hearing is adequate. Accordingly, the duty-to-assist requirements under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c) are satisfied for the claims decided herein. II. Higher initial ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In this case, the appeal arises from initially assigned ratings and consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. (a) Knees The Veteran's service-connected patellofemoral syndrome left knee is currently rated as 10 percent disabling under Diagnostic Code (DC) 5260 for limitation of flexion. 38 C.F.R. § 4.71a, DC 5260. Under DC 5260, limitation of flexion of a leg warrants a 10 percent rating is if flexion is limited to 45 degrees, and a 20 percent rating is warranted if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees warrants a 30 percent rating. Id. The Veteran's service-connected patellofemoral syndrome right knee is currently rated as 10 percent disabling under DC 5261 for limitation of extension. 38 C.F.R. § 4.71a, DC 5261. Under DC 5261 for limitation of extension of a leg provides a noncompensable when extension is limited to 5 degrees, a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Id. VA's General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2017). Further, pursuant to DC 5257, which evaluates recurrent subluxation or lateral instability, a 10 percent evaluation is warranted for slight impairment of either knee, a 20 percent evaluation is warranted for moderate impairment, and a 30 percent evaluation is warranted for severe impairment. See 38 C.F.R. § 4.71a. The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. In July 2010, the Veteran was afforded a VA knee examination. He complained about knee swelling, popping, locking and buckling. He denied grinding sensations. He had a history for fluid drainage in each knee. He complained about constant knee pain with the right being greater than the left. It was associated with walking more than 10 to 15 minutes, standing more than 5 to 10 minutes and sitting more than an hour. Accordingly, he limited standing, sitting and walking activities. He was unable to jog or run. He currently worked as forklift operator. He had knee pain from operating the forklift pedal, but denied missing any work due it. Clinical evaluation showed the Veteran to present with a limp and without any assistive device. Right knee was tender to palpation for the medial and lateral surfaces. No edema or warmth was found. There was positive crepitus. Lachman's test and McMurray's test were negative. The examiner deemed the right knee stable. Right knee range of motion (ROM) was extension to 10 degrees with pain and flexion to 100 degrees with pain. Left knee ROM was extension to 0 degrees without pain and flexion to 110 degrees with pain. The examiner stated that there was no additional limitation from pain, fatigue, weakness or lack of endurance following repetitive use. X-rays returned normal. He diagnosed bilateral patellofemoral syndrome. November 2011 VA treatment records show that the Veteran complained about his right knee giving out. Clinical examination showed good ROM. He had full strength in his left knee and 4/5 strength in his right knee. Posterior drawer and McMurray's testing was listed as positive. The clinician advised several physical therapy exercises. September 2012 VA orthopedic clinic records indicate that the Veteran had continued knee pain and was interested in having Viscosupplementation (visco) injections for both knees. Clinical examination was negative for effusion in either knee. He demonstrated a good ROM for each knee. The clinician noted mild patellofemoral crepitus during movement. He described the knees as ligamentously stable. He scheduled the visco injections for each knee. In January 2013, the Veteran was afforded another VA knee examination. The examiner continued the bilateral patellofemoral syndrome knee diagnosis. Currently, the Veteran reported constant knee pain with the right greater than the left. He denied any surgical history. He also reported popping and instability for the right knee. He wore a right knee brace. He currently had steroid injection treatment for both knees. The Veteran denied flare-ups. ROM for right knee was flexion to 105 degrees with pain beginning at 90 degrees. Right knee extension was to 0 degrees without pain. Left knee flexion was to 110 degrees with pain beginning at 90 degrees. Left knee extension was to 0 degrees without pain. Repetitive motion did not further restrict ROM in either knee. The examiner identified pain on movement and disturbance of locomotion as the factors of functional impairment. Tenderness for both joints was noted. The Veteran exhibited full muscle strength for both lower extremities. Joint stability testing was normal for each knee. The examiner reported that there was no history or evidence for recurrent patellar subluxation or dislocation. She also indicated that there was no meniscal condition. She further commented that the Veteran had a slight antalgic gait and used a brace and cane as assistive devices. She reported that there was degenerative arthritis shown on X-ray for both knees. She also reported that the knee disabilities would impact the Veteran's ability to work in physically strenuous occupations or those requiring prolonged standing or walking. It would not affect sedentary work. February and March 2013 VA treatment records reflect that the Veteran received visco injections for each knee. Clinical examination for the knees showed a good ROM, stability to valgus and vagus testing, negative Drawer sign and no signs of infection. In July 2013, the Veteran complained about severe left knee pain and requested another visco injection. January 2014 VA primary care records include complaints of 6/10 chronic bilateral knee pain. In January 2015, the Veteran received additional visco injections for each knee. February 2015 VA Social Worker note included reports of worsening knee pain that affected employability. At the June 2015 RO hearing, the Veteran reported that his knees occasionally buckled and gave away, particularly when climbing the stairs or prolonged standing. He received injections for pain relief and was recommended for a total knee replacement. He affirmed noticing ROM loss. He believed he had the greatest restriction in bending his legs backwards. He stated that his only treatment option left was total knee replacements. He reported that his bilateral knee disability had worsened since 2013. October 2015 VA primary care records show that the Veteran requested another visco injection. He cited current right knee pain. In August 2016, a VA examiner completed a Disability Benefits Questionnaire (DBQ) for both knees. She listed a patellofemoral syndrome diagnosis for each knee. The Veteran described flare-ups of knee pain with walking or standing. The examiner listed functional impairment as an inability to walk for exercise. Right knee ROM flexion was to 115 degrees and extension was to 0 degrees. Due to the right knee motion loss, the Veteran had difficulty climbing stairs. The examiner reported pain on right knee palpation to anterior. She reported pain with weight-bearing and crepitus. Left knee ROM flexion was to 110 degrees and extension was to 0 degrees. Due to the left knee ROM loss, the Veteran had difficulty climbing stairs. The examiner reported pain and swelling of the upper and lateral left knee. No weight-bearing pain was observed for the left knee. There was evidence of left knee crepitus. Repetitive motion did not produce additional motion loss in either knee. For repeated use over time, the examiner reported that the Veteran was examined immediately after repetitive use over time. However, she was unable to state whether pain, weakness, fatigability or incoordination, significantly limit functional ability with repeated use over time. For flare-ups, she stated that the examination was not conducted during a flare-up. She indicated the clinical evaluation was medically consistent with the Veteran's description of functional impairment during flare-ups. She was unable to state whether pain, weakness, fatigability or incoordination significantly limited functional ability during flare-ups. She declined to estimate motion loss during a flare-up episode. She confirmed less movement than normal, disturbance of locomotion and interference with standing were additional factors contributing to disability. The Veteran exhibited full strength in both lower extremities and did not have muscle atrophy. The examiner indicated that there was not a history of recurrent subluxation or lateral instability. Stability testing was not performed. She reported the functional impact of the bilateral knee disability as an inability to walk more than 100 feet, kneel, stoop, squat or crawl. The Veteran contends ratings in excess of 10 percent are warranted for each knee. 38 C.F.R. § 4.71a, DCs 5260, 5261. The Board finds that ratings of 20 percent are warranted for each knee based on reports of functional impairment from flare-ups and that a separate 10 percent rating for right knee slight instability is warranted. Id.; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.59, 4.71a, DCs 5257, 5260, 5261. (i) Limitation of knee motion The above evidence reflects that the Veteran's right and left knee disabilities have been manifested by pain, tenderness, crepitation, swelling, occasional effusion, popping, locking, and painful and limited motion. Right knee flexion has been limited to at most 100 degrees and right knee extension has been limited to at most 10 degrees. Left knee flexion has been limited to at most 110 degrees and left knee extension has been limited to at most 0 degrees. (See July 2010, January 2013, and August 2016 VA examination reports). Thus, facially, the criteria for higher rating based upon the currently assigned DCs are not met. 38 C.F.R. § 4.71a, DC 5260, 5261. However, the Board must also consider additional functional loss due to symptoms such as pain, repetitive motion, and flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; Mitchell, 25 Vet. App. at 44; Correia, 28 Vet. App. at 169-170; Sharp, 29 Vet. App. at 33. The Veteran has provided competent and credible reports regarding limited ability to walk, stand, climb stairs, and sit due to episodes of increased knee pain from these activities. None of the VA examiners have provided an estimated motion loss for periods of flare-ups from increased activity. Sharp, supra. The Board acknowledges that it cannot be stated with certainty as to the precise limitation of motion experienced during flare-up periods. However, the record is reasonably clear that the Veteran experiences additional motion loss in both knees during certain activities. To account for additional motion loss during periods of activity or flare-ups, the Board grants an additional 10 percent rating under DC 5260 for the left knee and DC 5261 for the right knee for estimated motion loss during flare-up periods. The Board finds that a rating in excess of 20 percent for motion loss for each knee is not warranted. 38 C.F.R. § 4.71a, DC 5260, 5261. The medical and lay statements do not indicate that the flare-ups are so severe as to more nearly approximate the 30 percent rating criteria for each knee. All clinical evaluations indicate that the Veteran has significantly greater movement than the motion loss contemplated for the 30 percent rating criteria for DCs 5260, 5261. Id.; see July 2010, January 2013, and August 2016 VA examination reports. The Board notes the June 2015 hearing report that his greatest restriction was bending his knee backwards. However, this report and his other lay assertions are vague as to precise motion loss for either knee. The Veteran does not specifically identify more motion loss suggestive of left knee ROM flexion to 15 degrees or right knee ROM extension to 20 degrees. For these reasons, a rating in excess of 20 percent for each knee is denied. Id.; Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the Veteran in weighing evidence). The Board has also considered separate ratings for motion loss in a different plane of motion. Id.; VAOPGCPREC 9-2004. As noted above, the clinical evaluations do not show compensable motion loss for left knee extension and right knee flexion. The Board has accounted for additional motion loss during periods of functional impairment above. Thus, awarding a separate rating wholly premised on the effects of functional loss would constitute pyramiding. 38 C.F.R. § 4.14; Id. Separate ratings for motion loss are not for further consideration. There has been no knee ankylosis, meniscus disorder, impairment of the tibia or fibula, or genu recurvatum at any time during the claim period. Therefore, separate/higher ratings are not warranted under DCs 5256, 5258, 5262 or 5263 at any time during the claim period. 38 C.F.R. § 4.71a, DCs 5256, 5258, 5262, 5263. (ii) Instability The Veteran has provided several reports of knee instability type symptoms, to include locking, buckling and giving way. See July 2010 VA examination report; VA treatment records from November 2011 (right knee); January 2013 VA examination report (right knee); June 2015 RO hearing. The evidence does not include any clinical correlation for his knee instability reports. Nonetheless, the Veteran is competent and credible to report these readily observable knee symptoms. Caluza, 7 Vet. App. at 506; Jandreau v. Nicholson, 492 F.3d 1372, 1377, n4 (Fed. Cir. 2007). Based on the clinical evidence and the Veteran's competent and credible reports, the Board assigns a separate 10 percent rating for slight right knee instability. Id.; 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.71a, DC 5257. The Veteran's reports are generalized and not noted in any clinical report. However, he has identified right knee instability type symptoms on several occasions noted above and such symptoms are readily observable. In this particular case, the Board considers the evidence to be approximately evenly balanced on the question of whether the Veteran has experienced right knee instability ever since the effective date of service connection for his bilateral knee disabilities. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, a compensable rating for slight right knee instability is warranted for the entire period since the effective date of service connection for the service-connected knee disabilities (i.e., September 30, 2009). The Board also finds that the right knee instability has been at most slight during the claim period (which equates to a 10 percent rating under DC 5257) due to the normal stability testing on examination, reflecting a lack of significant recurrent subluxation or lateral instability. Caluza, 7 Vet. App. at 506. Thus, an initial 10 percent rating, but no higher, for right knee instability is warranted since September 30, 2009. Id. The Board finds the evidence weighs against a separate compensable rating for left knee instability. Id. As noted above, the evidence in support of left knee instability is limited to July 2010 VA examination report and June 2015 RO hearing. These reports concerning left knee instability are generalized as to its nature, frequency and duration and less consistent than the reports of right knee instability. See November 2011, January 2013 (specifically identifying instability affecting the right knee). Additionally, the Veteran has periodically sought knee treatment during the claims period and declined to identify left knee instability as a specific problem when he would be expected to report it. See VA treatment records from November 2011, September 2012, February and March 2013, January and October 2015. It is reasonable to infer from the absence of consistent report regarding left knee stability that the disability manifestations weigh against a finding of slight left knee instability. AZ v. Shinseki, 731 F.3d 1303, 1315-16 (Fed. Cir. 2013) (silence within records is pertinent evidence when records would typically document event in dispute). Moreover, the prior clinical reports also weigh against a finding of slight left knee instability. (January 2013 VA examination report; VA treatment records from September 2012, February 2013 and March 2013). For all these reasons, the evidence does not show symptoms more nearly approximating recurrent subluxation or lateral instability, and a separate compensable rating for left knee instability under DC 5257 is thus not warranted. (b) Hypertension The Veteran's hypertension has been assigned a 10 percent rating under 38 C.F.R. § 4.104, DC 7101. Under that DC, a 10 percent evaluation is warranted where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. A 20 percent evaluation is warranted where diastolic blood pressure is predominantly 110 or more, or systolic blood pressure is predominantly 200 or more. A 40 percent evaluation is warranted where diastolic pressure is predominantly 120 or more, and a 60 percent evaluation is warranted where diastolic blood pressure is predominantly 130 or more. 38 C.F.R. § 4.104. The Veteran's service-connected hypertension is assigned a 10 percent evaluation under DC 7101 prior to April 1, 2015. The Board notes that service connection was severed for hypertension in a December 2014 rating decision that is now final. The Board finds that a higher initial disability rating prior April 1, 2015 is not warranted. VA treatment records from September 2009 to April 2015 include blood pressure readings weighing against a diastolic blood pressure that is predominantly 110 or more, or systolic blood pressure that is predominantly 200 or more. In February 2013, the Veteran was afforded a VA hypertension examination. He reported a lengthy history for hypertension. He currently took three medications to treat it. He reported monitoring his blood pressure at home with average readings of 130/80. He denied any complications. The examiner took three blood pressure measurements listed as follows: 136/88; 130/84; and 130/90. The examiner reported that the condition did not have any functional impact. At the June 2015 RO hearing, the Veteran reported that he continued to take hypertension medication and had typical blood pressure readings of 140/90. In sum, the evidence of record does not demonstrate any findings of diastolic pressure of 110 or more, or systolic pressure of 200 or more. McCarroll v. McDonald, 28 Vet. App. 267. 276-77 (2016) (Board may properly consider ameliorative effects of blood pressure medication). The criteria for a 20 percent rating, or higher, are not met at any time during the relevant appeal period. Id.; 38 C.F.R. §§ 4.3, 4.7, 4.104, DC 7101. As the preponderance of the evidence is against a higher rating, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b). c. Additional Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating criteria adequately contemplate disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms, i.e., marked interference with employment and frequent hospitalization. If the disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of Compensation Service to determine whether an extraschedular rating is warranted. The above evidence reflects that the knee symptoms the Veteran experiences are manifestations of pain and instability, which are contemplated by the criteria. See Burton v. Shinseki, 25 Vet.App. 1, 5 (2011) (holding that § 4.59 applies to "joint pain in general" and is not limited to joint pain due to arthritis); see also 38 C.F.R. §§ 4.40 4.45. Cf. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (difficulty in distinguishing sounds in a crowded environment, locating the source of sounds, understanding conversational speech, hearing the television, and using the telephone are each a manifestation of difficulty hearing or understanding speech, which is contemplated by the schedular rating criteria for hearing loss). Moreover, the symptoms of hypertension including high blood pressure readings and medication are contemplated by the rating criteria. Consequently consideration of whether there is marked interference or frequent hospitalization is not required. In Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), the Federal Circuit held that "[t]he plain language of § 3.321(b)(1) provides for referral for extra-schedular consideration based on the collective impact of multiple disabilities." Here, however, the issue has not been argued by the Veteran or reasonably raised by the evidence of record. The Veteran has not asserted, and the evidence of record does not suggest, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016) ("the Board is required to address whether referral for extraschedular consideration is warranted for a veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities"). The Board will therefore not address the issue further. The Veteran reported that he was laid off beginning January 2015 and is not employed. There are several reports that his bilateral knee disability interferes with his ability to complete occupational task. The Board has referred an extraschedular TDIU claim based upon these reports. Given that the Board found that the criteria for rating the knees and hypertension contemplated the symptoms, and that there was no unusual circumstance warranting consideration of the collective impact of multiple disabilities, there is no inconsistency in determining that remand for referral for extraschedular rating is not required and remanding the issue of entitlement to a TDIU pursuant to 38 C.F.R. § 4.16(b). Cf. Brambley v. Principi, 17 Vet.App. 20, 24 (2003) (it is "premature for the Board to decline extraschedular consideration where the record was [ ] incomplete" on an issue relevant to the extraschedular determination, such as occupational impairment). ORDER Entitlement to an initial 20 percent rating, from September 30, 2009, for left knee limitation of flexion is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial 20 percent rating, from September 30, 2009, for right knee limitation of extension is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial 10 percent rating, from September 30, 2009, for right knee instability is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an initial rating in excess of 10 percent for service-connected hypertension is denied. REMAND For the service connection claims, the Veteran was afforded a January 2013 VA examination. However, the claims folder was unavailable and the examiner did not furnish medical opinions for these claims. VA medical opinions are needed to fulfill VA's duty to assist. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination or to obtain an opinion when developing a service connection claim, even if not statutorily obligated to do so, it must provide or obtain one that is adequate for purposes of the determination being made). The AOJ must obtain appropriate medical opinions for the claimed shin splints of the right lower extremity and sleep apnea as instructed below. For TDIU, the Veteran was laid off from work effective January 1, 2015 and was then unemployed. (See RO hearing transcript, p. 5). He has consistently reported that his service-connected bilateral knee disabilities significantly interfere with work. (June 2015 RO hearing transcript, pp. 3-5; February 2015 VA treatment records; January 2013 VA examination report). His current employment status is unclear. Based on the above, the Board finds there is an indication in the evidence of record that the Veteran's service-connected disabilities would significantly interfere with his ability to secure or follow a substantially gainful occupation. The Veteran does not currently meet the TDIU criteria laid out in 38 C.F.R. § 4.16(a) and the Board is precluded from considering TDIU in the first instance pursuant to 4.16(b). Bowling v. Principi, 15 Vet. App. 1 (2001). Based upon reports of occupational interference above, the Board finds that a sufficient showing has been made to warrant remand of the claim for referral to the Director of Compensation Service for consideration of whether a TDIU is warranted on an extraschedular basis. Accordingly, the claims remaining on appeal are REMANDED for the following action: 1. Obtain relevant VA treatment records since July 5, 2016 for the Veteran and associate them with the record. 2. Then, contact an appropriate clinician for a VA shin splint medical opinion. The clinician should conduct a complete review of the electronic claims folder. (If the clinician indicates physical examination is needed, this should be scheduled). (a) Is it at least as likely as not that any shin splint disability of right lower extremity present since September 2009 is the result of a disease or injury in active service, or had its onset in such service? (b) The examiner should provide comprehensive reasons for this opinion. The examiner should consider the Veteran's reports of a 1985 physical training injury and shin splint symptoms since this injury. (c) The examiner is advised that the Veteran is competent to report symptoms and observable history. (d) The absence of evidence of treatment for shin splint symptoms in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. 3. Then, contact an appropriate clinician for a VA sleep apnea medical opinion. The clinician should conduct a complete review of the electronic claims folder. (If the clinician indicates physical examination is needed, this should be scheduled). (a) Is it at least as likely as not that the current sleep apnea is the result of a disease or injury in active service, or had its onset in such service? (b) The examiner should provide comprehensive reasons for this opinion. The examiner should consider the Veteran's reports of snoring dating to 1987 and accounts of poor sleep. His reports of being informed by others during active military service about his snoring should be considered. (c) The examiner is advised that the Veteran is competent to report symptoms and observable history. (d) The absence of evidence of treatment for a sleep disorder or sleep disturbances in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. 4. Furnish VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) to the Veteran and request that he complete and return the form. 5. Adjudicate the service connection claims. 6. If after adjudicating the service connection claims, these claims are denied and the Veteran indicates unemployability, refer to the Director of Compensation Service the issue of entitlement to a TDIU pursuant to 38 C.F.R. § 4.16(b). 7. If after adjudicating the service connection claim, the Veteran indicates unemployability and meets the schedular TDIU criteria pursuant to 38 C.F.R. § 4.16(a), adjudicate the issue of TDIU on a schedular basis. 8. If any benefit remains denied, issue a supplemental statement of the case. Then return the appeal to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs