Citation Nr: 1756842 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 14-08 604 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a right hip disability, to include degenerative joint disease (DJD), to include as due to service-connected bilateral knee disabilities. 2. Entitlement to service connection for a left hip disability, to include DJD, to include as due to service-connected bilateral knee disabilities. 3. Entitlement to service connection for left leg amputation below the knee, to include as due to service-connected right knee DJD with chondromalacia. 4. Entitlement to a rating in excess of 10 percent for right knee DJD with chondromalacia. 5. Entitlement to a rating in excess of 10 percent for left knee DJD with chondromalacia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel INTRODUCTION The appellant served on active duty in the Marine Corps from February 1977 to November 1979 and from October 1980 to January 1998. He is the recipient of the Good Conduct Medal with five stars, the Navy and Marine Corps Achievement Medal, the Navy and Marine Corps Commendation Medal, and the Meritorious Service Medal. This matter comes before the Board of Veterans' Appeals (Board) from September 2012 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The appellant was afforded a Decision Review Officer (DRO) hearing in July 2016. A transcript is of record. The appellant was afforded a Board videoconference hearing before the undersigned in April 2017. A transcript is of record. During his July 2016 DRO hearing, the appellant reported back problems. In May 2017, the appellant's wife reported that the appellant had back pain and that he had sleep apnea which she believed began while the appellant was on active duty. The Board observes that entitlement to service connection for sleep apnea was denied in May 2009. The appellant and his representative are advised that, effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form. See 79 Fed. Reg. 57,660 (Sept. 25, 2014), codified as amended at 38 C.F.R. §§ 3.151, 3.155. Should the appellant wish to file claims of service connection or to reopen previously denied claims, he and his representative should file such claims in accordance with these procedures. The issues of entitlement to service connection for bilateral hip disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The appellant's left leg amputation below the knee is not causally related to his active service or any event therein, nor is it caused or aggravated by his service-connected right knee DJD with chondromalacia. 2. Throughout the period on appeal, the appellant's right knee DJD with chondromalacia has been manifested by flexion greater than 30 degrees and extension to greater than 15 degrees. There is X-ray evidence of arthritis involvement of no more than one major joint or minor joint group. There is no malunion of the tibia and fibula, dislocated semilunar cartilage, genu recurvatum, or instability. 3. Throughout the period on appeal, the appellant's left knee DJD with chondromalacia and limited extension has been manifested by flexion greater than 30 degrees and extension to greater than 15 degrees. There is X-ray evidence of arthritis involvement of no more than one major joint or minor joint group. There is no malunion of the tibia and fibula, dislocated semilunar cartilage, or genu recurvatum, or instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left leg amputation below the knee have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 2. The criteria for entitlement to a rating in excess of 10 percent for right knee DJD with chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5260 (2017). 3. The criteria for entitlement to a rating in excess of 10 percent for left knee DJD with chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5261 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) In a statement received in December 2016 on a VA Form 9, the appellant stated that he was dissatisfied with his contracted examinations in November 2016. He reported that he attempted to explain his symptomatology, but the nurse practitioner did not allow him to. However, the Board has reviewed the medical opinions in question and finds that the examiner did, in fact, note the appellant's lay reports of symptomatology and take such into consideration when rendering opinions. The examination report contains sufficient reference to the pertinent rating criteria. Thus, the Board finds that such reports and opinions are adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Neither the appellant nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "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 a duty to assist argument). II. Applicable Law A. Standard of Proof The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. B. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. § 1110. "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). C. Increased Evaluations Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim of an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Under Diagnostic Code 5257, the criteria for a 10 percent rating is slight knee disability due to recurrent subluxation or slight lateral instability. Moderate knee disability due to recurrent subluxation or moderate lateral instability is rated 20 percent disabling. Severe knee disability due to recurrent subluxation or lateral instability is rated 30 percent. Under Diagnostic Code 5260, flexion of the knee, limitation of knee flexion under Diagnostic Code 5260 is rated 10 percent with flexion limited to 45 degrees. Flexion limited to 30 degrees is rated 20 percent, and flexion limited to 15 degrees is rated 30 percent, the maximum schedular rating under that Diagnostic Code. 38 C.F.R. § 4.71a. Limitation of knee extension under Diagnostic Code 5261 is rated noncompensable or zero percent with extension limited to 5 degrees. Extension limited to 10 degrees is rated 10 percent. Extension limited to 15 degrees is rated 20 percent. Extension limited to 20 degrees is rated 30 percent. Extension limited to 30 degrees is rated 40 percent. Extension limited to 45 degrees or greater is rated 50 percent, which is the maximum rating available. Id. Normal range of knee motion is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A Precedent Opinion of the VA General Counsel has held that that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (2004)). In addition, a veteran who has both compensable limitation of motion and instability of the knee may be evaluated separately under separate diagnostic codes provided when additional disability is shown. VAOPGCPREC 23-97 (July 1, 1997); VAOPGCPREC 9-98 (Aug. 14, 1998). Ten percent is awarded under Diagnostic Code 5259 for meniscectomy (removal of semilunar cartilage), which is the highest rating available under that Diagnostic Code. Under Diagnostic Code 5258, a 20 percent rating is available for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. In addition, when evaluating musculoskeletal disabilities based on limitation of motion, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination. See 38 C.F.R. § 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). III. Analysis A. Evidence Although such examination took place well before the period on appeal, during his May 2001 VA examination, the appellant reported intermittent pain, stiffness, and weakness of the bilateral knees. Examination revealed no signs of painful motion, edema, instability, weakness, or tenderness. A May 2008 emergency note from Tuomey Healthcare states that the appellant was seen for a left leg fracture after falling 10 to 12 feet from a barn loft. It was noted that the left leg wound was contaminated, due to landing in hay and manure. Chronic infections and multiple surgeries followed. An April 2009 clinical note from Dr. K.W. explains that the appellant ended up with a below-knee amputation as a result of his May 2008 open distal fibula fracture. The appellant was afforded a VA examination in August 2009 for his bilateral knees. He reported that he has experienced increasing pain and more frequent limping due to his left leg amputation. The appellant reported that such amputation was unrelated to his service-connected knees. Constant, moderate pain with intermittent locking, instability, and swelling bilaterally was reported. The appellant stated that he was currently employed as a polygraph specialist. He stated that his knees affect his occupation as his mobility is limited and he must avoid stairs. Daily living is affected regarding sleeping and chores. Weekly, severe flare-ups last approximately one day. He uses a walker and a cane. Range of motion testing revealed right extension to 0 degrees with pain and right flexion to 90 degrees with pain. Left extension was to 10 degrees with pain and left flexion was to 82 degrees with pain. There was no additional limitation following repetitive-use testing. Knees were stable per Lachman, drawer, valgus, and varus stressing. Bilateral palpable tenderness was present. Moderate crepitus and bilateral medial McMurray sign for meniscal derangement were observed. The left knee showed evidence of disuse osteodystrophy while the right knee showed arthritis. He was diagnosed with bilateral grade 2 moderate chondromalacia of the bilateral knees, right knee mild DJD, and left knee disuse osteodystrophy. An April 2013 Amputation Disability Benefits Questionnaire (DBQ) was received from Dr. K.W., a private clinician. It noted that the appellant's open distal tibia fracture from May 2008 and failed limb reconstruction eventually required a left below knee amputation. Degenerative changes of the left knee were noted. The appellant was unable to tolerate prolonged standing. No etiological opinion was offered. An April 2013 Knee DBQ was received from Dr. K.W. The appellant reported daily bilateral knee pain. Flare-ups were endorsed in the form of pain and aching. Right knee flexion was measured to 105 degrees, with pain at 90 degrees. Extension was to 0 degrees. Pain began at 10 degrees. Left knee flexion was measured to 100 degrees, with pain at 85 degrees. Left knee extension was to 20 degrees. Pain began at 25 degrees. Following repetitive-use testing, right knee flexion was to 105 degrees, right knee extension was to 0 degrees, left knee flexion was to 100 degrees, and left knee extension was to 15 degrees. There was no additional limitation following repetitive-use testing. Rather, left knee extension was greater by five degrees. Functional loss or impairment in the form of less movement than normal, excess fatigability, pain on movement, and disturbance of locomotion was present bilaterally. There was tenderness or pain to palpation bilaterally. Joint stability testing was negative bilaterally. Anterior instability, posterior instability, and medial-lateral instability testing were all normal bilaterally. There was no evidence or history of recurrent patellar subluxation or dislocation. There were no meniscal conditions or procedures. He occasionally used crutches or a cane. There was no impact on the appellant's ability to work. In a statement received in March 2014, the appellant reported that he has daily pain in his bilateral knees and has problems getting up and down and when using stairs. He stated that his knees sometimes give out and cause him to fall, which caused his left leg injury which ultimately resulted in an amputation. A VA medical opinion was obtained in May 2014. The claims file was reviewed. It was noted that the appellant fell out of a barn in May 2008 and fractured his left tibia. Such was complicated by osteomyelitis and eventually resulted in left below knee amputation in February 2009. 2009 X-rays of the right knee revealed mild osteoarthritis; thus, the right knee arthritis would have been mild at worst, or may not have even existed, in 2008 when he fell out of the barn. The examiner explained that there was simply no medical evidence other than his wife's statements which supported the appellant's claim that bilateral knee arthritis led to his fall. Likewise, there was no medical evidence of instability, aside from his wife's statements, at the time of the fall. Therefore, based upon the evidence available, it was pure conjecture and speculation that mild bilateral osteoarthritis resulted in the May 2008 fall which caused the appellant's left leg amputation below the knee. October 2014 and February 2015 clinical notes state that the bilateral knees had decreased range of motion, but do not report such in degrees. April and July 2015 clinical notes state that the left residual limb had full range of motion. A June 2015 clinical note states that right knee range of motion was unchanged, but does not reference what or when the last measurement was. In August 2015, right knee range of motion was from 25 to 90 degrees and was painful. A statement from the appellant was received in April 2015. He explained that he experienced knee pain and instability while on active duty. He stated that, although he fell many times due to knee instability, he did not normally go to sick bay because he was afraid it would hurt his career advancement opportunities while on active duty. He reported that he broke his tail bone twice since retiring by falling down stairs at his house. He did not go to the doctor because he did not feel that a doctor could do anything for him. He explained that he fell in May 2008 from a barn loft because his right knee gave out on him. This fall broke his left leg and he eventually had to get it amputated due to complications following numerous surgeries. He stated that his knees have worsened and his knee and hip flexibility and mobility have diminished. A September 2015 VA orthopedic surgery note states that the appellant fell in May 2008 when his service-connected right knee gave way. The VA clinician opined that it was more likely than not that the May 2008 left leg open tibia fracture was the result of the appellant's service-connected right knee giving way and causing him to fall on his left leg. Therefore, the VA clinician explained, the left leg disability is proximately due to his service-connected right knee disability. During his July 2016 DRO hearing, the appellant explained that, while he was working in his barn loft, he experienced a severe right knee pain which caused him to stumble and fall from the loft. He broke his left leg and underwent ten months of surgeries before the doctors eventually amputated his left leg below the knee due to infections and other complications. He contends that his service-connected bilateral knee disabilities were the cause of the pain that caused his fall and eventual amputation. He reported that he has experienced numerous other falls due to his knee pain, including when he was wearing a prosthesis. He explained that he has undergone other surgeries due to problems from additional falls which caused problems with the prosthesis attachment. The appellant was afforded a contracted examination in November 2016 for his bilateral knees. The claims file was reviewed. He was diagnosed with bilateral knee DJD with chondromalacia and left knee limited extension. The appellant reported constant, deep, aching pain bilaterally, which makes moving around and working extremely difficult. Examination was positive for active resistance of range of motion, with displayed range of motion far less than observed range of motion with changing positions and entering and leaving the examination room. Therefore, the examiner stated that the examination results were invalid and could not be used to assess objective functional loss. Flare-ups were denied. Walking and standing were reported to be difficult. Right knee flexion was measured from 15 to 45 degrees and extension was measured from 45 to 15 degrees. Range of motion did not contribute to functional loss. No pain was noted on examination. There was no objective evidence of localized tenderness or pain on palpation. There was no evidence of pain with weightbearing or crepitus. Left knee flexion was measured from 15 to 40 degrees and extension was measured from 40 to 15 degrees. Range of motion did not contribute to functional loss. There was no pain noted on examination. There was no objective evidence of localized tenderness or pain on palpation. There was no evidence of pain with weightbearing or crepitus. There was no additional limitation following repetitive-use testing. There were no additional contributing factors of disability. There was no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. There was no joint instability in either knee. The examiner indicated that the appellant did not, nor had he ever had, a meniscal condition. He was noted to regularly use a scooter walker for left below knee amputation. Functional loss was likely considering the appellant's diagnoses; however, the examiner was unable to assess functional impact on occupational tasks due to poor cooperation during the examination. The examiner noted that results for range of motion and pain were the same for nonweight-bearing, weight-bearing, active, and passive motion. The appellant was afforded a contracted examination in November 2016 for his left leg amputation. The appellant reported that his right knee gave out in May 2008, causing him to fall from the second floor of a barn. Such resulted in a severe left tibia/fibula fracture which required several surgeries. These surgeries ultimately led to amputation and multiple stump revisions. The amputation was between the forefoot and the knee and allows the use of a suitable prosthesis. The examiner opined that current examination of the right knee did not indicate any instability which would lead to a fall. Such would be required in order to lead to the described events resulting in the May 2008 fall. The examiner noted that a May 2001 knee examination also stated that there was no objective instability. The examiner explained that, even if the right knee were unstable, it is an unlikely scenario, backed only by the appellant and other interested parties, and would not hold objective likelihood, even in the setting of right knee instability. During his April 2017 video Board hearing, it was noted that the appellant's wife was a registered nurse. The appellant testified that he fell out of a barn in 2008 because his right knee buckled and he was unable to regain his balance. This eventually resulted in amputation of the left leg below the knee due to complications from multiple surgeries and infections. He reported that his knee has buckled on other occasions, including when wearing his left leg prosthesis. He stated that this occurs during normal walking. The appellant reported the positive medical opinion regarding whether his service-connected right knee disability was the cause of his May 2008 fall and eventual amputation. He reported experiencing buckling or instability in his right knee and that a total knee replacement has been recommended. A May 2017 statement from the appellant's representative waived AOJ consideration of newly-submitted medical evidence. Statements from the appellant's wife were received in May 2015 and May 2017. She explained that she worked as a nurse for more than 20 years, with experience in the emergency room, intensive care unit, and cardiac care unit. She reported that, while the appellant was still on active duty, she observed him fall and stumble due to his knee problems. After the appellant retired, his wife observed him falling on multiple occasions. Generally, it would take him weeks to months to heal from each fall. The appellant fell down the stairs and broke his tailbone on two occasions, but did not see a doctor, despite his wife's recommendations. The appellant must take Ambien to help him sleep due to his pain, although he awakens in the night due to the pain frequently. The appellant's wife states that the appellant's quality of life has drastically declined. He has great difficulty with stairs due to pain and flexibility issues. He also has difficulty walking any distances without using a knee walker, crutches, or a wheelchair. She also opined that the appellant experiences bouts of depression and anxiety due to his service-connected disabilities. She reported that the appellant fell from a barn loft in May 2008 after his right knee gave out. His left lower leg was eventually amputated. Since then, both knees have worsened. She noted that his falls have increased in frequency and his pain has increased in severity. Further, his flexibility and mobility have worsened over time. B. Entitlement to service connection for left leg amputation below the knee. The appellant and his wife contend that his May 2008 fall from the second story of a barn which resulted in a left tibial fracture, and eventually required amputation following multiple infections and surgeries, was due to instability in his service-connected right knee. The Board notes that the appellant's wife is a registered nurse and offered a medical opinion that the appellant's right knee giving out was the cause of his May 2008 fall, and multiple other falls. In a 2014 VA medical opinion , the examiner observed that 2009 X-rays of the right knee revealed mild osteoarthritis; thus, the right knee arthritis would have been mild at worst, or may not have even existed, in 2008 when he fell out of the barn. The examiner explained that there was simply no evidence which supported the appellant's claim that bilateral knee arthritis led to his fall. There was no clinical evidence of instability at the time of the fall. Therefore, based upon the evidence available, the examiner opined that it was pure conjecture and speculation that mild bilateral osteoarthritis resulted in the May 2008 fall which caused the appellant's left leg amputation below the knee. In September 2015, a VA clinician opined that it was more likely than not that the May 2008 left leg open tibia fracture was the result of the appellant's service-connected right knee giving way and causing him to fall on his left leg. Therefore, the VA clinician explained, the left leg disability is proximately due to his service-connected right knee disability. There is no indication that the claims file was reviewed, however, nor was a rationale provided. The November 2016 contracted examiner opined that current examination of the right knee did not indicate any clinical instability which would lead to a fall. Such would be required in order to lead to the described events resulting in the May 2008 fall. The examiner noted that a May 2001 knee examination also stated that there was no objective instability. The examiner explained that, even if the right knee were unstable, such was an unlikely scenario, and would not hold objective likelihood, even in the setting of right knee instability. The appellant's wife and the September 2015 VA clinician both offered positive nexus opinions. The Board has carefully considered these opinions, but finds that they are less probative than the negative May 2014 and November 2016 medical opinions. These latter opinions included thorough rationales and were based upon reviews of the claims file, including the clinical evidence such as examination reports noting no instability and X-ray evidence of mild arthritis. There is no indication that the appellant's wife or the September 2015 VA clinician reviewed the evidence of record when offering their positive opinions. Although the Board recognizes the appellant's wife's medical training and experience, the May 2014 and November 2016 opinions are entitled to greater probative weight because such have thorough rationales and were based upon reviews of the relevant clinical evidence of record. There is no contemporaneous medical evidence from the 2008 incident which contradicts such opinions regarding the presence instability. Further, despite the competent statements from the appellant and his wife that he has experienced symptoms of knee instability, the May 2001 VA examiner, the August 2009 VA examiner, Dr. K.W. in April 2013, and the November 2016 contracted examiner all consistently found that there was no clinical knee instability. Such opinions are entitled to greater probative weight as they were based on clinical stability testing. There is no indication that the appellant's wife or the September 2015 VA clinician performed joint stability testing on the appellant's knees. The examiners' unsolicited opinions regarding the credibility of the appellant's wife's statements and opinions have not been taken into account by the Board when weighing the evidence of record. For the foregoing reasons, entitlement to service connection for left leg amputation below the knee must be denied. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). C. Entitlement to a rating in excess of 10 percent for right knee DJD with chondromalacia. Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the award of a rating in excess of 10 percent for any portion of the period on appeal. Flexion has consistently been measured at 30 degrees or greater and extension has consistently been measured at 15 degrees or greater. The results from the November 2016 examination showing more severe limitations of flexion and extension are entitled to minimal probative weight because, as the examiner explained, such results were invalid because the appellant's observed range of motion during the remainder of the examination was far greater than during focused range of motion testing. There is no X-ray evidence of arthritis involvement in more than one major joint or more than one minor joint group. There is no evidence, nor does the appellant contend, that he experienced ankylosis. There is no malunion of the tibia and fibula, dislocated semilunar cartilage, or genu recurvatum. Again, despite the competent statements from the appellant and his wife that he has experienced knee instability, the May 2001 VA examiner, the August 2009 VA examiner, Dr. K.W. in April 2013, and the November 2016 contracted examiner all consistently found that there was no clinical knee instability. Such opinions are entitled to greater probative weight than the appellant's wife's opinions because stability testing was performed. There is no indication that the appellant's wife performed joint stability testing on the appellant's knees. The Board finds that the preponderance of the evidence is against the appellant experiencing knee instability at any point during the period on appeal. Thus, a separate rating for instability is not warranted. The Board observes that an August 2015 clinical note states that right knee range of motion was from 25 to 90 degrees and was painful. However, such examination was described as "brief" and was during an orthopedic follow-up appointment regarding the left leg amputation stump. No other testing was performed during this admittedly brief examination. It is also unclear whether only flexion was measured from 25 to 90 degrees or if such note means that extension was limited to 25 degrees. Therefore, the Board finds that the VA, private, and contracted examination reports are entitled to greater probative weight regarding the severity of the appellant's right knee disability throughout the period on appeal. In August 2009, the VA examiner measured flexion to 90 degrees and extension to 0 degrees. In April 2013, Dr. K.W., the private clinician, measured flexion to 105 degrees and extension to 0 degrees. In November 2016, the contracted examiner observed that the appellant had a great deal more range of motion during the overall examination than he exhibited during focused range of motion testing. Even if the 25 degrees notation was a measurement of extension showing substantial limitation and not simply part of a flexion measurement, the Board finds that such is an outlier compared to the VA, private, and contracted examination reports regarding extension and thus affords such August 2015 clinical note minimal probative weight. The Board has considered whether the grant of a higher rating due to additional functional loss due to pain, weakness, excess fatigability, or incoordination is warranted. See 38 C.F.R. § 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). However, the Board notes that the November 2016 examiner observed gross inconsistencies between range of motion displayed on focused examination and range of motion observed with the appellant changing positions in the room and that the latter was near normal and without any pain. The Board has considered the appellant's reports of flare-ups and functional loss, but the record does not support that such symptoms result in limitation of motion commensurate with the next higher rating. Thus, the Board concludes that a higher rating under DeLuca is not warranted for any portion of the period on appeal. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). D. Entitlement to a rating in excess of 10 percent for left knee DJD with chondromalacia and limited extension. Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the award of a rating in excess of 10 percent for any portion of the period on appeal. Flexion has consistently been measured at 30 degrees or greater and extension has consistently been measured at 15 degrees or greater. The results from the November 2016 examination showing more severe limitations of flexion and extension are entitled to minimal probative weight because, as the examiner explained, such results were invalid because the appellant's observed range of motion during the remainder of the examination was far greater than during focused range of motion testing. There is no X-ray evidence of arthritis involvement in more than one major joint or more than one minor joint group. There is no evidence, nor does the appellant contend, that he experienced ankylosis. There is no malunion of the tibia and fibula, dislocated semilunar cartilage, or genu recurvatum. Again, despite the competent statements from the appellant and his wife that he has experienced knee instability, the May 2001 VA examiner, the August 2009 VA examiner, Dr. K.W. in April 2013, and the November 2016 contracted examiner all consistently found that there was no knee instability. Such opinions are entitled to greater probative weight than the appellant's wife's opinions because stability testing was performed. There is no indication that the appellant's wife performed joint stability testing on the appellant's knees. The Board finds that the preponderance of the evidence is against the appellant experiencing knee instability at any point during the period on appeal. Thus, a separate rating for instability is not warranted. The Board has considered whether the grant of a higher rating due to additional functional loss due to pain, weakness, excess fatigability, or incoordination is warranted. See 38 C.F.R. § 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). However, the Board notes that the November 2016 examiner observed gross inconsistencies between range of motion displayed on focused examination and range of motion observed with the appellant changing positions in the room and that the latter was near normal and without any pain. Again, the Board has considered the appellant's reports of flare-ups and functional loss, but the record does not support that such symptoms result in limitation of motion commensurate with the next higher rating. Thus, the Board concludes that a higher rating under DeLuca is not warranted for any portion of the period on appeal. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). E. TDIU The Board has considered a total rating based on individual unemployability due to service-connected disability (TDIU), pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). However, absent any indication or allegation that the appellant is unemployable as a result of his service-connected bilateral knee disabilities, consideration of a TDIU is not warranted. There is competent and credible evidence that the appellant is employed, including his testimony during his April 2017 Board hearing. There is no evidence that such employment is not substantially gainful. Thus, the record does not reasonably raise the issue of TDIU. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). ORDER Entitlement to service connection for left leg amputation below the knee is denied. Entitlement to a rating in excess of 10 percent for right knee DJD with chondromalacia is denied. Entitlement to a rating in excess of 10 percent for left knee DJD with chondromalacia is denied. REMAND The appellant contends that he developed a bilateral hip disability as a result of his service-connected bilateral knee disabilities. Per an April 2013 private DBQ, Dr. K.W. diagnosed the appellant with bilateral hip DJD, based upon imaging studies which documented arthritis. The November 2016 contracted examiner stated that the appellant did not have a current bilateral hip disorder because there was no objective evidence upon which to render a diagnosis. The contracted examiner also observed that there were gross inconsistencies between the appellant's range of motion during focused testing and range of motion observed when the appellant changed positions in the room. The latter was observed to be near normal and without any pain. The Board finds that the November 2016 examination report is inadequate on the issue of entitlement to service connection for right and left hip disabilities because it did not address the April 2013 diagnosis of bilateral hip arthritis based upon imaging studies. Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Upon remand, appropriate measures should be taken to attempt to obtain the private medical records which include the imaging studies referenced in April 2013 by Dr. K.W., to include requesting any appropriate authorizations from the appellant such that VA may obtain such records. The appellant is advised that he is ultimately responsible for providing this evidence. See 38 C.F.R. § 3.159(e). Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate efforts to attempt to obtain private medical records from Dr. K.W., including the radiographic reports documenting bilateral hip arthritis referenced in the April 2013 private Disability Benefits Questionnaire (DBQ). 2. Then, afford the appellant an appropriate examination to determine the nature and etiology of any bilateral hip disorders present. The claims file should be reviewed. The examiner is directed to review the private April 2013 DBQ from Dr. K.W., which states that imaging studies document bilateral hip arthritis, and the November 2016 contracted examination report, which states that there was no objective evidence upon which to render a bilateral hip diagnosis. Any and all appropriate testing should be performed. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current hip disability found to be present was incurred during the appellant's active service, or was a result of an in-service disease, event, or injury. If not, the examiner must provide an opinion as to whether it is at least as likely as that any current hip disability found to be present was proximately due to or the result of (caused by) a service-connected disability, to include his service-connected bilateral knee disabilities. If neither, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current hip disability found to be present is aggravated (permanently made worse) by a service-connected disability, to include his service-connected bilateral knee disabilities. If aggravation is found, the examiner must attempt to establish a baseline level of severity of such hip disability or disabilities prior to aggravation by a service-connected disability, to include the appellant's service-connected bilateral knee disabilities. The examiner must provide supporting rationale for all opinions, addressing the relevant medical and lay evidence. Absent such supporting rationale, the opinion will be deemed inadequate. 3. After conducting any additional development deemed necessary, the AOJ should reconsider the claims, considering all the evidence of record. If the benefits sought remain denied, a Supplemental Statement of the Case should be provided followed by an appropriate period of time to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters 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. §§ 5109B, 7112 (2012). ______________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs