Citation Nr: 1759983 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 13-06 734 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for left knee strain with arthritis. 2. Entitlement to a rating in excess of 10 percent for right knee strain with arthritis, status post right lateral meniscectomy. 3. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities prior to June 4, 2015, or due solely to service-connected bilateral knee disabilities. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Koria B. Stanton, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1978 to March 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In February 2014, the Veteran testified at a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In March 2015, the Board remanded the case for additional development and it now returns for further appellate review. In a July 2017 rating decision, a TDIU based on the Veteran's service-connected major depressive disorder and degenerative joint disease and degenerative disc disease of the thoracolumbar spine was granted, effective June 4, 2015. Consequently, as the Veteran's claim for increased ratings for his bilateral knee disabilities stem from March 31, 2011, and June 14, 2011 claims, the Board must still consider whether a TDIU based on all of his service-connected disabilities is warranted prior to June 4, 2015, and whether a TDIU based on solely on his bilateral knee disabilities is warranted at any time pertinent to the appeal. See Rice v. Shinseki, 22 Vet. App. 447, 452 (2009); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280 (2008). Therefore, such issue has been characterized as shown on the title page of this decision. The Board observes that the Veteran has also perfected an appeal as to the issues of entitlement to increased ratings for degenerative joint disease and degenerative disc disease of the thoracolumbar spine and associated bilateral lower extremity radiculopathy. However, as he has requested a Board hearing before a Veterans Law Judge in connection with such appeal, the matter will be the subject of a separate Board decision issued at a later date. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire period, the Veteran's left knee strain with arthritis is manifested by objective evidence of arthritis, and subjective complaints of pain, stiffness, weakness, swelling, popping, giving way, and locking, with flexion limited to no more than 110 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without recurrent subluxation or lateral instability, ankylosis, dislocation or removal of semilunar cartilage, malunion of the tibia or fibula, or genu recurvatum. 2. For the entire period, the Veteran's right knee strain with arthritis, status post right lateral meniscectomy, is manifested by objective evidence of arthritis, and subjective complaints of pain, stiffness, weakness, swelling, popping, giving way, and locking, with flexion limited to no more than 70 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without recurrent subluxation or lateral instability, ankylosis, dislocation of semilunar cartilage, malunion of the tibia or fibula, genu recurvatum, or symptomatic scarring or scarring of such a size so as to warrant a compensable rating. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for left knee strain with arthritis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5260-5010 (2017). 2. The criteria for a rating in excess of 10 percent for right knee strain with arthritis, status post right lateral meniscectomy, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, DC 5003 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Further, neither the Veteran nor his representative has alleged any deficiency with respect to VA's duties to notify or assist. See Scott, supra (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 duty to assist argument). II. Analysis Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath, supra. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires 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." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The Veteran's service-connected left knee strain with arthritis is currently evaluated as 10 percent disabling, effective June 14, 2011, pursuant to DC 5003. With respect to his service-connected right knee strain with arthritis, status post right lateral meniscectomy, he filed a claim in March 2011 seeking an increased rating for such disorder, which is currently evaluated as 10 percent disabling, effective April 20, 2009, pursuant to 5260-5010. Therefore, the appeal period for such disorder begins on March 31, 2010, one year prior to the date VA received the Veteran's claim for an increased rating. Gatson v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Under DC 5010, traumatic arthritis is evaluated as degenerative arthritis. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. DC 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. In the absence of limitation of motion, DC 5003 provides for a 10 percent rating with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating under DC 5003 requires involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, DC 5260 and 5261. DC 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. For a 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. DC 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. 38 C.F.R. § 4.71a, DC 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent evaluation for severe recurrent subluxation or lateral instability. VA's General Counsel has stated that when a knee disorder is rated under 38 C.F.R. § 4.71a, DC 5257 and an appellant also has limitation of knee motion which at least meets the criteria for a noncompensable evaluation under 38 C.F.R. § 4.71a, DC 5260 or 5261, separate evaluations may be assigned for arthritis with limitation of motion and for instability. However, General Counsel stated that, if an appellant does not meet the criteria for a noncompensable rating under either DC 5260 or DC 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). If a rating is assigned under the provisions for other knee impairment (38 C.F.R. § 4.71a, DC 5257) a separate 10 percent rating may be assigned where some limitation of motion, albeit noncompensable, has been demonstrated. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Specifically, for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable, but must at least meet the criteria for a zero-percent rating. Id. VA's General Counsel has also stated that separate ratings under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 2004). The Veteran generally contends that higher ratings are warranted for his bilateral knee disabilities. In this regard, at the February 2014 Board hearing, he reported experiencing more pronounced bowing to the inside of his right knee with pain instantly with any motion. He further reported experiencing locking and giving way of his right knee, which resulted in falls, and consistent popping in his left knee. Additionally, the Veteran indicated that he had to get a wheelchair due to his difficulty with ambulation. The evidence referable to the Veteran's claims for increased ratings consists of VA examination reports dated in July 2011 (right knee), August 2011 (left knee), July 2013, and January 2016; his own statements, including those made at the February 2014 Board hearing; and his VA and private treatment records dated throughout the appeal period. At the July 2011 VA examination, the Veteran complained of mild to moderate pain in his right knee daily that was localized at the joint. The Veteran indicated that his treatment included Naprosyn and injections. He further indicated that he experienced stiffness and occasional swelling, but denied heat, redness, drainage, instability, locking, and giving way. The Veteran noted that he was prescribed a knee brace, occasionally used a cane, and there was no functional impairment as it related to his ability to perform his activities of daily living resulting from his right knee disorder. He denied flare-ups. The examiner noted diagnoses of right knee strain and status post right lateral meniscectomy with degenerative joint disease. With respect to range of motion (ROM) testing, the examiner reported that active range of motion of the right knee was attempted, but the Veteran stated that he was unable to participate in the examination secondary to pain. The examiner explained that the Veteran's knee was in a full extension position without pain upon initiation of the examination; however, while attempting to have him actively flex his knee, he would not move past 5 degrees despite encouragement. The examiner further explained that the Veteran did not allow him to passively flex his knee. With respect to repetitive-use testing, the examiner indicated that the Veteran would not perform ROM testing three times. The examiner further indicated that the Veteran did not allow him to sufficiently examine his right knee for objective signs of instability. Here, the examiner noted that he attempted to perform the Lachman's test, anterior and posterior drawer sign, and varus valgus assessment; however, the Veteran felt that he was in too much pain for him to continue with the examination. Diagnostic testing revealed an X-ray of the Veteran's right knee from May 2009, which indicated moderate degenerative change. Additionally, the examiner noted a lateral meniscectomy scar on the lateral portion of the Veteran's right knee joint. At the August 2011 VA examination, the Veteran denied flare-ups, and reported that he was currently taking Tramadol and Naproxen for his left knee pain. The examiner noted diagnosis of left knee strain with arthritis. ROM testing of the left knee revealed flexion to 110 degrees and extension to 0 degrees. There was no objective evidence of moderate pain in the left knee with flexion and extension of 100 degrees to 100 degrees. The examiner reported that, with respect to repetitive-use testing, the ROM did not elicit additional pain, fatigue, or weakness. The examiner indicated that the Veteran had functional loss, which included mildly decreased strength; mildly decreased coordination; and mildly decreased weakened movement. There was no excessive fatigability noted. The examiner further indicated that there was no swelling, instability, deformity, or atrophy. The examiner noted that the Veteran had a moderate antalgic altered gait. The examiner further noted that the Veteran's functional impairments included difficulty standing and walking for more than 15 minutes; walking up and down steps; climbing; and squatting as a result of his activities of daily living and his occupation in construction. The examiner reported that the Veteran's left knee had tenderness on palpation. Muscle strength testing of the left knee was 4/5. The examiner indicated a normal Lachman test, posterior drawer test, and mediolateral instability test. There was no objective evidence of recurrent patellar subluxation or dislocation. The examiner did not note any surgical procedures. The examiner reported that the Veteran used assistive devices including a brace and a cane for ambulation. Diagnostic testing revealed an X-ray of the Veteran's left knee from July 2009 that indicated arthritis. At the July 2013 VA examination, the Veteran complained of constant bilateral knee pain. He reported flare-ups with walking up steps and lifting anything greater than 15 pounds. The examiner noted diagnoses of right knee strain with arthritis, status post lateral meniscectomy, and left knee strain with arthritis secondary to service-connected right knee disorder. ROM testing of the right knee revealed flexion to 70 degrees and extension to 0 degrees. There was no objective evidence of painful motion. ROM testing of the left knee revealed flexion to 110 degrees and extension to 0 degrees. There was no objective evidence of painful motion. Repetitive-use testing of the right knee indicated flexion to 70 degrees and extension to 0 degrees. Repetitive-use testing of the left knee indicated flexion to 110 degrees and extension to 0 degrees. The examiner reported that the Veteran did not have additional limitation in ROM following repetitive-use testing; functional loss; or functional impairment in either knee. The examiner reported that the Veteran's right knee had tenderness or pain on palpation. Muscle strength testing of both knees was full. There was no joint instability of bilateral knees. There was no objective evidence of recurrent patellar subluxation or dislocation, shin splits, stress fractures, or chronic exertional compartment syndrome. The examiner indicated that the Veteran had a right knee meniscal condition with no symptoms. The examiner further indicated that the Veteran had a right knee meniscectomy in 1979 with no residual signs and/or symptoms except for bilateral knee pain. The examiner noted that the Veteran had a scar that was not painful and/or unstable or had a total area greater than 39 square centimeters. The examiner reported that the Veteran used an assistive device including a cane (regularly) to assist with off-loading pressure placed on his knee joints from walking. Following diagnostic testing, the examiner noted that bilateral knee degenerative or traumatic arthritis was documented. The examiner reported that the Veteran's bilateral knee conditions would impact his ability to work. In this regard, the examiner indicated that the Veteran reported that he had been a construction worker but stopped working in 2010 due to his knees. The examiner noted that the Veteran further reported that he was a pastor in his church, and that his knees did not prevent him from doing such activity. At the January 2016 VA examination, the Veteran complained of daily exertional pain. He reported flare-ups with walking up steps, and excessive standing or walking. Here, the Veteran further reported not having any functional loss or functional impairment of his bilateral knee joints, including but not limited to repeated use over time. The examiner noted diagnoses of bilateral knee strain and right knee meniscal tear. ROM testing of the right knee revealed flexion to 70 degrees and extension to 0 degrees; the ROM itself did not contribute to functional loss; there was no pain noted on the examination; there was no pain with weight-bearing; and there was no objective evidence of crepitus. The examiner noted that there was objective evidence of tenderness on palpation. Additionally, the examiner indicated that ROM testing of the left knee revealed flexion to 110 degrees and extension to 0 degrees; the ROM itself did not contribute to functional loss; there was no pain noted on the examination; there was no pain with weight-bearing; there was no objective evidence of localized tenderness or pain on palpation; and there was no objective evidence of crepitus. The examiner further indicated that there was no additional loss on repeat testing bilaterally. The examiner reported that the Veteran was being examined immediately after repetitive use over time; that there was no additional functional loss or ROM after three repetitions bilaterally; and that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time bilaterally. The examiner further reported that the Veteran was not being examined during a flare-up; that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare-ups; and that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups bilaterally. Muscle strength testing was full bilaterally. There was no objective evidence of muscle atrophy or ankylosis. The examiner noted that there was no history of recurrent subluxation, lateral instability, or recurrent effusion. There was no joint instability of bilateral knees. There was no objective evidence of recurrent patellar subluxation or dislocation, shin splits, stress fractures, or chronic exertional compartment syndrome. The examiner noted a right meniscal tear resulting in a right lateral meniscectomy in 1979. The examiner further noted that the Veteran had a scar that was not painful and/or unstable; had a total area greater than 39 square centimeters; or was located on the head, face, or neck. Here, the examiner explained that the scar was located in the healed arthroscopic portals, and was 0.3 centimeters in length and 0.2 centimeters in width. The examiner indicated that the Veteran used an assistive device, including a cane (regularly) to off-load pressure on his knee joints while walking. Following diagnostic testing, the examiner noted that degenerative or traumatic arthritis of the left knee was documented. The examiner further noted that a May 2009 bilateral X-ray revealed degenerative arthritis. The examiner reported that the Veteran's knee conditions would impact his abilities to perform occupational tasks. Here, the examiner explained that the Veteran reported problems with standing and walking, and that such could interfere with physical work at his job. With respect to the VA examination reports dated in July 2011 (right knee), August 2011 (left knee), July 2013, and January 2016, the Board has considered the Court's recent holding in Correia v. McDonald, 28 Vet. App. 158 (2016), addressing the proper interpretation of the final sentence of 38 C.F.R. § 4.59, which states "[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." In this regard, the Court concluded that VA examinations should include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with ROM measurements of the opposite undamaged joint. In addition, assignment of a disability rating should take into account consideration of limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Additionally, the Board has considered the Court's recent holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), addressing 38 C.F.R. § 4.40, which states that a VA examiner must "express an opinion on whether pain could significantly limit functional ability" and the examiner's determination in such regard "should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." In this regard, the Court concluded that, when a VA examiner is asked to provide an opinion as to additional functional loss during flare-ups of a musculoskeletal disability, the examiner must obtain information from the Veteran regarding the severity, frequency, duration, characteristics, and/or functional loss related to such flare-ups. The Court further concluded that, if the examination was not being conducted during a flare-up, the examiner should provide an opinion based on estimates derived from the information above as to the additional loss of ROM that may be present during a flare-up. Additionally, if the examiner cannot provide an opinion as to additional loss of motion during a flare-up without resorting to mere speculation, the examiner must make clear that s/he has considered all procurable data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups elicited from the veteran), but any member of the medical community at large could not provide such an opinion without resorting to speculation. See DeLuca, supra; see also Mitchell, supra. In this case, the Board finds the musculoskeletal examinations of record are adequate for rating purposes and that higher disability rating are not warranted based on limitation of motion, even when considering the functional effects of pain, to include during flare-ups and after repetitive use. At the examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiner. Here, if the Veteran endorsed experiencing flare-ups during the examinations, the examiner elicited information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups. Although the July 2013 VA examiner did not provide information regarding the additional loss of ROM that may be present during the Veteran's endorsed bilateral knee flare-ups, he did not endorse flare-ups at the July and August 2011 VA examinations. Also, at the January 2016 VA examination, the Veteran did not report an increased limitation of motion due to his endorsed flare-ups, and the examiner reported that pain, weakness, fatigability, or incoordination did not significantly limit the Veteran's functional ability with flare-ups bilaterally. Additionally, the reports do not suggest that the findings on examination, in terms of ROM, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record, to include the Veteran's lay statements. Moreover, as there was no opposite "undamaged" joint, as the Veteran has bilateral knee disorders, testing in such regard was not possible. The Board further finds that there is no reason to suspect that passive range of motion would be any less than that of active motion absent a finding of such on examination or report of such by the Veteran, neither of which is present in this case. As such, further examination or opinion is unnecessary to decide the claims. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant). In addition to the VA examinations, private and VA treatment records reflect complaints and findings referable to the Veteran's bilateral knee disabilities. In this regard, an April 2012 VA treatment record indicates that the Veteran reported struggling financially since being out of work, and that he was not sure whether he would be able to return to the construction work he used to do now that he had significant joint pain. A March 2014 private treatment record notes that the Veteran was a candidate for a bilateral knee replacement and was being referred to an orthopedic surgeon at that time. An August 2014 VA treatment record reveals the Veteran's complaint of pain with walking (more pain in the right knee), and the clinician noted no knee swelling/inflammation. Furthermore, an August 2016 VA treatment record notes the Veteran's complaint of knee pain and report of multiple falls and that "my equilibrium is off because of my back pain and pain in my legs and both knees feel unstable." Here, the clinician indicated an assessment of bilateral knee instability; however, no objective testing was performed. Upon consideration of the evidence of record and the relevant laws and regulations, the Board finds that ratings in excess of 10 percent for the Veteran's bilateral knee disabilities are not warranted. In this regard, for the entire period, the Veteran's left knee disability is manifested by objective evidence of arthritis, and subjective complaints of pain, stiffness, weakness, swelling, popping, and locking, with flexion limited to no more than 110 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without recurrent subluxation or lateral instability, ankylosis, dislocation or removal of semilunar cartilage, malunion of the tibia or fibula, or genu recurvatum. Additionally, for the entire period, the Veteran's right knee disability is manifested by objective evidence of arthritis, and subjective complaints of pain, stiffness, weakness, swelling, popping, giving way, and locking, with flexion limited to no more than 70 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without recurrent subluxation or lateral instability, ankylosis, dislocation of semilunar cartilage, malunion of the tibia or fibula, genu recurvatum, or symptomatic scarring or scarring of such a size so as to warrant a compensable rating. As an initial matter, the Board observes that the Veteran's left and right knee disabilities have been assigned 10 percent ratings pursuant to DC 5010 and/or 5003 in contemplation of painful motion of a major joint, with X-ray evidence of arthritis. Further, throughout the appeal period, the Veteran's bilateral degenerative joint disease has been manifested by pain and limitation of motion; however, as will be discussed below, such limitations of motion do not reach even the noncompensable level that is required for a rating based on limitation of flexion or extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. With regard to the Veteran's left knee flexion, the August 2011, July 2013, and January 2016 VA examination reports noted flexion to 110 degrees, without pain. With regard to the Veteran's right knee flexion, the July 2013 and January 2016 VA examination reports noted flexion to 70 degrees, without pain. Furthermore, pertinent to extension, the August 2011, July 2013, and January 2016 VA examination reports noted full extension in the Veteran's left knee. Additionally, the July 2013 and January 2016 VA examination reports noted full extension in the Veteran's right knee. Therefore, while the Veteran has been awarded 10 percent ratings in light of arthritis with limitation of motion in the form of limited flexion, he does not meet even the minimum noncompensable level required under DC 5260 or 5261. Specifically, under DC 5260, flexion must be limited to 60 degrees in order to warrant a noncompensable rating. Additionally, under DC 5261, extension must be limited to 5 degrees in order to warrant a noncompensable rating. Thus, the Veteran's left and right knee disabilities have been assigned 10 percent ratings as a result of painful motion with noncompensable limitation of motion. 38 C.F.R. §4.71, DCs 5003, 5010. The Board has considered the DeLuca provisions in reaching these conclusions. In this regard, the Board acknowledges the Veteran's reports that he has functional impairment including pain, stiffness, weakness, swelling, popping, giving way, and locking. The Board further acknowledges, with respect to the Veteran's left knee, the August 2011 VA examination report noted functional loss, including mildly decreased strength; mildly decreased coordination; and mildly decreased weakened movement. However, the Veteran did not report pain during ROM testing and the examiner found that there was no additional loss in range of motion due to pain, fatigue, or weakness after repetitive use. Furthermore, with respect to the Veteran's right knee, while ROM testing was not completed at the time of the July 2011 VA examination due to the Veteran's report of pain, during the July 2013 VA examination, the Veteran did not report pain during ROM testing of either knee and the examiner found that the Veteran did not have additional limitation in ROM following repetitive-use testing; functional loss; or functional impairment in either knee. Moreover, during the January 2016 VA examination, the Veteran did not report pain during ROM testing of either knee and the examiner found that the ROM itself did not contribute to functional loss of either knee; there was no additional functional loss or ROM after three repetitions bilaterally; and pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time bilaterally. In addition, the Veteran did not endorse flare-ups at the July and August 2011 VA examinations; and, at the January 2016 VA examination, the Veteran did not report an increased limitation of motion due to his endorsed flare-ups, and the examiner reported that pain, weakness, fatigability, or incoordination did not significantly limit the Veteran's functional ability with flare-ups bilaterally. Therefore, as the evidence fails to show limitation of flexion or extension to even a noncompensable degree in either knee, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, the Board finds that the Veteran is not entitled to separate or higher ratings under DC 5260 and 5261. See DeLuca, supra; Mitchell, supra. Additionally, the objective evidence of record fails to show the presence of recurrent subluxation or lateral instability at any point during the appeal period. In this regard, while the Veteran uses an assistive device such as a cane, and the medical record reflects complaints of stiffness, weakness, swelling, popping, giving way, and locking, he has denied incoordination, dislocation, or subluxation when seeking treatment and all objective testing conducted during the course of the appeal has failed to reveal the presence of subluxation or instability. Specifically, while objective testing of instability was not completed at the time of the July 2011 VA examination due to the Veteran's report of pain in his right knee, testing conducted at the August 2011 (left knee), July 2013, and January 2016 VA examinations revealed no subluxation or lateral instability and the Veteran's left and right knee disabilities were consistently found to be stable. In this regard, the Board is aware of the August 2016 VA treatment record containing the Veteran's complaint of knee pain, and report of multiple falls and that "my equilibrium is off because of my back pain and pain in my legs and both knees feel unstable;" and the assessment of bilateral knee instability. It does not appear from this report, however, that this instability was confirmed by objective testing, as opposed to the Veteran's own subjective complaints. Furthermore, while the Veteran similarly reported experiencing giving way of his right knee, which resulted in falls during the February 2014 Board hearing, the subsequent January 2016 VA examination report containing stability testing made it demonstrably clear that there was no objective evidence of any degree of recurrent subluxation or lateral instability. Here, the Board finds, as a lay person, the Veteran is not competent to diagnose internal instability or subluxation. In this regard, while he is competent to report that his knees feel unstable or weak, or gives way, there is no indication that he possesses the requisite knowledge to administer or interpret specialized testing that would reveal instability or subluxation. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, the August 2011 (left knee), July 2013, and January 2016 VA examiners, who are medical professionals and conducted specialized testing, found that there was no laxity in either knee. Based on the foregoing, the Board finds that the most probative evidence, i.e., objective medical evidence, shows that the Veteran's knees are stable without instability or subluxation for the entirety of the appeal period. Based on the foregoing, higher or separate ratings for recurrent subluxation or lateral instability are not warranted for either knee at any point during the appeal period. See 38 C.F.R. § 4.71a, DC 5257. The Board notes that, with respect to the Veteran's right knee, the evidence indicates that he has a history of a meniscus tear resulting in a right lateral meniscectomy in 1979. Thus, the Board has considered the applicability of Diagnostic Code 5259, which provides for a 10 percent rating where there is symptomatic removal of semilunar cartilage. In the instant case, as noted, the evidence indicates that the Veteran has a history of a right lateral meniscectomy in 1979. His right knee disability manifests with various symptoms including pain, stiffness, weakness, swelling, popping, giving way, and locking. At the July 2013 VA examination, the examiner reported that the Veteran had a right knee meniscectomy in 1979 with no residual signs and/or symptoms except for bilateral knee pain. Additionally, at the January 2016 VA examination, the examiner reported that the Veteran had a right lateral meniscectomy in 1979, and did not indicate any residual signs and/or symptoms. Here, the Veteran's bilateral knee pain associated with his right knee meniscectomy is already compensated in the assigned 10 percent rating discussed above under DC 5003. The critical element in permitting the assignment of separate ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban, at 261-62. As the pain attributed to the meniscectomy overlaps with the symptomatology upon which the 10 percent rating under DC 5003 has been based, assigning a separate compensable rating under DC 5259 would constitute pyramiding prohibited by 38 C.F.R. § 4.14. Thus, to assign the Veteran a separate rating under DC 5259 would compensate the Veteran twice for the same symptoms. Furthermore, as the Veteran does not currently have a right or left knee meniscus condition, and has never undergone meniscus surgery on the left knee, DC 5258 is inapplicable to both knees and DC 5259 is inapplicable to the left knee. The Board further notes that the July 2011 VA examination reported indicated a lateral meniscectomy scar on the lateral portion of the Veteran's right knee joint. The July 2013 VA examination report further indicated that the Veteran had a scar that was not painful and/or unstable or had a total area greater than 39 square centimeters. The January 2016 VA examination report revealed that the Veteran had a scar that was not painful and/or unstable; had a total area greater than 39 square centimeters; or was located on the head, face, or neck. Here, the examiner explained that the scar was located in the healed arthroscopic portals, and was 0.3 centimeters in length and 0.2 centimeters in width. Therefore, the Board finds that the medical and lay evidence is against a finding that the scar is painful, unstable, deep, or greater than 39 square centimeters; consequently, the Board further finds that the Veteran is not entitled to a separate compensable rating under DCs 7800 through 7805 for a right knee scar. 38 C.F.R § 4.118. The Board has also considered the applicability of other potential diagnostic codes referable to the evaluation of knee disabilities. However, as the evidence of record fails to demonstrate ankylosis, impairment of the tibia or fibula, or genu recurvatum in either knee, the Veteran is not entitled to higher or separate ratings under DCs 5256, 5262, or 5263, respectively. In making its determination in this case, the Board acknowledges the Veteran's belief that his left and right knee symptoms are more severe than the current disability ratings reflect. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, supra. The Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms as to both knees, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of such conditions. The Board notes that the Veteran takes medication for his bilateral knee disabilities. However, the Board has not denied his claims for higher evaluations based on any relief provided by such medication. Even excluding any ameliorative effects of the Veteran's medication, the Board still concludes that the Veteran's symptoms do not more nearly approximate those described encompassed by higher or separate ratings. See Jones v. Shinseki, 26 Vet. App. 56 (2012) (when a DC is silent as to the effects of medication, VA may not deny entitlement to a higher disability rating based on the relief provided by medication). The Board has considered whether staged ratings under Fenderson, supra, and Hart, supra, are appropriate for the Veteran's service-connected left and right knee disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disabilities are not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under Section 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria is reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Thun, supra. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected left and right knee disabilities with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which such disabilities are currently evaluated. In this regard, the rating criteria contemplates the Veteran's bilateral knee symptomatology. Specifically, his symptoms, to include pain, stiffness, weakness, swelling, popping, giving way, locking, difficulty with walking up and down steps, prolonged walking, lifting anything over 15 pounds, climbing, squatting, and instability are specifically contemplated in the rating criteria. Furthermore, to the extent that the Veteran's activities are limited as a result of such symptoms, such limitations are contemplated by the 10 percent ratings assigned for such disabilities. Therefore, there are no additional symptoms of the Veteran's service-connected left and right knee disabilities that are not contemplated by the rating schedule to warrant extra-schedular ratings. In this regard, a wide range of signs and symptoms are contemplated in the applicable rating criteria for the Veteran's left and right knee disabilities. Indeed, his knee disorders require application of the holding in Deluca, supra, and Mitchell, supra, which, in turn, requires consideration of 38 C.F.R. §§ 4.40 and 4.45. 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation as well as any painful arthritic motion. As such, in the instant case, the Veteran's current ratings contemplate his functional loss as a result of his bilateral knee symptomatology. Thus, the assigned schedular evaluations are, therefore, adequate. Regarding his use of a brace and cane, the Board has specifically considered whether the Veteran's use of such devices warrant extra-schedular consideration. While the use of an assistive device, such as a brace or cane, is not specifically listed in the rating criteria for evaluating knee disabilities, assistive devices are provided to alleviate the presence of symptoms and/or functional limitations caused by an individual's disability. For instance, a cane is provided to normalize an abnormal gait pattern that may be limited by pain, weakness, or decreased endurance. The symptoms that necessitate use of an assistive device are fully contemplated by the rating criteria and associated regulations, and the use of such assistive device directly addresses a veteran's functional limitations. See 38 C.F.R. §§ 4.40, 4.45, 4.59. The Board has fully considered the occasional/regular use of an assistive device in the Veteran's case as it relates to the symptomatology and functional independence associated with his bilateral knee disorders, but finds that the use of such devices does not create an exceptional disability picture such that the rating criteria is inadequate. The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in Yancy v. McDonald, 27 Vet. App. 484 (2016), the Court stated that "[n]othing in Johnson changes the long-standing principle that the issue of whether referral for extra-schedular consideration is warranted must be argued by the claimant or reasonably raised by the record." Id. at 495. The Court held that "the Board is required to address whether referral for extra-schedular 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. Id., citing Thun, supra; Robinson v. Nicholson, 21 Vet. App. 545, 552 (2008). In the instant case, while such issue has not been raised by the Veteran or the record, the Board finds that, even after affording the Veteran the benefit of the doubt, there is no additional impairment that has not been attributed to a specific, rated disability. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability levels and symptomatology associated with his service-connected left and right knee disabilities. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Thun, supra; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Neither the Veteran nor his representatives have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In sum, the Board finds that an initial rating in excess of 10 percent for the Veteran's left knee strain with arthritis is not warranted. Additionally, a rating in excess of 10 percent for the Veteran's right knee strain with arthritis, status post right lateral meniscectomy, is not warranted. In denying higher ratings, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER An initial rating in excess of 10 percent for left knee strain with arthritis is denied. A rating in excess of 10 percent for right knee strain with arthritis, status post right lateral meniscectomy, is denied. REMAND Although the Board regrets the additional delay, another remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In its March 2015 remand, the Board found that a claim for a TDIU had been raised in connection with the Veteran's claim for increased ratings for his bilateral knee disabilities pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). In this regard, during his February 2014 Board hearing, the Veteran alleged that he was no longer able to work construction, as he had for most of his career, due to his knee disabilities. However, while on remand, a July 2017 rating decision granted a TDIU based on the Veteran's service-connected major depressive disorder and degenerative joint disease and degenerative disc disease of the thoracolumbar spine, effective June 4, 2015. Consequently, as the Veteran's claim for increased ratings for his bilateral knee disabilities stem from March 31, 2011, and June 14, 2011 claims, the Board must still consider whether a TDIU based on all of his service-connected disabilities is warranted prior to June 4, 2015, and whether a TDIU based on solely on his bilateral knee disabilities is warranted at any time pertinent to the appeal. In this regard, the Veteran is service-connected for major depressive disorder, evaluated as 70 percent disabling as of June 4, 2015; degenerative joint disease and degenerative disc disease of the thoracolumbar spine, evaluated as 20 percent disabling as of March 31, 2011; radiculopathy of the right lower extremity, evaluated as 20 percent disabling as of March 31, 2011; radiculopathy of the left lower extremity, evaluated as 10 percent disabling as of March 31, 2011; right knee strain with arthritis, status-post right lateral meniscectomy, evaluated as 10 percent disabling for the entirety of the appeal period; and left knee strain with arthritis, evaluated as 10 percent disabling as of June 14, 2011. However, as noted previously, the Board is only considering whether all of the Veteran's disabilities rendered him unable to secure and follow a substantially gainful occupation prior to June 4, 2015, which is the same date that service connection for major depressive disorder was established. Consequently, for the purposes of the current claim for a TDIU, the issue is whether the Veteran's service-connected back disability with associated radiculopathy and bilateral knee disabilities rendered him unable to secure and follow a substantially gainful occupation prior to June 4, 2015, and whether his bilateral knee disabilities rendered him unable to secure and follow a substantially gainful occupation at any point pertinent to the appeal period stemming from his March 31, 2011, and June 14, 2011, claims. The evidence of record reflects that the Veteran has a high school education and one year of college education. Regarding his work history, his VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) submitted in June 2015, reflects that he worked from 2004 to 2010 as a general contractor in carpentry, and became too disabled to work as of April 2009. Consequently, the Veteran has been unemployed the entirety of the appeal period. With respect to the Veteran's service-connected degenerative joint disease and degenerative disc disease of the thoracolumbar spine, and radiculopathy of the bilateral lower extremities, a September 2013 VA examiner reported that such disabilities would impact his ability to work insofar as the fact that the Veteran had a decreased ability to bend, twist, and carry items. With respect to the impact the Veteran's bilateral knee disabilities had on his functional impairment as it related to his occupation in construction, a June 2009 VA examiner and the August 2011 VA examiner noted that the Veteran had difficulty with prolonged standing; walking for more than two hours; walking up and down steps; climbing; and squatting. Additionally, the July 2013 VA examiner reported that that the Veteran's bilateral knee conditions would impact his ability to work. Here, the examiner indicated that the Veteran reported that he had been a construction worker but stopped working in 2010 due to his knees. The examiner noted that the Veteran further reported that he was a pastor in his church, and that his knees did not prevent him from doing such activity. The Board finds that a remand is necessary in order to obtain an opinion addressing the functional impairment resulting from the combined effects of the Veteran's back disability with associated radiculopathy and bilateral knee disabilities prior to June 4, 2015. In this regard, the Board notes that the Federal Circuit held that VA's duty to assist does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities in TDIU cases. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Further, the Court found that the need for a combined-effects medical examination report or opinion with regard to multiple-disability TDIU entitlement decisions is to be determined on a case-by-case basis, and depends on the evidence of record at the time of decision by the RO or the Board. The Court emphasized that this was not to say that a combined-effects medical examination report or opinion likely would not be helpful to the proper adjudication of entitlement to TDIU for a veteran with multiple service-connected disabilities, but such an examination is not required per se as a matter of statute, regulation, or policy. Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). In the instant case, the Board finds that such opinion would be helpful in adjudicating the Veteran's TDIU claim. Thereafter, in the readjudication of the Veteran's claim, if the AOJ determines that his service-connected disabilities render him unable to secure and follow a substantially gainful occupation, but he does not meet the schedular threshold for a TDIU, the claim should referred to the Director of Compensation Service for extra-schedular consideration pursuant to 38 C.F.R. § 4.16(b). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Forward the record to an appropriate VA examiner so as to determine the functional impairment resulting from the combined effects of the Veteran's back disability with associated radiculopathy and bilateral knee disabilities prior to June 4, 2015, on his ordinary activities, to include his employability. The record contents must be made available for review. The examiner is requested to review the record, to include the Veteran's June 2015 application for a TDIU, which reflects that he completed high school and one year of college, and worked solely in construction. The examiner should assess the functional impairment caused by the Veteran's service-connected back disability with associated radiculopathy and bilateral knee disabilities prior to June 4, 2015, in the aggregate (i.e., jointly), on his ordinary activities, to include his employability, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. All opinions offered should be accompanied by a rationale. 2. After completing the above action, to include any other development as may be indicated by any response received as a consequence of the action taken in the preceding paragraph, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the AOJ determines that the Veteran's service-connected disabilities render him unable to secure and follow a substantially gainful occupation, but he does not meet the schedular threshold for a TDIU, the claim should referred to the Director of Compensation Service for extra-schedular consideration pursuant to 38 C.F.R. § 4.16(b). If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs