Citation Nr: 18143801 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 12-02 737 DATE: October 22, 2018 ORDER Entitlement to a rating in excess of 60 percent from May 1, 2014, for residuals of a left total knee replacement is denied. Entitlement to a rating in excess of 20 percent prior to August 9, 2012, and in excess of 50 percent from August 9, 2012, to March 5, 2013, for post-operative synovitis of the left knee with degenerative arthritis and limited motion is denied. REMANDED Entitlement to a total disability rating based on individual unemployability prior to February 26, 2011 (TDIU) is remanded. FINDINGS OF FACT 1. From May 1, 2014, the Veteran’s residuals of a left total knee replacement had been mainly productive of residual weakness, pain or limitation of motion. 2. Prior to August 9, 2012, the Veteran’s left knee condition was not manifested by limitation of flexion to 15 degrees or less. 3. From August 9, 2012 to March 5, 2013, the Veteran was assigned the maximum schedular rating for limitation of extension of the left knee condition. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 60 percent from May 1, 2014, for residuals of a left total knee replacement have not been met. 38 U.S.C § 1155 (2012); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.68, 4.71a, Diagnostic Code 5055 (2017). 2. The criteria for entitlement to a rating in excess of 20 percent prior to August 9, 2012, and in excess of 50 percent from August 9, 2012, to March 5, 2013, for post-operative synovitis of the left knee with degenerative arthritis and limited motion have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Codes 5260, 5261 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1968 to April 1969. This matter comes before the Board of Veterans’ Affairs (Board) from a September 2011 and March 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in March 2013. A transcript of the hearing is of record. The Board previously remanded this matter in June 2014, February 2017, and July 2017. Entitlement to a total disability rating based on individual unemployability (TDIU) is an element of all appeals for a higher rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised when a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. In this case, he has alleged in the record that he was unable to work based on his disabilities during a May 1998 VA examination and April 1999 statement. As such, TDIU has been raised. The Board finds there has been substantial compliance with its July 2017 remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board’s remand.) Increased Rating Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as in the present case, entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a “staged rating” (i.e., assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. 1. Entitlement to a rating in excess of 60 percent from May 1, 2014, for residuals of a left total knee replacement From May 1, 2014, the Veteran has been assigned a 60 percent rating under Diagnostic Code 5055. A 60 percent rating is the maximum rating available under Diagnostic Code 5055, and Diagnostic Codes 5256, 5261, and 5262 do not provide for any higher ratings. The maximum ratings available under these codes are 60 percent, 50 percent, and 40 percent, respectively. Further, as this is the maximum rating under the diagnostic codes pertaining to the knee, and because Diagnostic Code 5055 specifically addresses limitation of motion, the Board finds no legal basis for further consideration of 38 C.F.R. §§ 4.40 and 4.45. Johnston, 10 Vet. App. at 85 (consideration of 38 C.F.R. §§ 4.40 and 4.45 is unnecessary where an appellant is in receipt of the maximum rating for limitation of motion). There is a general rule against the “pyramiding” of benefits. See 38 C.F.R. § 4.14; see also Brady v. Brown, 4 Vet. App. 203, 206 (1993). However, the Board acknowledges that a Veteran is entitled to separate disability ratings for different manifestations of the same disability when the symptomatology of one manifestation is not duplicative or overlapping of the symptomatology of the other manifestations. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA’s General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). In VAOPGCPREC 9-98, 63 Fed. Reg. 56703 (1998), the VA General Counsel further explained that, to warrant a separate rating, the limitation of motion need not be compensable under Diagnostic Code 5260 or 5261; rather, such limited motion must at least meet the criteria for a 0 percent rating. More recently, the VA General Counsel held that a separate rating could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). In a March 2013 private treatment record, the Veteran underwent a total knee replacement. It was noted that the Veteran tolerated the procedure well and was transported to the Recovery Room in satisfactory condition. The Board notes that following this procedure in a March 2015 rating decision, the RO assigned a 100 percent disability rating from March 6, 2013, and then an evaluation of 60 percent was assigned from May 1, 2014. In an August 2014 VA examination, the examiner noted that the Veteran had a left total knee replacement in March 2013. However, the Veteran said that his left knee condition had worsened severely despite the knee replacement. In an April 2018 VA examination, the examiner noted that the Veteran had a knee replacement. The Veteran stated that he had pain every day and was only able to walk 100 plus yards until he needed a break. The Veteran’s left leg below the knee had remained slightly swollen since surgery. The Veteran said he was not happy with the left knee outcome, but he was toleration the pain. However, the Veteran did not report flare-ups. The Veteran said he had functional impairment which consisted of him only being able to walk about 100 yards or so until he needed a break. Upon examination there was evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran specifically said his entire knee was tender. There was crepitus. The Veteran was able to perform repetitive use testing with at least 3 repetitions without additional function loss or range of motion. Pain significantly limited functional ability with repeated use over a period of time. There was deformity, and disturbance of locomotion – specifically, both knees showed the typical deformity from arthritis and there was more limitation in walking with the left knee. There was no muscle atrophy. Ankylosis was noted but there was favorable angle in full extension or in slight flexion between 0 and 10 degrees. Specifically, it was 5 degrees. There was no recurrent subluxation, lateral instability, or recurrent effusion. There was no joint instability. There was no recurrent patellar dislocations, medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. There was no semilunar cartilage condition. It was noted that the Veteran’s total left knee replacement exhibited intermediate degrees of residual weakness, pain or limitation of motion. The Veteran did not use assistive devices. The Board acknowledges that the Veteran complains of pain in his left knee and inability to walk long distances. However, in light of the favorable award of 60 percent for the left knee from May 1, 2014, the assignment of separate disability ratings for the left knee from May 1, 2014 is precluded as a matter of law, in light of the “amputation rule” which provides that the combined rating for disabilities of an extremity cannot exceed the rating for amputation at the elective level. 38 C.F.R. § 4.68 (2015). In this case, a 60 percent disability rating is assigned if there was an amputation of the thigh, above the knee, at the middle or lower third. 38 C.F.R. § 4.71a, Diagnostic Code 5162 (2015). Amputation of a leg with defective stump and thigh amputation recommended or amputation not improvable by prosthesis controlled by natural knee action may also be assigned a 60 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Codes 5163 and 5164 (2017). Thus, considering the “amputation rule” pursuant to 38 C.F.R. § 4.68 and 38 C.F.R. § 4.71a, Diagnostic Codes 5161, 5162-5164, a 60 percent disability rating would be the maximum assignable disability rating for the Veteran’s right knee disability. In fact, it would seem from the April 2018 VA examination, that the Veteran’s left knee shows improvement under Diagnostic Code 5055 as the examiner found that the Veteran’s left knee exhibited intermediate degrees of residual weakness, pain, or limitation of motion, which would warrant a 30 percent evaluation. Accordingly, as a matter of law, a disability rating in excess of the 60 percent rating for total left knee replacement is not assignable. Extraschedular Consideration Referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321 (b) (2013); Thun v. Peake, 22 Vet. App. 111, 114 (2008), aff’d, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Veteran’s left knee disability has been manifested by symptoms and functional impairment expressly addressed by the rating criteria, including weakness, limitation of motion, and pain. These symptoms and functional limitations are also contemplated by, and indeed directly addressed by sections 4.40, 4.45, and 4.59 of the regulations, as well as by Diagnostic Code 5055, which provides for compensation for residuals of knee replacement including pain, weakness, and limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5055. A comparison of the Veteran’s left knee disability with the rating criteria does not show “such an exceptional or unusual disability picture... as to render impractical the application of the regular schedular standards,” especially considering that the Veteran does not have any symptoms or functional limitations not accounted for in the ratings assigned under the schedular criteria. See 38 C.F.R. § 3.321 (b). Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321 (b)(1) is not met. Thun, 22 Vet. App. 111; see Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Accordingly, the Board finds that the schedular rating criteria adequately address his disability, and referral for extraschedular consideration is not warranted. Thun, 22 Vet. App. at 115. 2. Entitlement to a rating in excess of 20 percent prior to August 9, 2012, and in excess of 50 percent from August 9, 2012, to March 5, 2013, for post-operative synovitis of the left knee with degenerative arthritis and limited motion The Veteran’s left knee disability has been evaluated as 20 percent prior to August 9, 2012, and 50 percent from August 9, 2012, to March 5, 2013. He asserts that an increased evaluation is warranted. Under Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5257, which evaluates recurrent subluxation or lateral instability of a knee, assigns a 10 percent disabling for a slight impairment, 20 percent disabling for a moderate impairment, and 30 percent disabling for a severe impairment. Diagnostic Code 5257 is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Under Diagnostic Code 5258, a maximum 20 percent rating is warranted for semilunar cartilage, dislocated, with frequent episodes of “locking”, pain, and effusion into the joint. Lastly, under Diagnostic Code 5259, a maximum 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. Separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Additionally, for a knee disability already rated under Diagnostic Codes 5260 and/or 5261, a claimant would have additional disability justifying a separate rating if there is instability and/or subluxation of the knee joint under Diagnostic Code 5257. See generally VAOPGCPREC 23-97. Furthermore, the rating criteria do not preclude separate ratings for meniscal injury under Diagnostic Codes 5258 and 5259 where there are separate ratings for limitation of motion under Diagnostic Codes 5260 and/or 5261, or instability under Diagnostic Codes 5257. Lyles v. Shulkin, 29 Vet. App. 107 (2017). Finally, the normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Prior to August 9, 2012 Prior to August 9, 2012, the Veteran’s left knee condition was rated under Diagnostic Code 5260. In a May 1998 VA examination, it was noted that the Veteran had surgery for his left knee in service, and suffered from episodic swelling since surgery. The Veteran specifically reported episodes of sharp pain followed by dull, aching pain, associated with swelling anteriorly. The flare-ups consisted of left knee pain and swelling with prolonged standing, and walking for 2 to 3 hours at work. He said the flare-ups would last 2 to 3 days. He wore a metal brace for his left knee. The Veteran reported recurrent left knee dislocations prior to receiving closed reduction by a surgeon. There was chronic pain noted on range of motion and the Veteran had a slow, unsteady gait. There was no ankylosis noted. Range of motion was limited to 30 to 35 degrees and extension was normal. Stability was normal. X-ray showed that the Veteran had joint space narrowing in medial compartment area due to osteoarthritis. There were multiple metallic clips in the soft tissue posteriorly from his previous surgery. The examiner diagnosed the Veteran with status post left knee trauma; status post partial excision of the left patella; and osteoarthritis of the left knee. In a June 1999 general VA examination, the Veteran was noted to have an unsteady gait, braces on both knees, and used a walking cane. Upon examination, there was no muscle atrophy or weakness. Range of motion was limited to 30 to 35 degrees, and extension to 0 degrees. There was soft tissue swelling anteriorly, and there was tenderness on palpation of the superior border of the patella. In an August 1999 VA treatment note, there was no significant edema. Range of motion was flexion to 45 degrees with complaints of joint pain. Muscle guarding was noted. In a November 1999 VA treatment note, the Veteran said he ambulated using a cane due to his knees, and presently due to exacerbation of gout. He described improvement with his physical therapy. He had chronic bilateral knee pain left greater than right secondary to osteoarthritis. A February 2000 x-ray showed no evidence of fracture, dislocation or subluxation. There was narrowing of the joint space at the medial compartment area with sclerosis of the articular surface. There was a spur in the medial aspect of the distal femur as well as a spur in the superior margin of the patella. There were multiple metallic clips in the medial posterior aspect from previous surgical intervention in this area. The examining physician overall noted osteoarthritic changes. In a February 2000 VA examination, the Veteran complained of pain in the left knee anteriorly, laterally, which appeared on and off. This occurred after prolonged walking more than 1 1/2 miles or standing more than 2 hours. This usually occurred 4 or 5 times per month and each time it would take him 2 to 3 days to recover. He wore a knee brace and walked with a cane. He did not report any episodes of locking or giving way. Upon examination, range of motion was extension to 0 degrees, flexion to 70 degrees. There was pain on flexion to more than 70 degrees. There was pain on the lateral aspect of the left knee with pressure at the lateral aspect with 30 degrees of flexion. There was pain at the suprapatellar area of the left knee and lateral aspect of the left knee with 90 degrees of flexion. There was pain at the medial aspect of the left knee with pressure on the medial aspect with 90 degrees of flexion. There was no evidence of weakness of the anterior and posterior cruciate ligament. In a November 2000 VA examination, the Veteran described experiencing a daily sore pain in his left knee joint. He said that this pain increased and became tender on standing and walking. He also described stiffness in the left knee joint usually precipitated by increased bending activity or by exposure to cold, damp weather. He said that swelling occurred in the anterior aspect of this joint on prolonged walking. He also said that prolonged standing caused heat sensation and redness in the anterior aspect of the left knee. He said that he experienced instability and weakness in the left knee joint resulting in multiple falls. He used a metal knee brace and walking cane. The Veteran further reported that he had fatigability and lack of endurance with aggravation of pains in the left knee when standing for more than 15 to 20 minutes and when walking more than 1 1/2 blocks. Additionally, he had to change the position of his left leg when sitting in order to alleviate pain in the left knee joint, and he was not able to kneel no the left knee due to pain. Upon examination, the Veteran noted painful motion on flexion and extension. There was point tenderness in the anterior patella as well as along the medial, lateral, and inferior borders of the patella. There was effusion in the anterior patella as well as along the medial lateral, and inferior borders of the patella. There was slight redness and heat in the patella area. He exhibited instability, weakness, abnormal movement, and guarding of movement in the left knee with an unsteady gait due to pain. Range of motion was minus 10 degrees due to joint pain and stiffness – he was not capable of joint extension to 0 degrees. Flexion was from 10 degrees to 30 to 35 degrees at which point he described severe joint pain. There was no significant ligament laxity in the anterior-posterior and in the medial-lateral planes of the left knee joint during the examination. In an August 2011 VA examination, the Veteran reported that he continues to have pain in his left knee. The Veteran did not report any flare-ups. Upon examination, range of motion was flexion to 90 degrees, with painful motion at 90 degrees, extension to 0 degrees, with no evidence of painful motion. The Veteran was able to perform repetitive use testing with 3 repetitions with no loss of range of motion. There was functional loss and/or functional impairment shown by less movement than normal, pain on movement, and disturbance of locomotion. There was tenderness or pain to palpation for joint line or soft tissue. Joint stability was normal. There was no patellar subluxation/dislocation, medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. There were no meniscal conditions or surgical procedures for a meniscal condition, or semilunar cartilage condition. The Veteran had not had a meniscectomy. In a January 2012 VA Form 9, the Veteran stated that during his August 2011 VA examination, he had just undergone a pain treatment which temporarily allowed him to flex and extend the joint to a greater extent than he could normally do. Overall, the Board cannot factually ascertain from the lay and medical evidence a worsening of motion loss greater than the 20 percent rating level prior to August 9, 2012. The Board notes the November 2000 VA examination which showed extension to minus 10 degrees, flexion from 10 to 30 to 35 degrees, and effusion and instability. However, the overall evidence of record consistently shows that the Veteran’s flexion ranged from 30 to 35 degrees to 90 degrees, and his extension was to 0 degrees. The Board also notes that the Veteran states that his August 2011 VA examination was inaccurate because he had recently had pain treatment and was able to extend and flex more than normal. However, even without considering the August 2011 VA examination, the Veteran’s consistent range of motion was flexion 30 to 35 degrees and extension to 0 degrees, with no instability, ankylosis, recurrent subluxation, locking, semilunar cartilage, or tibia or fibula impairment. The Board further notes that though the Veteran wore a brace, this is contemplated in the 20 percent disability rating. Finally, the Board also acknowledges the Veteran’s complaints of pain through his ranges of motion. However, the objective evidence of record indicates such pain does not limit the Veteran’s functional range of motion of the left knee to levels so severe as to warrant an increased evaluation at any point during the appeal period. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (“pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system.”). In light of the above, the Board finds that the Veteran is not entitled to an increased evaluation for his service-connected left knee disability based on limitation of motion prior to August 9, 2012. The Board has considered whether the benefit of the doubt rule applies to this portion of the appeal. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). As a preponderance of the evidence is against an increased evaluation prior to August 9, 2012, this rule does not apply and the claim must be denied. From August 9, 2012, to March 5, 2013 From August 9, 2012, to March 5, 2013, the Veteran’s left knee condition was rated under Diagnostic Code 5261. In an August 2012 VA examination, the Veteran described constant left knee pain. The Veteran reported flare-ups where he was intolerant of excessive, repetitive, or prolonged activity of the left knee, prolonged inactivity, heavy lifting, ascending and descending stairs, and prolonged standing and walking. Upon examination, range of motion was flexion to 65 degrees, with evidence of painful motion at 65 degrees, and extension to 45 degrees or greater, with evidence of painful motion to 45 degrees or greater. The Veteran did not have additional limitation in range of motion following repetitive-use testing. There was functional loss and/or functional impairment indicated by less movement than normal, pain on movement, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing, and pain on palpation. There was no recurrent patellar subluxation/dislocation, or medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There were no meniscal conditions or surgical procedures for a meniscal condition, or a meniscectomy. The Veteran used a brace, cane, and walker. At the March 2013 Board hearing, the Veteran testified that he was scheduled for a total knee replacement. The Veteran said he could hardly walk and that it was “bone on bone.” He stated that he wore a brace and used his canes for his left knee, and had a lift in his house for his knee and his heart condition. The Veteran reported he could not bend his knee. In an August 2014 VA examination, the Veteran reported that his left knee had worsened severely since his left total knee replacement. The Veteran reported flare-ups that he was intolerant of excessive, repetitive, or prolonged activity, prolonged inactivity, heavy lifting, ascending and descending stairs, and prolonged standing and walking. Upon examination, range of motion was flexion to 90 degrees, with evidence of painful motion at 90 degrees, extension to 20 degrees, with evidence of painful motion at 25 degrees. There was limitation of range of motion following repetitive-use testing, shown at flexion to 75 degrees, and extension to 45 degrees or greater. There was functional loss and/or functional impairment shown by less movement than normal, pain on movement, and disturbance of locomotion, interference with sitting, and pain on palpation. There was tenderness or pain to palpation for joint line or soft tissue. Joint stability was normal; there was no patellar subluxation/dislocation. He did not have medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. There were no meniscal conditions or surgical procedures for a meniscal condition. He used a brace and a chair lift. There was no patellar subluxation. In an April 2018 VA examination, the examiner noted that the Veteran had a knee replacement. The Veteran stated that he had pain every day and was only able to walk 100 plus yards until he needed a break. The Veteran’s left leg below the knee had remained slightly swollen since surgery. The Veteran said he was not happy with the left knee outcome, but he was tolerating the pain. However, the Veteran did not report flare-ups. The Veteran said he had functional impairment which consisted of him only being able to walk about 100 yards or so until he needed a break. Upon examination there was evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran specifically said his entire knee was tender. There was crepitus. Range of motion was flexion 5 to 90 degrees, and extension was 90 to 5 degrees. The Veteran was able to perform repetitive use testing with at least 3 repetitions without additional function loss or range of motion. Pain significantly limited functional ability with repeated use over a period of time. There was deformity, and disturbance of locomotion – specifically, both knees showed the typical deformity from arthritis and there was more limitation in walking with the left knee. There was no muscle atrophy. Ankylosis was noted but there was favorable angle in full extension or in slight flexion between 0 and 10 degrees. Specifically, it was 5 degrees. There was no recurrent subluxation, lateral instability, or recurrent effusion. There was no joint instability. There was no recurrent patellar dislocations, medial tibial stress syndrome, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. There was no semilunar cartilage condition. Overall, under Diagnostic Code 5261 a 50 percent rating is the maximum schedular rating assignable for limited extension of a knee. Thus, based on the overall evidence the Veteran receives the highest schedular rating possible based on the symptoms of his disability. The only other higher disability rating would be under Diagnostic Code 5256 extremely favorable ankylosis at 60 percent; however, the evidence does not show this to be the case. Accordingly, the Board finds that from August 9, 2012, to March 5, 2013, a schedular rating greater than 50 percent for limited right knee extension was not warranted based on the facts in this case. Extraschedular Consideration Referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321 (b) (2013); Thun, 22 Vet. App. at 114, aff’d, Thun, 572 F.3d 1366. The Veteran’s left knee disability has been manifested by symptoms and functional impairment expressly addressed by the rating criteria, including weakness, limitation of motion, and pain. These symptoms and functional limitations are also contemplated by, and indeed directly addressed by sections 4.40, 4.45, and 4.59 of the regulations. A comparison of the Veteran’s left knee disability with the rating criteria does not show “such an exceptional or unusual disability picture... as to render impractical the application of the regular schedular standards,” especially considering that the Veteran does not have any symptoms or functional limitations not accounted for in the ratings assigned under the schedular criteria. See 38 C.F.R. § 3.321 (b). Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321 (b)(1) is not met. Thun, 22 Vet. App. 111; see Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Accordingly, the Board finds that the schedular rating criteria adequately address his disability, and referral for extraschedular consideration is not warranted. Thun, 22 Vet. App. at 115. REASONS FOR REMAND Entitlement to a total disability rating based on individual unemployability prior to February 26, 2011 (TDIU) The Veteran asserted that prior to February 26, 2011 he was unemployable as a result of his service-connected disabilities. The Board notes that he did not submit a Form 21-8940. However, in a May 1998 joints VA examination, the Veteran stated he had been unable to work since September 1997. In an April 1999 statement, the Veteran stated that in October 1997 he underwent open heart surgery, where he received a quadruple bypass. After surgery, he developed respiratory complications and was informed by a pulmonary specialist that his hemi-diaphragm had been paralyzed. He said he took home oxygen therapy, and since then has been unable to work. In an April 1999 Form VA 21-527 the Veteran reported that he was self-employed and completed 1 year of college. However, information regarding the nature of this employment is needed on remand via completion of an updated VA Form 21-8940. Additionally, a VA opinion is needed to determine whether he was able to obtain or maintain substantially gainful employment consistent with his education and history. The matter is REMANDED for the following actions: 1. Obtain any outstanding private or VA treatment records. Request that the Veteran assist with locating these records, if possible. Associate these records with the claims file. 2. Then, obtain a VA 21-8940 claim for TDIU with the most accurate information regarding the Veteran’s employment and education prior to February 26, 2011. The form should contain the names and addresses of prior employers, so that VA 21-4192 forms can be requested of the prior employers. 3. After obtaining a VA 21-8940, forward the claims file and a copy of this remand to an appropriate VA examiner to determine whether the Veteran was unable to obtain or maintain substantially gainful employment prior to February 26, 2011. The examiner should be made aware of all service-connected disabilities prior to February 26, 2011. The examiner is requested to comment upon the Veteran’s ability to function in an occupational environment considering his education and work experience due to his service-connected disabilities. The examiner should elicit from the Veteran a full work history and educational history. A complete rationale should be provided for all opinions expressed. The examiner must consider all lay statements including in the May 1998 VA examination and the April 1999 statement. If the examiner is unable to provide an opinion without resorting to mere speculation then the examiner must state this and provide any information necessary to make an opinion, if possible. 3. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning this matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Saudiee Brown, Associate Counsel