Citation Nr: 1828656 Decision Date: 05/10/18 Archive Date: 05/18/18 DOCKET NO. 14-22 007 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an increased disability rating greater than 10 percent for RIGHT foot post-operative bunionectomy, fracture of the big toe with arthritis, and Morton's neuroma. 2. Entitlement to an increased disability rating greater than 10 percent for LEFT foot post-operative bunionectomy, fracture of the big toe with arthritis, and Morton's neuroma. 3. Entitlement to an increased disability rating greater than 10 percent for hypertension. 4. Entitlement to an increased disability rating greater than 40 percent for a RIGHT knee disability, status post replacement surgery, prior to September 28, 2016. 5. Entitlement to an increased disability rating greater than 30 percent for a RIGHT knee disability, status post replacement surgery, on and after September 28, 2016. 6. Entitlement to an increased disability rating greater than 10 percent for a RIGHT knee surgical scar. 7. Entitlement to an increased disability rating greater than 10 percent for a LEFT knee disability, status post replacement surgery, prior to October 1, 2018. 8. Entitlement to an increased disability rating greater than 30 percent for a LEFT knee disability, status post replacement surgery, on and after October 1, 2018. 9. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: David S. Russotto, Attorney at Law ATTORNEY FOR THE BOARD P.S. Rubin, Counsel INTRODUCTION The Veteran had active service in the United States Army from March 1984 to July 1997. This matter comes to the Board of Veterans' Appeals (Board) on appeal from May 2011, March 2012, May 2012, July 2012, March 2015, June 2016, December 2016, and October 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. During the course of the appeal, the Veteran has received multiple staged ratings for his right and left knee disabilities. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). He has continued to disagree with the various staged ratings assigned by the RO in the ratings decisions on appeal. The Veteran has also received 100 percent temporary total disability ratings due to convalescence on multiple occasions pursuant to 38 C.F.R. § 4.30 (2017). But he has not requested an extension for any of these 100 percent ratings. In March 2016, the Board remanded the appeal for further development. The case has since been returned to the Board for appellate review. Previously, the issues of service connection for left foot nerve damage and bilateral foot pes planus were on appeal before the Board in March 2016. However, after complying with the development requested by the Board's March 2016 remand, the RO in a December 2016 rating decision granted the Veteran service connection for left foot peroneal nerve damage and bilateral foot pes planus. A review of the record shows that the Veteran has not submitted a Notice of Disagreement (NOD) or Substantive Appeal (e.g., VA Form 9 or equivalent statement) for these particular issues. See 38 U.S.C. § 7105(a) (2012); 38 C.F.R. §§ 20.200, 20.201, 20.202, 20.300, 20.302 (2017). That is, he has not appealed either the initial rating or effective date assigned for his service-connected left foot or bilateral pes planus disabilities. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (the veteran must separately appeal these downstream issues). Thus, the issues of higher initial ratings or earlier effective dates for these service-connected disabilities are not on appeal before the Board. The following issues are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ): entitlement to increased disability ratings for both the right and left knees; entitlement to an increased disability for a right knee surgical scar; and entitlement to a TDIU. FINDINGS OF FACT 1. The Veteran is in receipt of the maximum 10 percent ratings for his right and left foot bunionectomies under Diagnostic Code 5280. 2. The Veteran's service-connected Morton's neuroma of both feet manifests in separate and distinct symptomatology from his big toe bunionectomy with arthritis. This symptomatology includes intermittent pain, paresthesias, and numbness in the plantar aspect of both feet. 3. The Veteran service-connected arthritis of the big toe in both feet does not exhibit any distinct and separate symptomatology from his already service-connected foot disabilities. 4. The Veteran's service-connected hypertension has a history of diastolic pressure predominantly 100 or more with the need for continuous medication for control; however, it has not been productive of diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. CONCLUSIONS OF LAW 1. The criteria are not met for an increased disability rating greater than 10 percent RIGHT foot post-operative bunionectomy. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5280 (2017). 2. The criteria are not met for an increased disability rating greater than 10 percent LEFT foot post-operative bunionectomy. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5280 (2017). 3. The criteria are met for a separate 10 percent rating, but no greater, for RIGHT foot Morton's neuroma. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5279 (2017). 4. The criteria are met for a separate 10 percent rating, but no greater, for LEFT foot Morton's neuroma. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5279 (2017). 5. The criteria are not met for an increased disability rating greater than 10 percent for hypertension. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.104, Diagnostic Code 7101 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). A remand by the Board confers on the claimant a legal right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Failure of the Board to ensure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. Id. However, only "substantial" compliance with the remand order, not strict compliance, is required. Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010); Dyment v. West, 13 Vet. App. 141, 147 (1999). In this respect, the AOJ has substantially complied with the Board's previous remand instructions. But subsequent to the March 2016 Board remand, neither the Veteran nor his attorney has advanced any procedural arguments in relation to VA's duties to notify and assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . ."). II. Increased Rating (IR) Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations 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. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and duration of his service-connected foot and hypertension disabilities. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). The Veteran filed increased rating claims for his service-connected disabilities in August 2010 and November 2011. As noted above, the Veteran's entire history is reviewed when assigning a disability evaluation. 38 C.F.R. § 4.1. However, where service connection has already been established and an increase in the disability ratings is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board must consider whether there have been times when his disabilities on appeal have been more severe than at others, and rate them accordingly. "The relevant temporal focus for adjudicating an increased-rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart, 21 Vet. App. at 509. Therefore, in the present case, the Board will place a specific focus on evidence of record back to August 2009. A. RIGHT and LEFT Feet - Post-Operative Bunionectomy at 10% The Veteran's service-connected post-operative bunionectomies, fractures of the big toe with arthritis, and Morton's neuroma, are rated as 10 percent disabling (for each foot) under Diagnostic Code 5280, hallux valgus, unilateral. 38 C.F.R. § 4.71a (2017). Both 10 percent ratings are effective from July 20, 1997. The Veteran filed increased rating claims in August 2010 and November 2011. Hallux valgus is defined as an "angulation of the big toe away from the midline of the body (toward the other toes) [that] can be caused by bunions." Verdon v. Brown, 8 Vet. App. 529, 530 (1996) (citing Dorland's Illustrated Medical Dictionary 244, 729 (27th ed.1988)). A bunion is an abnormal prominence of the inner aspect of the first metatarsal head, accompanied by bursal formation and resulting in a lateral or valgus displacement of the big toe. See Dorland's Illustrated Medical Dictionary 261 (30th ed. 2003). The Veteran has had multiple surgeries to correct his service-connected bunions of his feet. Under Diagnostic Code 5280, a maximum 10 percent rating may be assigned for each foot for unilateral hallux valgus if the disability is severe, analogous to amputation of the big toe, or if operated with resection of the metatarsal head. 38 C.F.R. § 4.71a. Thus, the currently assigned 10 percent ratings for each foot are the maximum ratings available under this diagnostic code. Accordingly, no higher evaluation is warranted under Diagnostic Code 5280 for each foot. By law, the Veteran cannot be entitled to a higher rating under this diagnostic code. The Veteran can only secure a higher rating under a separate diagnostic code. Accordingly, the Board concludes Veteran is not entitled to increased evaluations in excess of 10 percent for each foot for his service-connected bunionectomies, fractures of the big toe with arthritis, and Morton's neuroma, when only considering Diagnostic Code 5280. See 38 C.F.R. § 4.3. For the post-operative bunionectomies of both feet, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (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). B. Separate Ratings for RIGHT and LEFT Foot Morton's Neuroma The Board can consider whether an increased evaluation would be in order under other relevant diagnostic codes. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate rating for the feet, under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The evaluation of the same disability or the same manifestations of disability under multiple diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a big extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. See also Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) ("two defined diagnoses constitute the same disability for purposes of section 4.14 if they have overlapping symptomatology"). However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes with different ratings. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also Fanning v. Brown, 4 Vet. App. 225 (1993). The critical inquiry in making such a determination is whether any of the disabling symptomatology is duplicative or overlapping. The Veteran is entitled to a combined rating only where the symptomatology is distinct and separate. Id. The Court has also held that if the evidence warrants a separate evaluation for different manifestations of disability under a different diagnostic code, VA may assign such rating, but must also maintain the original evaluation under the diagnostic code protected under § 3.951(b) (for an assigned rating in effect for more than 20 years). Murray v. Shinseki, 24 Vet. App. 420, 426 (2011). Under Diagnostic Code 5279 for Morton's disease, a maximum 10 percent evaluation is provided for unilateral or bilateral anterior metatarsalgia (Morton's disease). 38 C.F.R. § 4.71a. Morton's disease is defined as "a form of foot pain, metatarsalgia caused by compression of a branch of the plantar nerve by the metatarsal heads....chronic compression may lead to the formation of a neuroma." See Dorland's Illustrated Medical Dictionary 1281 (31st ed. 2007). Upon review, the evidence of record is consistent with separate, additional 10 percent ratings, but no greater, for the already service-connected Morton's neuroma of both feet under 38 C.F.R. § 4.71a, Diagnostic Codes 5279. 38 C.F.R. § 4.7. That is, in an earlier November 1997 rating decision, the RO previously granted service connection for post-operative bilateral bunionectomies with Morton's neuroma and arthritis of big toes. The RO combined the ratings for bilateral bunionectomies and Morton's neuroma into one diagnostic code. At that time, bilateral Morton's neuroma was noted with pain or tenderness between the 3rd and 4th toes of both feet. X-rays from 1997 also showed retained hardware in the left big toe and arthritic changes in both big toes. At present, medical evidence of record reveals separate and distinct symptomatology for both feet due to Morton's disease, which would entitle the Veteran to separate 10 percent ratings under Diagnostic Code 5279. Esteban, 6 Vet. App. at 262. His service-connected arthritis and bunionectomies only pertains to the big toe of each foot, while his service-connected Morton's disease appears to affect a wider area of the metatarsals. In other words, the symptomology and area of the feet affected are somewhat different. The manifestations are distinct and separate for his Morton's disease. In particular, a July 2009 VA podiatry note revealed accommodations for Morton's extension in both feet. Moreover, a September 2016 VA peripheral nerves examiner, upon objective examination and testing, assessed plantar nerve lesion (Morton's Neuroma) for the bilateral feet. This was described as mild to moderate in severity. The Veteran has numbness in the second toe and dorsal and lateral aspects of the metatarsals. He has mild intermittent pain, paresthesias, and numbness. He reports paresthesia in the medial aspect of the feet bilaterally when touched. Moreover, another September 2016 VA foot examiner diagnosed Morton's neuroma in both feet. Although a June 2012 VA foot examiner stated his belief that the Veteran no longer has metatarsalgia or Morton's neuroma in both feet, this is unsupported by both earlier and latter clinical evidence of record. Thus, the currently assigned 10 percent ratings for Morton's neuroma of each foot are the maximum ratings available under Diagnostic Code 5279. It follows that by law, the Veteran cannot be entitled to a higher rating under this particular diagnostic code. For the Morton's neuroma of each foot, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (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). C. Separate Ratings for Arthritis of the Big Toes of Both Feet. The Board has also considered whether the Veteran is entitled to separate, additional compensable ratings for his already service-connected arthritis of his big toes. VA X-rays of the foot dated in September 2016 reveal degenerative changes of the first metatarsophalangeal (MTP) joint in both feet. In this respect, at this juncture, the Veteran is currently service connected for the following foot disabilities: post-operative bunionectomies, rated as 10 percent disabling in each foot under Diagnostic Code 5280; Morton's neuroma, rated as 10 percent disabling in each foot under Diagnostic Code 5279; bilateral foot pes planus, rated as 30 percent disabling under Diagnostic Code 5276; and left foot deep peroneal nerve damage, rated as 10 percent disabling in the left foot only under Diagnostic Code 8623. The Board emphasizes that the Veteran's service-connected post-operative bunionectomies, Morton's neuroma, bilateral foot pes planus, and left foot deep peroneal nerve damage all encompass different areas of the feet, such that the manifestations are distinct and separate, which has entitled the Veteran to separate ratings for each disability. Esteban, 6 Vet. App. at 262. That notwithstanding, the Board finds that any foot symptomatology such as metatarsal head pain or aching or discomfort or swelling or neuropathy, and related functional loss, from the service-connected arthritis of his big toes has already been considered within the above diagnostic codes - in particular Diagnostic Code 5280 for hallux valgus. In effect, the Veteran is not entitled to separate and additional ratings under any other diagnostic code for arthritis of the big toes, as manifestations of a disability under multiple diagnoses (i.e., pyramiding) is to be avoided under 38 C.F.R. § 4.14. His toes symptoms are already compensated within the existing ratings above. His functional loss such as difficultly standing at work for more than 30 minutes or walking more than a block has also been compensated by existing ratings assigned. Any symptomatology is duplicative or overlapping. The same signs and symptoms cannot be used to support more than one evaluation. Thus, separate ratings cannot be established for his arthritis of the big toes. In fact, neither the Veteran nor his attorney has addressed any separate foot symptomatology due to arthritis of the big toes. Moreover, other diagnostic codes for foot disabilities that provide additional ratings are not more appropriate because the facts of the case do not support their application. See 38 C.F.R. § 4.71a, Diagnostic Code 5277 (weak foot), Diagnostic Code 5278 (claw foot), Diagnostic Code 5281 (hallux rigidus), Diagnostic Code 5282 (hammer toes), Diagnostic Code 5283 (malunion or nonunion of the tarsal and metatarsal bones). From 2009 to 2017, none of the VA, private, or SSA clinical evidence of record diagnosed any of the above foot disabilities. Although there is some evidence of hammertoes in a March 2011 VA foot examination and June 2011 computed tomography (CT) scan of the left foot, the June 2012 VA foot examiner and September 2016 VA foot examiner found no evidence of hammertoes upon objective and radiographic testing. Also, there is no argument or evidence that hammertoes would be service-connected. Therefore, the above-listed foot diagnostic codes will not be applied. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Finally, Diagnostic Code 5284 refers to "other" foot injuries. But the Veteran's service-connected foot disabilities are specifically listed in the Rating Schedule under Diagnostic Codes 5276, 5279, 5280, and 8623. Where a disability is listed in the rating schedule, rating by analogy to another disability is inappropriate. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015) (quoting Suttmann v. Brown, 5 Vet. App. 127, 134 (1993) ("[a]n analogous rating . . . may be assigned "only" where the service-connected condition is 'unlisted.'"). The Veteran's service-connected foot disabilities have been diagnosed as post-operative bunionectomies, fracture of the big toe with arthritis, Morton's neuroma, bilateral foot pes planus, and left foot deep peroneal nerve damage; there is no other evidence of another service-connected condition of the feet; therefore, Diagnostic Code 5284 does not apply. D. Hypertension at 10% The Veteran's service-connected hypertension has been assigned a 10 rating pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7101 (hypertensive vascular disease). This 10 percent rating has remained in effect since April 14, 2000. The Veteran filed an increased rating claim for hypertension in 2011. Under Diagnostic Code 7101, a 10 percent rating is assigned for hypertension with diastolic pressure (bottom number) predominantly 100 or more, or systolic pressure (top number) predominantly 160 or more. A 10 percent rating also is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for hypertension with diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent rating is assigned for hypertension with diastolic pressure predominantly 120 or more. The maximum 60 percent rating is assigned for hypertension with diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104 (2017). There are three notes to 38 C.F.R. § 4.104, Diagnostic Code 7101. Note (1) provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure (i.e., bottom number) is predominantly 90 mm or greater, and isolated systolic hypertension means the systolic blood pressure (i.e., top number) is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Note (2) requires the evaluation of hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. Note (3) states that hypertension should be evaluated separately from hypertensive heart disease and other types of heart disease. The Board emphasizes that more than one blood pressure reading is not required for evaluation purposes for rating hypertension under VA regulations. See Gill v. Shinseki, 26 Vet. App. 386, 391 (2013) (holding that the need for a specific number of blood pressure readings over multiple days is not required for determining disability evaluation, as the need for multiple blood pressure readings pertains only to the confirmation of the existence of hypertension). Upon review, there is no basis for an increased rating beyond the 10 percent level for hypertension. 38 C.F.R. § 4.7. In this regard, the probative lay and medical evidence of evidence of record does not reveal blood pressure readings with diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more, which are the criteria necessary to demonstrate a 20 percent rating. See 38 C.F.R. § 4.104, Diagnostic Code 7101. In making this determination, the Board has viewed the Veteran's lay and buddy statements, VA treatment records dated from 2010 to 2017, private treatment records and SSA records dated from 2010 to 2017, and VA hypertension examinations dated from 2010 to 2017. After carefully reviewing dozens of blood pressure readings in the claims file, these records are unremarkable for any evidence supportive of a 20 percent rating. In fact, neither the Veteran nor his attorney has specifically discussed any elevated blood pressure readings indicative of a 20 percent rating. Lastly, the Board has considered whether without continuous hypertension medication, the Veteran's blood pressure readings would elevate to higher levels. On this issue, the Board acknowledges the Court's holding that VA may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). However, the Court subsequently determined that for hypertension, the plain language of Diagnostic Code 7101 contemplates the effects of medication and, thus, the Jones case is not applicable to cases involving hypertension. McCarroll v. McDonald, 28 Vet. App. 267, 271-73 (2016). That is, the rating criteria for hypertension already take into account the ameliorative effects of medication. Id. As such, the Board is not required to discuss the ameliorative effects of medication when evaluating whether the Veteran is entitled to a rating over 10 percent for hypertension. Accordingly, the Board finds that the evidence does not support an increased disability rating above 10 percent for hypertension. 38 C.F.R. § 4.3. For hypertension, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (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). ORDER An increased disability rating greater than 10 percent for RIGHT foot post-operative bunionectomy, fracture of the big toe with arthritis, and Morton's neuroma is denied. An increased disability rating greater than 10 percent for LEFT foot post-operative bunionectomy, fracture of the big toe with arthritis, and Morton's neuroma is denied. A separate 10 percent rating for Morton's neuroma of the RIGHT foot, already part of the Veteran's service-connected right foot disability, is granted. A separate 10 percent rating for Morton's neuroma of the LEFT foot, already part of the Veteran's service-connected left foot disability, is granted. An increased disability rating greater than 10 percent for hypertension is denied. REMAND However, before addressing the merits of the claims of entitlement to increased disability ratings for both the right and left knees; entitlement to an increased disability for a right knee surgical scar; and entitlement to a TDIU, the Board finds that additional development of the evidence is required. First, for both the service-connected bilateral knee and right knee surgical scar disabilities, a remand is required for a current VA examination. The Veteran was last provided a VA examination in connection with his service-connected knees and surgical scar in September 2016 - so fairly recent in time. Nonetheless, after the September 2016 VA examination, the Veteran underwent additional right knee surgery in May 2017 and left knee surgery in August 2017. See May and August 2017 private surgery records. For a period of time after these surgeries, the Veteran was awarded 100 percent temporary total disability ratings for each knee due to convalescence pursuant to 38 C.F.R. § 4.30 (2017). After the 100 percent temporary total disability ratings ended, he was assigned 30 percent ratings for each knee under Diagnostic Code 5055 (knee replacement / prosthesis). The 30 percent ratings under Diagnostic Code 5055 are the minimum ratings to be assigned following replacement of a knee joint. Id. In any event, the knee surgeries provide evidence that the severity of the Veteran's knee disabilities may have increased since the most recent September 2016 VA knee examination, and the evidence of record is otherwise insufficient to evaluate the appeal, such that an additional VA knee examination is appropriate. See VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, new VA examinations are necessary for the purpose of ascertaining the current severity and manifestations of the Veteran's service-connected bilateral knee and right knee surgical scar disabilities. On a side note, in order to comply with the Court's recent decision in Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016), it is requested that the VA knee examiner test the range of motion for both knees with consideration of joint pain in active motion, passive motion, weight-bearing, and nonweight-bearing situations. If the VA examiner is unable to conduct the required Correia testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Second, the TDIU claim on appeal is inextricably intertwined with the increased rating claims on appeal. If the increased rating claims for bilateral knee and right knee surgical scar disabilities are granted by the AOJ, this will directly impact the adjudication of the TDIU claim. See 38 C.F.R. § 4.16(a) (2017). For this reason, the increased rating claims being remanded in the present case must be resolved prior to resolution of the claim for TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, a remand is required for the AOJ to adjudicate the inextricably intertwined increased rating and TDIU claims. Third, as the increased rating and TDIU issues on appeal are already being remanded for further development, the Board sees the Veteran's VA treatment records on file from the Fayetteville, North Carolina VA Medical Center (VAMC) date to October 2017. If the Veteran has had any additional treatment at the VA, these records should be obtained. VA's duty to assist includes obtaining records of VA medical treatment identified by the Veteran, regardless of their relevance. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). VA must continue to obtain such records unless it is documented that the records do not exist or that further efforts would be futile. 38 U.S.C. § 5103A(c)(2); 38 C.F.R. § 3.159(c)(2), (c)(3). See Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA is charged with constructive knowledge of evidence generated by VA). Accordingly, the appeal for increased ratings for both knees and entitlement to a TDIU are REMANDED for the following action: 1. The AOJ should obtain VA treatment records from the VAMC in Fayetteville, North Carolina dated from October 2017 to the present, and associate them with the claims file. All attempts to secure these records, and any response received, must be documented in the claims file. If no VA treatment records are available, a response to that effect is required and should be documented in the file. 2. After completion of step 1, the AOJ should secure the appropriate VA knee examination to ascertain the current severity and manifestations of the Veteran's service-connected bilateral knee disabilities. Access to the electronic claims file must be made available to the VA examiner for review. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, including X-rays of the both knees. The examination should include a statement as the effect of the Veteran's service-connected bilateral knee disabilities on the Veteran's occupational functioning and daily activities. The appropriate DBQ for the service-connected knees should be utilized. The VA examiner should provide a complete rationale for any opinions provided. In particular, in order to comply with the Court's recent precedential decision in Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016), the VA knee examination should include range of motion testing for both knees in the following areas: • Active motion; • Passive motion; • Weight-bearing; and • Nonweight-bearing. (The earlier VA knee examinations of record failed to conduct passive range of motion for the knees). ***If the VA knee examiner is unable to conduct all the required Correia testing or concludes that certain aspects of the required testing are not necessary or are not relevant for the knees, he or she should clearly explain why that is so.*** 3. After completion of step 1, the AOJ should secure the appropriate VA skin examination to ascertain the current severity and manifestations of the Veteran's service-connected right knee surgical scar. Access to the electronic claims file must be made available to the VA examiner for review. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examination should include a statement as the effect of the Veteran's service-connected right knee surgical scar on the Veteran's occupational functioning and daily activities. The appropriate DBQ for the service-connected right knee scar should be utilized. The explanation for all opinions expressed must be provided. 4. After completion of steps 1-3, the AOJ should review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. After completion of steps 1-4, the AOJ should consider all of the evidence of record and readjudicate the following issues on appeal: entitlement to increased disability ratings for both the right and left knees; entitlement to an increased disability for a right knee surgical scar; and entitlement to a TDIU. If the benefit sought is not granted, the AOJ should issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his attorney an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs