Citation Nr: 20049975 Decision Date: 07/28/20 Archive Date: 07/28/20 DOCKET NO. 14-21 426 DATE: July 28, 2020 ORDER An initial evaluation in excess of 20 percent for diabetes mellitus type II is denied. For the period on appeal prior to June 17, 2014, an evaluation in excess of 10 percent for a service-connected right knee disability based on degenerative arthritis with noncompensable limitation of motion that is painful, is denied. For the period on appeal from June 17, 2014 to February 16, 2015, an evaluation in excess of 20 percent for a service-connected right knee disability based on dislocated semilunar cartilage with frequent episodes of locking, pain and effusion, is denied. For the period on appeal from July 11, 2013 to February 16, 2015, a separate 10 percent evaluation for a varus deformity of the right knee manifested by weakness and insecurity in weight-bearing, is granted. For the period on appeal from April 1, 2016, an evaluation in excess of 30 percent for right total knee arthroplasty is denied. For the period on appeal from April 1, 2016, a separate 10 percent evaluation, but no higher, for right knee instability that is slight is granted. REMANDED An initial evaluation in excess of 30 percent for coronary artery disease status post myocardial infarction from October 1, 2012 is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s diabetes mellitus type II is manifested by a need for restricted diet and an oral glycemic medication; the requirement for regulation of activities to control blood sugar is not shown. 2. For the period on appeal prior to June 17, 2014, the Veteran’s service-connected right knee disability was manifested by degenerative joint disease with noncompensable limitation of motion and chronic pain. 3. For the period on appeal from July 11, 2013 to February 16, 2015, the Veteran’s service-connected right knee disability was manifested by dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion; and a varus deformity with symptoms of weakness and insecurity in weight-bearing. 4. For the period on appeal from April 1, 2016, the Veteran’s service-connected right total knee arthroplasty has been manifested by prosthetic replacement of the knee joint with minimal weakness, pain, or limitation of motion. 5. For the period on appeal from April 1, 2016, the Veteran’s service-connected right total knee arthroplasty has been manifested by slight instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 20 percent for diabetes mellitus type II have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7913. 2. For the period on appeal prior to June 17, 2014, the criteria for an evaluation in excess of 10 percent for a service-connected right knee disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261, 5259. 3. For the period on appeal from June 17, 2014 to February 16, 2015, the criteria for an evaluation in excess of 20 percent for a service-connected right knee disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261, 5258. 4. For the period on appeal from July 11, 2013 to February 16, 2015, the criteria for a separate evaluation of 10 percent for a varus deformity of the right knee manifested by weakness and insecurity in weight-bearing have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.71a, Diagnostic Code 5263. 5. For the period on appeal from April 1, 2016, the criteria for an evaluation in excess of 30 percent for right knee total arthroplasty have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 6. For the period on appeal from April 1, 2016, the criteria for a separate 10 percent evaluation based on slight instability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1966 to July 1968. As a preliminary matter, the issue of entitlement to service connection for residuals of cancer of the renal pelvis, to include as due to Agent Orange exposure and claimed as secondary to service-connected prostate cancer, was remanded by the Board in August 2018. In an April 2020 rating decision, service connection for renal cancer status post left nephroureterectomy was granted. As such, that issue is no longer before the Board. Increased Rating Disability ratings are determined by the criteria set forth in the VA Schedule for Rating Disabilities, and are intended to represent the average impairment of earning capacity resulting from the disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999). “Staged” ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetes Mellitus Type II Procedurally, the Veteran was awarded service connection for diabetes mellitus type II with an evaluation of 20 percent from January 2015. See April 2015 rating decision. The Veteran timely appealed the evaluation of his diabetes mellitus type II, indicating that he was seeking a 40 percent disability rating. See March 2016 notice of disagreement. In November 2016, the Board remanded the Veteran’s increased rating claim for issuance of a statement of the case. See 38 C.F.R. § 19.9(c); see also Manlincon v. West, 12 Vet. App. 238 (1999). Although a substantive appeal was not received with 60 days of the November 2017 statement of the case addressing the Veteran’s increased rating claim for diabetes mellitus type II, the Board took jurisdiction of the issue and remanded it again in August 2018 for the Agency of Original Jurisdiction (AOJ) to consider additional evidence associated with the claims file. As such, the Board finds the issue of timeliness with regard to a substantive appeal was waived. As it relates to the Veteran’s claim for an initial disability rating in excess of 20 percent for diabetes mellitus type II, the rating criteria for diabetes mellitus provides for a structured scheme of specific, successive, cumulative criteria. 38 C.F.R. § 4.119, Diagnostic Code 7913. Each higher rating includes the same criteria as the lower rating plus distinct new criteria. Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013). As Diagnostic Code 7913 contains successive criteria, the criteria for the lower rating must be met before a higher disability rating may be awarded. A higher rating cannot be granted based on a finding that the Veteran’s disability picture more nearly approximates the criteria for the next higher rating. However, reasonable doubt regarding the presence of a criterion may be resolved in the Veteran’s favor. Johnson v. Wilkie, 30 Vet. App. 245 (2018). A 10 percent rating is warranted when diabetes is manageable by restricted diet only. A 20 percent rating is warranted when diabetes requires one or more daily injection of insulin and restricted diet, or an oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted when it requires one or more daily injection of insulin, restricted diet, and regulation of activities. Regulation of activities is defined as avoidance of strenuous occupational and recreational activities. A 60 percent rating is warranted when diabetes requires one or more daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted when diabetes requires more than one daily injection of insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. The criterion of “regulation of activities” requires medical evidence that occupational and recreational activities have been restricted by the diabetes. Camacho v. Nicholson, 21 Vet. App. 360, 364 (2011). In reviewing the evidence of record, the Veteran was afforded a VA diabetes mellitus examination in April 2015. The examiner reported the Veteran was prescribed oral hypoglycemic agents. The examiner reported the Veteran did not require regulation of activities as part of the medical management of his diabetes mellitus type II. The examiner reported the Veteran visited his diabetic care provider less than two times per month for episodes of ketoacidosis or hypoglycemia. The examiner reported the Veteran had no episodes of ketoacidosis or hypoglycemia requiring hospitalization over the past year. The examiner reported the Veteran had no progressive unintentional weight loss and loss of strength due to diabetes mellitus. The Veteran was afforded another VA diabetes mellitus examination in February 2017. The findings on examination in February 2017 were the same as those reported in the April 2015 VA diabetes mellitus examination above. In a letter from the Veteran’s primary care provider received by VA in March 2016, Dr. A.K. reported that “medication, diet, and exercise has kept the [Veteran’s] diabetes under control.” Throughout VA treatment records, the Veteran’s diabetes mellitus type II was indicated as under control through medication, diet, and exercise. In a February 2020 VA diabetes mellitus examination, the examiner reported the Veteran’s diabetes mellitus was managed by restricted diet, and did not require the regulation of activities. While there is evidence in the record indicating the Veteran is limited in his activities, the limitations related to diabetes mellitus are reportedly due to diabetic peripheral neuropathy of the bilateral upper and lower extremities, and not avoidance of strenuous occupational and recreational activities with the intention of avoiding hypoglycemic episodes. Contrary to avoiding strenuous activities, VA treatment records indicate the Veteran was encouraged to continue physical activity to help manage his diabetes mellitus. See November 2018 VA cardiology note. The Board adds that Diagnostic Code 7913, Note (1), directs that compensable complications of diabetes are to be evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process. In this case, the Veteran has already been awarded separate evaluations for diabetic peripheral neuropathy of the bilateral upper and lower extremities. The evidence of record does not indicate the Veteran has other separate compensable complications of diabetes. The preponderance of evidence is against a finding that the Veteran requires regulation of activities as part of medical management of his diabetes. As such, the Veteran does not meet the successive criteria for a 40 percent disability rating, and the claim for a disability rating in excess of 20 percent must be denied. Right Knee Procedurally, the Veteran filed an informal increased rating claim for his service-connected right knee disability in September 2011. See September 2011 VA Form 21-4138. In an August 2013 Decision Review Officer decision, an evaluation in excess of 10 percent for his service-connected right knee disability was denied. The Veteran timely appealed the August 2013 rating decision. See August 2013 notice of disagreement. In a November 2014 Decision Review Officer decision, the evaluation of the Veteran’s right knee disability was increased to 20 percent from June 17, 2014. During the pendency of the Veteran’s appeal, he underwent a right total knee arthroplasty on February 16, 2015. In a November 2015 rating decision, the Veteran was awarded a temporary total evaluation for his right knee disability status post total knee arthroplasty from February 16, 2015 through March 31, 2016, and an evaluation of 30 percent was assigned from April 1, 2016. In November 2016, the Board remanded the Veteran’s claim for an evaluation in excess of 10 percent for a service-connected right knee disability for the period on appeal prior to June 17, 2014; an evaluation in excess of 20 percent for the period on appeal from June 17, 2014 to February 16, 2015; and an evaluation in excess of 30 percent from April 1, 2016 (when the temporary total rating status post right knee total arthroplasty was discontinued). In relevant part, the Board instructed the AOJ to schedule the Veteran for a VA knee examination to assess the current severity of his right knee disability, which was scheduled and conducted in February 2017. The Board remanded this issue again in August 2018 for the AOJ to consider additional evidence associated with the claims file since the statement of the case was issued. The AOJ has complied with the Board’s remand directives, and the Board will proceed with a decision on the merits of the Veteran’s increased rating claim for his service-connected right knee disability. Knee disabilities are unique, as they are one of a few orthopedic disabilities in which multiple ratings may be assigned based on separate and distinct manifestations of the same disability. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. When the limitation of motion is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is applied for each major joint affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by such findings as swelling, muscle spasm or satisfactory evidence of painful motion. Limitation of flexion is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5260. A noncompensable disability rating is assigned for limitation of flexion to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a maximum 30 percent rating is warranted for flexion limited to 15 degrees. Limitation of extension is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5261. A noncompensable disability rating is assigned for limitation of extension to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. VA’s General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for recurrent subluxation or lateral instability of the knee, a 10 percent rating is assigned for slight impairment. A 20 percent rating is assigned for moderate impairment. A 30 percent rating is assigned for severe impairment. Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, a maximum 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, a maximum 10 percent rating is assigned for symptomatic removal of semilunar cartilage. Under 38 C.F.R. § 4.71a, Diagnostic Code 5262, for malunion of the tibia and fibula, a 10 percent rating is assigned for slight knee or ankle disability. A 20 percent rating is assigned for a moderate knee or ankle disability. A 30 percent rating is assigned for a marked knee or ankle disability. A maximum 40 percent rating is assigned for nonunion of the tibia and fibula with loose motion requiring a brace. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, a maximum 10 percent rating is assigned for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Period on appeal prior to June 17, 2014. At the time of the Veteran’s informal increased rating claim for his service-connected right knee disability, he was in receipt of a 10 percent evaluation based symptomatic removal of semilunar cartilage. See March 2004 rating decision. In his increased rating claim, the Veteran reported he had arthritic changes to his right knee and that his right knee was giving him problems. See September 2011 VA Form 21-4138. In a September 2011 VA primary care note, the provider indicated the Veteran had good strength and full range of motion of his extremities. The Veteran reported he exercised three times per week for two hours at a time, including bicycling and the elliptical machine with increasing resistance. In a February 2012 VA primary care note, the Veteran reported pain in his right knee with exercising. The Veteran indicated he wanted to know the source of the aching. The Veteran reported he exercised three times per week for two hours at a time, including bicycling and the elliptical machine. In an April 2012 VA orthopedic consult, the Veteran reported pain in his right knee had progressively increased, which prevented him from doing some of the activities he enjoyed. See also September 2012 VA orthopedic note. The Veteran reported he rode his bicycle and went to the gym three times per week. The Veteran reported he cut back on renovation projects due to right knee pain. The Veteran reported he used a hinged knee brace. The provider reported range of motion for right knee flexion was measured to 110 degrees. The provider reported the Veteran had a well-healed scar from a previous meniscectomy. The provider reported the Veteran demonstrated significant patellofemoral crepitus, tenderness to palpation along patellar facets and medial joint line, moderate varus deformity (correctible), stable to varus/valgus stress, 1A Lachman/Posterior drawer, and no effusion. Radiographs of the right knee revealed severe patellofemoral and medial compartment osteoarthritis, and mild lateral compartment osteoarthritis. In a June 2013 VA primary care note, the Veteran reported chronic pain in his right knee. The Veteran reported he wore a knee brace occasionally. The provider informed the Veteran that his problems initiating movement because of stiffness and aching in the knee were due to degenerative joint disease. The Veteran reported that he was still exercising two hours per day running or biking. The Veteran was afforded a VA knee examination in July 2013. The Veteran reported pain in his right knee had increased in severity, and problems with walking for a longer distance. The Veteran reported he had three cortisone shots in the right knee with limited benefit. The examiner indicated the Veteran denied flare-ups of his right knee disability. Initial range of motion for right knee flexion was measured to 130 degrees, with objective evidence of painful motion beginning at 130 degrees. Right knee extension was measured to 0 degrees, with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions, with no loss of range of motion of the right knee. The examiner reported the Veteran did not have tenderness or pain to palpation for joint line or soft tissues of the right knee. Muscle strength testing was normal for right knee flexion and extension. Joint stability tests were normal for the right knee. The examiner reported there was no evidence or history of recurrent patellar subluxation/dislocation. The examiner reported the Veteran did not have shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran reported constant use of a brace and cane for his right knee disability. The examiner indicated functional impairment due to the Veteran’s right knee disability included problems with walking for 1/3 of a mile and prolonged standing. In an August 2013 rating decision, an evaluation in excess of 10 percent for the Veteran’s service-connected right knee disability was denied. A 10 percent evaluation was continued based on x-ray evidence of degenerative arthritis in the right knee with noncompensable limitation of motion due to pain. In his August 2013 notice of disagreement, the Veteran indicated the July 2013 examiner did not sufficiently examine his knee. The Veteran reported the examination did not take into consideration that he walked with constant pain in his right knee, and that he had severe buckling of his right knee that resulted in him falling several times per day. In consideration of the lay and medical evidence of record for the period on appeal prior to June 17, 2014, the Board finds that an evaluation in excess of 10 percent for the Veteran’s service-connected right knee disability is not warranted. The diagnosis of arthritis in the right knee and noncompensable limitation of motion confirmed by evidence of painful motion is contemplated by the 10 percent disability rating for the period on appeal prior to June 17, 2014. The evidence of record does not demonstrate that the Veteran met the criteria for compensable limitation of flexion or extension at any time during the period on appeal. The Board has considered whether any other disability ratings based on separate and distinct manifestations of his right knee disability are warranted. The evidence of record does not demonstrate, and the Veteran has not asserted, he experienced dislocation of semilunar cartilage with frequent episodes of locking, pain, and effusion, warranting a separate 20 percent rating under Diagnostic Code 5258. In relation to Diagnostic Code 5259, for symptomatic removal of semilunar cartilage, the Board finds the Veterans right knee symptoms are specifically contemplated in the currently assigned 10 percent evaluation for degenerative arthritis with noncompensable limitation of motion due to pain. As such, it would violate the rule against pyramiding to compensate the Veteran’s knee pain symptomatology again under Diagnostic Code 5259. With respect to the August 2013 notice of disagreement in which the Veteran reported severe buckling of his right knee that resulted in him falling several times per day, the Board observes that this is the first evidence indicating such symptoms/impairment related to his right knee disability. However, the Board observes that a moderate varus deformity (correctible), stable to varus/valgus stress, was found on examination in July 2013. Additionally, the Veteran reported constant use of a brace and cane for his right knee disability during the July 2013 VA knee examination. Varus deformity, rated analogously under Diagnostic Code 5263 for genu recurvatum, considers symptoms of weakness and insecurity in weight-bearing. Given the medical evidence of a varus deformity, and the Veteran’s report of buckling of his right knee, the Board finds a separate 10 percent rating for is warranted under Diagnostic Code 5263. The Board finds a separate rating under Diagnostic Code 5263 is not warranted prior to July 11, 2013, as the medical and lay evidence of record does not demonstrate a basis for instability or weakness of the right knee. The Board finds that a separate rating is not warranted for recurrent subluxation or lateral instability of the right knee under Diagnostic Code 5257. Throughout the period on appeal prior to June 27, 2014, joint stability tests have been normal. Additionally, the Board finds the Veteran’s symptom of right knee buckling is contemplated by the assignment herein of a separate rating under Diagnostic Code 5263, which considers symptoms of weakness and insecurity in weight-bearing. As noted above, it would violate the rule against pyramiding to compensate the Veteran’s knee symptomatology again under Diagnostic Code 5257. The medical evidence of record has not demonstrated, nor has the Veteran or his representative asserted, that a separate disability rating is warranted for ankylosis of the knee under Diagnostic Code 5256; or malunion or nonunion of the tibia and fibula under Diagnostic Code 5262. Period on appeal from June 17, 2014 to February 16, 2015. The Veteran was afforded another VA knee examination on June 17, 2014. The Veteran reported he had increasing pain in his right knee, and less pain free range of motion. The Veteran reported swelling of his right knee after riding a stationary bike at the gym. The Veteran reported constant use of an unloader brace for his right knee when leaving the house and most times when at home. The Veteran reported he had two steroid injections in the right knee over the past 18 months that did not alleviate symptoms. The Veteran reported a feeling of grinding or crepitus in his right knee, and difficulty climbing stairs. The Veteran reported he experienced flare-ups of his right knee disability that resulted in less active pain free range of motion and swelling. Initial range of motion for right knee flexion was measured to 110 degrees, with objective evidence of painful motion beginning at 105 degrees. Right knee extension was measured to minus 5 degrees, with objective evidence of painful motion at minus 15 degrees. The Veteran was able to perform repetitive-use testing with three repetitions, with no loss of range of motion of the right knee. The examiner reported that contributing factors resulting in functional impairment or additional limitation of range of motion of the right knee after repetitive use included less movement than normal, weakened movement, excess fatigability, pain on movement, deformity, atrophy of disuse, and disturbance of locomotion. During flare-ups of the Veteran’s right knee disability, the examiner estimated flexion would be limited to 105 degrees and extension to minus 10 degrees due to pain, fatigue, and weakness. The examiner reported the Veteran had tenderness or pain to palpation for joint line or soft tissues of the right knee. Muscle strength testing was normal (5/5) for right knee flexion and decreased (4/5) for extension. Joint stability tests were normal for the right knee. The examiner reported there was no evidence or history of recurrent patellar subluxation/dislocation. The examiner reported the Veteran had a residual scar from his meniscectomy in service. The Veteran reported frequent episodes of right knee locking and pain. The examiner reported crepitus of the right knee was palpable and genu varum of the right knee. The examiner reported other pertinent physical findings included the Veteran’s right calf circumference measured 16 inches compared to 17 inches on the left, his right knee circumference measured 17.5 inches compared to 17 inches on the left, and his right thigh circumference measured 18 inches compared to 19 inches on the left. The Veteran reported constant use of a brace for his right knee disability. The examiner reported the functional impairment (including balance and propulsion) due to the Veteran’s right knee disability was not such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner indicated functional impairment due to the Veteran’s right knee disability included an inability to do heavy lifting or carrying, or activities involving heavy repetitive right foot controls, squatting, crouching, or kneeling. In a November 2014 Decision Review Officer decision, the evaluation of the Veteran’s service-connected right knee disability was increased to 20 percent based on dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion. The evidence for this period on appeal continued to demonstrate that the Veteran’s degenerative arthritis of the knee was manifested by noncompensable limitation of motion due to pain. Accordingly, a separate evaluation would not be warranted on this basis, and the functional impairment is already contemplated symptoms under Diagnostic Code 5258. Additionally, the Board finds that a separate rating is not warranted for recurrent subluxation or lateral instability of the right knee under Diagnostic Code 5257. As noted above, the Board has assigned a maximum 10 percent evaluation under Diagnostic Code 5263 from July 11, 2013 to February 16, 2015, based on evidence of genu varum of the right knee, which considers symptoms of weakness and insecurity in weight-bearing. To compensate the Veteran’s knee symptomatology again under Diagnostic Code 5257 would violate the rule against pyramiding. For this period on appeal, the medical evidence of record has not demonstrated, nor has the Veteran or his representative asserted, that a separate disability rating is warranted for ankylosis of the knee under Diagnostic Code 5256; or malunion or nonunion of the tibia and fibula under Diagnostic Code 5262. Period on appeal from April 1, 2016. The Veteran underwent a right total knee arthroplasty on February 16, 2015. In a November 2015 rating decision, the Veteran was awarded a temporary total evaluation for his right knee disability status post total knee arthroplasty from February 16, 2015 through March 31, 2016, and an evaluation of 30 percent was assigned from April 1, 2016. Under 38 C.F.R. § 4.71a, Diagnostic Code 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis (The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30). Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. The Veteran was afforded a VA knee examination in February 2017. The Veteran reported pain and swelling in the right knee that increased with standing. The Veteran reported flare-ups of his right knee. The Veteran reported functional impairment due to his right knee disability, including but not limited to repeated use over time, was an inability to climb ladders and the knee joint giving out. On initial range of motion testing, flexion was measure to 110 degrees and extension to 0 degrees. Pain was observed on flexion, but the examiner indicated pain did not result in functional loss. The examiner reported there was no evidence of pain with weight-bearing. The examiner reported there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The examiner reported there was objective evidence of crepitus. The examiner reported there was no additional functional loss or range of motion after three repetitions. The examiner reported additional contributing factors of disability included less movement than normal, swelling, and interference with standing. Muscle strength testing of the right knee was normal for flexion and extension. The examiner reported the Veteran did not have ankylosis of the right knee. The examiner reported there was no history of recurrent subluxation, lateral instability, or effusion of the right knee. The examiner reported the Veteran did not have any other tibial or fibular impairment. The examiner reported the Veteran had intermediate degrees of residual weakness, pain, or limitation of motion as a result of his right total knee arthroplasty. Diagnostic imaging revealed satisfactory alignment of the right knee replacement prosthesis, with no fracture or loosening of the prosthesis. The examiner reported the Veteran’s right knee disability would prevent him from engaging in activities involving prolonged standing or ambulation. In a February 2017 VA primary care note, the Veteran reported his right knee felt like it would give out, and he experienced bothersome stiffness. In a March 2017 VA cardiology note, the Veteran reported edema and numbness in his right leg. The Veteran reported his ability to do household chores, including cooking, cleaning, and laundry, was limited due to right leg discomfort. In an April 2017 VA orthopedic note, the provider indicated the Veteran’s swelling of the right knee had largely resolved. The Veteran reported pain with any prolonged standing or walking, and continued stiffness of the right knee. The provider reported right knee flexion was measure to 110 degrees. The provider reported there was no effusion or areas of tenderness of the right knee. The provider recommended nonsteroidal anti-inflammatory drugs for management of the Veteran’s right knee symptoms of pain and stiffness, given his excellent stability, normal x-rays, and normal range of motion. In a February 2018 VA emergency department note, the Veteran reported he twisted his right ankle and knee going down the stairs after his right knee gave out, which the Veteran indicated was common for him. See also March 2018 VA primary care note. In an April 2018 VA physical therapy note, the Veteran reported right leg weakness and three falls since June 2017. See also May and June 2018 VA physical therapy notes. The Veteran reported stiffness of his right knee with prolonged standing. The Veteran denied pain. Active range of motion of the right knee was measured to 113 degrees flexion, and minus 2 degree extension. Muscle strength testing of the right knee was normal for flexion and extension. The Veteran was afforded a VA knee examination in January 2020. The Veteran reported his right knee disability had improved since the total knee arthroplasty in February 2015. The Veteran reported current symptoms of his right knee disability included stiffness. The Veteran denied flare-ups of his right knee disability. Initial range of motion measurements for the right knee were normal, with flexion to 140 degrees, extension to 0 degrees. The examiner reported there was no objective evidence of pain on passive range of motion testing or when the right knee joint was used in non-weight bearing. The examiner reported there was no evidence of pain with weight-bearing, and no objective evidence of crepitus. The examiner reported the Veteran’s right knee functional ability after repeated use was not significantly limited by pain, weakness, fatigability, or incoordination. The examiner reported swelling was an additional factor contributing to the Veteran’s right knee disability. Muscle strength testing of the right knee was normal for flexion and extension. Muscle atrophy was not demonstrated. The examiner reported there was no history of recurrent subluxation or lateral instability. The examiner reported there was no tibial or fibular impairment. The examiner reported the Veteran did not utilize any assistive devices for his right knee disability. The Board has considered the evidence of record from April 1, 2016, when the temporary total rating was discontinued, and finds that a disability rating in excess of 30 percent is not warranted for residuals of his right total knee arthroplasty. From April 1, 2016, the Veteran’s right knee disability was manifested by pain, swelling, weakness, and flexion limited to 110 degrees at worst. Severe painful motion or weakness is simply not shown. The Board recognizes the Veteran’s reports of his knee occasionally giving out, with an emergency room visit following a fall in February 2018. The Board has considered whether a separate compensable rating under Diagnostic Code 5257 for instability may be warranted. As noted above, for recurrent subluxation or lateral instability of the knee, a 10 percent rating is assigned for slight impairment. A 20 percent rating is assigned for moderate impairment. A 30 percent rating is assigned for severe impairment. In this case, even if the Board were to concede the presence of instability based on the Veteran’s own lay statements, the Board does not find that the evidence dating from his surgery shows that such instability is any more than slight in degree. At both VA examinations, instability was specifically tested by trained medical utilizing professionals and was found to be non-existent. Taking into consideration both the lay descriptions of feelings of instability, his fall history, and the assessments identifying the presence of no instability following testing specifically designed to identify and assess the severity of subluxation or instability, at the very worst, the severity of instability existing since his surgery is slight in degree. As the Veteran’s instability symptoms are not contemplated by the current rating under Diagnostic Code 5055, a separate 10 percent rating is awarded effective April 1, 2016. Higher or separate evaluations under other codes are not warranted. The Veteran’s knee is not ankylosed, and there is no nonunion of the tibia and fibula with loose motion, requiring a brace. Symptoms of pain, weakness are contemplated by the 30 percent rating assigned, and the Board has assigned a separate 10 percent rating to contemplate slight instability. As noted above, a higher evaluation of 60 percent is not warranted unless there is post-prothesis placement with chronic residuals consisting of severe painful motion or weakness in the affected extremity, which is not shown by the evidence of record. Accordingly, a disability rating in excess of 30 percent from April 1, 2016 for residuals of the Veteran’s service-connected right total knee arthroplasty is denied. However, a separate 10 percent rating based on slight instability is granted, effective April 1, 2016. REASONS FOR REMAND Coronary Artery Disease Historically, the Veteran was awarded service connection for coronary artery disease with a temporary total evaluation (100 percent) based on a history of myocardial infarction. Although the myocardial infarction occurred in June 2012, a temporary total evaluation for coronary artery disease was assigned from the date the Veteran’s claim was received by VA on August 28, 2012, and a 30 percent evaluation was assigned from October 1, 2012. See May 2014 Decision Review Officer Decision. In a July 2013 notice of disagreement, the Veteran indicated he was seeking an evaluation of 60 percent for his coronary artery disease. The Veteran indicated that his cardiologist believed his heart disease was more pronounced than contemplated by the rating assigned. In November 2016, the Board denied a disability rating in excess of 30 percent for coronary artery disease from October 1, 2012. In a July 2017 Joint Motion for Remand (JMR), the United States Court of Appeals for Veterans Claims (Court) vacated and remanded the November 2016 Board decision that denied entitlement to a disability rating in excess of 30 percent for coronary artery disease from October 1, 2012. Specifically, the JMR noted that the Board failed to discuss a February 2015 VA medical assessment that the Veteran’s functional capacity was limited to less than 4 METs. In August 2018, the Board remanded this issue to the AOJ for additional development and to consider in the first instance relevant VA treatment records that were added to the record since the claim was last considered. As it relates to the Veteran’s claim for an initial disability rating in excess of 30 percent for coronary artery disease, the August 2018 Board remand instructed that, if evaluated, testing should include an assessment of work capacity in METs by exercise testing. The Board further directed that a METs estimate may only be substituted if studies cannot be conducted for medical reasons, in which case the examiner must support the estimate with specific examples. The Veteran submitted a VA Ischemic Heart Disease Disability Benefits Questionnaire (DBQ) completed by his VA cardiology treatment provider in May 2019. Based on interview with the Veteran, DNP P.G. indicated he reported symptoms of dyspnea at 1 to 3 METs. DNP P.G. indicated the Veteran reported increasing shortness of breath with prolonged standing or walking longer distances (one mile) at moderate exertion. The Veteran was afforded a VA examination in January 2020. The examiner indicated the Veteran reported no current symptoms of shortness of breath and no chest pain. The examiner reported that an exercise stress test was not performed on examination in January 2020 because exercise stress testing was not required as part of the Veteran’s current treatment plan and such testing was not without significant risk. Based on interview with the Veteran, the examiner indicated the Veteran reported no symptoms attributable to a cardiac condition with any level of physical activity. The January 2020 VA examination, indicating the Veteran reported no symptoms attributable to a cardiac condition with any level of physical activity, is not consistent with other medical and lay evidence of record. Furthermore, the August 2018 Board remand instructed that if the Veteran’s coronary artery disease was evaluated, testing should include an assessment of work capacity in METs by exercise testing and a METs estimate may only be substituted if studies cannot be conducted for medical reasons. Given that VA cardiology notes associated with the file suggest the Veteran has been encouraged to remain physically active, it is not clear why the January 2020 VA examiner indicated exercise testing was not without significant risk, and whether such (in combination with the May 2019 DBQ indicating functional capacity was limited to 1 to 3 METs) suggests the Veteran’s coronary artery disease disability has increased in severity. The Board sincerely regrets the additional delay, but finds remand is necessary given the inconsistent findings on examination in January 2020 and the failure to explain why an assessment of work capacity in METs by exercise testing could not be performed as directed in the August 2018 Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998) (A remand by the Board confers on an appellant the right to VA compliance with the terms of the remand order and imposes on the Secretary a concomitant duty to ensure compliance with those terms). TDIU The issue of entitlement to a TDIU is inextricably intertwined with the remanded issue of entitlement to an increased disability rating for coronary artery disease, and must be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination of the severity of his coronary artery disease disability. The examiner should take a history from the Veteran as to the progression of his coronary artery disease. Following a review of the record, interview and examination of the Veteran, the examiner should: (a.) Provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. (b.) Unless contraindicated for medical reasons, exercise testing should be performed to evaluate metabolic equivalents (METs) at which the Veteran experiences symptoms of dyspnea, fatigue, angina, dizziness, or syncope. If contraindicated for medical reasons, the examiner should identify whether such is due to the Veteran’s coronary artery disease, and the examiner should conduct interview-based METs testing. The examiner should attempt to estimate the workload that produces those symptoms solely due to the Veteran’s heart condition. The examiner should provide a full explanation as to how he or she arrived at that estimation. If the examiner is not able to provide an estimation as to the workload that produces those symptoms solely due to the Veteran’s heart condition, he or she should provide a full explanation for why that is the case. (Continued on Next Page) 2. Readjudicate the issues on appeal, to include the issue of entitlement to a TDIU. If any benefits sought remain denied, issue a supplemental statement of the case to the Veteran and his representative and inform the Veteran of his appeal options. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Mask, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.