Citation Nr: 21027397 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-11 297 DATE: May 5, 2021 ORDER For the period from July 5, 2013 to July 16, 2014, an increased rating for a right knee disorder is denied. For the period from July 5, 2013 to July 16, 2014, an increased rating for a left knee disorder is denied. A 20 percent rating for limited right knee extension is granted, effective July 16, 2014. A separate 10 percent rating for right knee instability is granted, effective July 16, 2014. A 30 percent rating for limited left knee extension is granted, effective July 16, 2014. A separate 10 percent rating for left knee instability is granted, effective July 16, 2014. REMANDED The issue of an initial rating of more than 10 percent for a right wrist disorder is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. From July 5, 2013 to July 16, 2014, the Veteran's bilateral knee disorder manifested with daily knee pain. 2. Since July 16, 2014, the Veteran's right knee disorder has manifested with constant pain; flare-ups; knee extension limited to 10 degrees; painful ROM; pain with active and passive ROM; pain with weight bearing and non-weight bearing; and additional functional loss during flare-ups and after repetitive use, including reduced mobility and balance, difficulty standing and walking, and occasional buckling. 3. Since July 16, 2014, the Veteran's left knee disorder has manifested with constant pain; flare-ups; knee extension limited to 15 degrees and extension limited to 20 degrees after repetitive use; painful ROM; pain with active and passive ROM; pain with weight bearing and non-weight bearing; and additional functional loss during flare-ups and after repetitive use, including reduced mobility and balance, difficulty standing and walking, and occasional buckling. CONCLUSIONS OF LAW 1. From July 5, 2013 to July 16, 2014, the criteria for a rating of more than 10 percent for a right knee disorder were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326 (a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5261. 2. Since July 16, 2014, the criteria for a 20 percent rating, but no higher, for limited right knee extension have been approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326 (a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5261. 3. Since July 16, 2014, the criteria for a separate 10 percent rating, but no higher, for patellar instability of the right knee have been approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326 (a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5257. 4. From July 5, 2013 to July 16, 2014, the criteria for a rating of more than 10 percent for a left knee disorder were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326 (a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5261. 5. Since July 16, 2014, the criteria for a 30 percent rating, but no higher, for limited left knee extension have been approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326 (a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5261. 6. Since July 16, 2014, the criteria for a separate 10 percent rating, but no higher, for patellar instability of the left knee have been approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326 (a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1980 to June 1983. In an October 2020 decision, the Board of Veterans' Appeals (Board) remanded the issues of increased ratings for right wrist and bilateral knee disorders and directed the VA Regional Office (RO) to schedule additional VA examinations pursuant to a February 2020 Memorandum Decision of the Court of Appeals for Veterans' Claims (Court). Specifically, the Board directed the RO to consider evidence, including lay statements, that the Veteran had right wrist pain and functional loss during flare-ups and after repeated use over time. The Board also directed the RO to obtain medical opinions addressing the severity of the Veteran's wrist and knee disorders, including during flare-ups and after repeated use over time. VA examinations were conducted in October 2020. Review of the completed development reveals that the RO substantially complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). As outlined in the remand section below, the Board will remand the claim for an increased rating for a right wrist disorder to VA's Director of Compensation and Pension Services for extra-schedular consideration. The TDIU issue is also remanded because it is intertwined with rating the right wrist. Increased Ratings Disability ratings are determined by applying criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). 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 which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59. Provision 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the DCs applicable to the affected joint). The provisions of 38 C.F.R. § 4.59 recognize that painful motion is an important factor of disability. Joints that are painful, unstable, misaligned or due to healed injury are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id.; see Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). In assigning a higher disability rating, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to an initial rating of more than 10 percent for a right knee disorder. Since July 5, 2013, the Veteran's right knee disorder has been assigned an initial 10 percent rating based on limited extension of the knee. See 38 C.F.R. § 4.71a; DC 5261. He contends his symptoms have worsened and a higher rating is warranted based on limited extension and additional pain and functional loss during flare-ups and after repeated use over time. See 38 C.F.R. § 4.59, Deluca, supra. The Veteran also contends that an additional, separate rating is warranted for instability of the knee. DC 5261 provides ratings based on limitation of extension of the leg. Limitation of extension to 5 degrees warrants a noncompensable (zero percent) rating. Limitation of extension to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. 38 C.F.R. § 4.71a, DC 5261. DC 5257 was amended, effective February 7, 2021, and now provides ratings for "recurrent subluxation or instability" or "patellar instability." With respect to patellar instability, DC 5257 provides: A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker; and A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. See 38 C.F.R. § 4.71a, DC 5257. Note 1 to DC 5257 provides that, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note 2 to DC 5257 provides that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). In his July 2013 Statement in Support of Claim, the Veteran reported experiencing shooting pain in the back side of both kneecaps daily. He reported his knee pain and lower back pain caused difficulty sitting or standing for long periods of time. VA treatment records from 2013 through July 2014 reflect continued treatment for lower back pain, with some reports of bilateral knee pain. Clinical testing during an April 2013 lower back examination revealed normal muscle strength, sensation, and reflexes in both knees. The Veteran was afforded three VA knee examinations during the appellate period. During the July 2014 VA examination, the Veteran reported bilateral knee pain that had worsened in the past two to three years. He denied a history of knee injuries or surgeries and denied flare-ups. However, the Veteran stated he had pain in both knees after standing for more than five minutes, walking for fifteen minutes, walking down an incline or stairs, and squatting. He reported that the pain was worse in the left knee than the right. He also reported "buckling" in both knees which was worse in the left knee. The Veteran indicated that he had seen a non-VA orthopedist who took X-rays of his knees and informed him that he had damage in both knees. The Veteran was asked to provide the medical records related to this treatment but did not do so. During initial ROM testing, the Veteran had right knee flexion to 135 degrees with pain, and extension to 10 degrees with pain. He was able to perform repetitive use testing without additional loss of ROM in his right knee. However, the VA examiner noted the Veteran had additional pain on movement and less movement than normal after repetitive use of both knees. The examiner also noted bilateral tenderness in both knees. Muscle strength and joint stability were normal and the Veteran did not have ankylosis or muscle atrophy. The examiner indicated there was no evidence of recurrent patellar subluxation (partial dislocation of the kneecap) and noted the Veteran had a normal gait. The examiner concluded that the Veteran's knee condition impacted the Veteran's ability to work and caused decreased mobility and "difficulty reaching." The report of the August 2014 VA peripheral nerves examination indicated the Veteran reported bilateral knee buckling, leg weakness and an occasional limp. X-rays of the knees taken in August 2014 revealed possible trace degenerative changes of the medial and lateral compartments of both knees. In his September 2015 NOD, the Veteran asserted he had chronic bilateral knee pain, bilateral knee extension limited to 15 degrees, buckling and instability. In an April 2016 Statement in Support of Claim, he reported daily knee pain of "4/10" in severity which interfered with his ability to drive, stand, and perform other activities. The Veteran was afforded an additional VA examination in October 2018. During the examination, he reported his bilateral knee pain had worsened in the past two years and that he treated the pain with over the counter and prescription pain medication. The Veteran reported flare-ups of knee pain to "7/10," during cold and damp weather and after any level of activity. He described functional loss and impairment including difficulty walking, standing, running, jumping, squatting, and climbing. The examiner indicated the Veteran's diagnoses included a bilateral knee strain and early degenerative arthritis in both knees. Initial ROM testing revealed right knee flexion from 10 to 85 degrees and extension from 85 to 10 degrees, with pain on all ranges of motion. The VA examiner noted the Veteran's limited ROM impacted activity, balance, and mobility. The Veteran had pain with weight bearing and non-weight bearing, pain on passive ROM testing, and moderate tenderness over the lateral and anterior aspects of the knee joint area. The Veteran did not have crepitus. He was able to perform repetitive use testing in both knees without any additional functional loss or reduction in ROM. The Veteran had normal muscle strength and reflexes and did not have ankylosis or muscle atrophy. He denied a history of recurrent subluxation, lateral instability, or recurrent effusion (swelling) in his right knee. Joint stability testing for the right knee was normal. The Veteran indicated that he occasionally used a knee brace when anticipating a higher degree of physical activity both at home and at work. The examiner took X-rays of both knees and indicated there was no evidence of an acute fracture, dislocation, or joint effusion in the right knee. He indicated that the X-rays revealed mild degenerative changes of the right knee, particularly in the medial compartment. Based on these findings, the examiner opined that the Veteran's chronic knee problem would impact the Veteran's ability to function in a physical work environment. In his September 2019 NOD, the Veteran continued to assert that his bilateral knee condition warranted higher evaluations based on the results of the July 2014 examination. He asserted his symptoms had worsened since that time. In October 2020, the Veteran was afforded an additional VA examination pursuant to the October 2020 Board remand. During the examination, the Veteran continued to report that his bilateral knee pain worsened over the past several months, but he indicated his knee function was essentially unchanged since the last VA examination. Initial ROM testing revealed normal ROM in both knees, although the examiner indicated there was evidence of pain at rest/non-movement. The examiner indicated there was no evidence of pain with weight bearing, localized tenderness, or crepitus. The Veteran was able to perform repetitive use testing without additional functional loss or reduction in ROM. The examiner indicated the Veteran was examined immediately after repetitive use over time, but opined that pain, weakness, fatigability and incoordination did not significantly limit the Veteran's functional ability after repeated use. The examiner declined to give an opinion on functional loss during flare-ups, as he noted the Veteran denied experiencing them. Additional testing continued to show normal muscle strength and joint stability. Based on these findings, the examiner concluded the Veteran's knee condition did not impact the Veteran's ability to perform any occupational tasks. The October 2020 examination report has limited probative value. Despite the Veteran's report that his knee condition had worsened, the examiner indicated the Veteran denied flare-ups and did not have any occupational impairments. The October 2020 examiner's conclusions are inconsistent with the Veteran's lay statements and prior examination reports documenting painful ROM, knee buckling, and flare-ups resulting in additional pain and functional loss. From July 5, 2013 to July 16, 2014, the Veteran's left knee disorder manifested with daily knee pain and difficulty standing and walking. Since the July 2014 VA examination, the Veteran's right knee disorder manifested with constant pain; knee extension limited to 10 degrees; painful ROM; pain with active and passive ROM; pain with weight bearing and non-weight bearing; and additional functional loss during flare-ups and after repetitive use, including reduced mobility and balance, difficulty standing and walking, and occasional buckling. Based on DC 5261, the Veteran's limited extension of 10 degrees would warrant a 10 percent rating. 38 C.F.R. § 4.71a, DC 5261. However, given the Veteran's painful ROM and additional functional loss during flare-ups and after repetitive use over time, the next highest rating of 20 percent is warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59, Deluca, supra. A rating of more than 10 percent is not warranted before July 16, 2014 because the evidence does not show that the Veteran had limited extension prior to that date. With respect to knee instability, the evidence is in relative equipoise. Clinical testing at all three VA examinations indicated normal knee joint stability and muscle strength. While the reports of the 2018 and 2020 VA examinations indicated the Veteran denied a history of instability, he has consistently reported bilateral knee instability during the appellate period. He has also reported occasionally using a knee brace and sometimes walking with a limp. Additionally, VA examiners have noted the Veteran has issues with balance, mobility, standing and walking. Given these symptoms, the Board will resolve all doubt in the Veteran's favor and approximates a separate 10 percent rating for "patellar instability" of the right knee under DC 5257. See 38 C.F.R. § 4.71a, DC 5257. A higher rating for knee instability is not warranted because the Veteran's knee condition has not required surgical repair, or surgery of any kind. See DC 5257 ((noting the next highest rating (20 percent) requires recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker)). Further, the Veteran has only reported occasional use of a knee brace, and he has consistently demonstrated normal joint stability and muscle strength during clinical testing. A rating of more than 10 percent for "recurrent subluxation or instability" under DC 5257 is not warranted because the record does not demonstrate that the Veteran has a "sprain, incomplete ligament tear, or repaired complete ligament tear," or an "unrepaired or failed repair of a complete ligament tear" that causes persistent instability. See DC 5257. The remaining DCs applicable to the knee do not warrant any additional separate ratings. A separate rating under DC 5256 is not warranted because no medical provider has found evidence of ankylosis and the Veteran has consistently demonstrated a range of motion in both knees. 38 C.F.R. § 4.71a, DC 5256. A separate rating under DC 5258 for dislocated semilunar cartilage (meniscus) is not warranted because the evidence does not show that the Veteran had frequent episodes of locking, pain, and effusion into the knee joint. See 38 C.F.R. § 4.71a, DC 5258. A separate rating under DC 5259 for removal of semilunar cartilage is not warranted because the Veteran has not been diagnosed with any meniscal condition during the appellate period. 38 C.F.R. § 4.71a, DC 5259. A separate rating under DC 5260 for limitation of flexion is not warranted because the Veteran has not had flexion limited to 60 degrees or lower. 38 C.F.R. § 4.71a, DC 5260. A separate rating under DC 5262 for tibia or fibula impairment is not warranted as there was no evidence of nonunion or malunion of the tibia or fibula. 38 C.F.R. § 4.71a, DC 5262. A separate rating under DC 5263 is not warranted because the Veteran has never had genu recurvatum (a deformity of the knee joint resulting in the knee being bent backwards). 38 C.F.R. § 4.71a, DC 5263. For these reasons, the Board will award a 20 percent rating under DC 5261 for limited extension of the right knee. Additionally, the Board will award a separate 10 percent rating for right knee instability under DC 5257. The effective date of these ratings is July 16, 2014, the date of the VA examination where the Veteran reported symptoms that warranted these ratings. See Hart v. Mansfield, supra. 2. Entitlement to an initial rating of more than 10 percent for a left knee disorder. The Veteran's left knee disorder has been evaluated as 10 percent disabling since July 5, 2013. He contends a higher rating is warranted based on limited extension and that a separate rating for instability is also warranted. During the July 2014 VA examination, the Veteran's left knee demonstrated flexion to 130 degrees with pain, and extension to 10 degrees with pain beginning at 15 degrees. After repetitive use testing, the Veteran's left knee extension was limited to 20 degrees, with no additional limitation in flexion. The VA examiner indicated the Veteran had additional functional loss in both knees after repetitive use, including less movement than normal and pain during movement. The Veteran also had pain and tenderness to palpation (to the touch) in the joint and soft tissues of the knees. Muscle strength and joint stability were normal, and the Veteran did not have ankylosis or muscle atrophy. The examiner indicated there was no evidence of recurrent patellar subluxation (partial dislocation of the kneecap) and noted the Veteran had a normal gait. The examiner concluded that the Veteran's knee condition impacted the Veteran's ability to work and caused decreased mobility and "difficulty reaching." The Veteran reported constant bilateral knee pain and "buckling," and these symptoms were worse in his left knee. Although the examination report indicates the Veteran denied flare-ups, he stated he had pain in both knees after standing for more than five minutes, walking for fifteen minutes, walking down an incline or stairs, and squatting. In his September 2015 NOD, the Veteran asserted he had chronic bilateral knee pain, bilateral knee extension limited to 15 degrees, buckling and instability. In an April 2016 Statement in Support of Claim, he reported daily knee pain of "4/10" in severity which interfered with his ability to drive, stand, and perform other activities. During the October 2018 VA examination, the Veteran's left knee demonstrated flexion from 10 to 80 degrees with pain, and extension from 80 to 10 degrees with pain. The examiner noted the Veteran's abnormal ROM impacted the Veteran's activity, balance and mobility. The Veteran was able to perform repetitive use testing without any additional functional loss of reduction in ROM. The Veteran had pain with weight bearing and non-weight bearing, pain on passive ROM testing, and moderate tenderness over the lateral and anterior aspects of the knee joint area. The Veteran did not have crepitus. The Veteran had normal muscle strength and reflexes and did not have ankylosis or muscle atrophy. He denied a history of lateral instability, or recurrent effusion in his left knee. The Veteran reported a history of "slight" recurrent subluxation of the left knee, however joint stability testing for both knees was normal. The Veteran also reported that he occasionally used a knee brace. Additionally, the Veteran reported flare-ups of knee pain to "7/10," during cold and damp weather and after any level of activity. He described functional loss and impairment including difficulty walking, standing, running, jumping, squatting, and climbing. The examiner declined to offer an opinion on functional loss during flare-ups. The examiner noted that X-rays did not reveal evidence of an acute fracture, dislocation, or joint effusion in the left knee. He indicated that the X-rays revealed mild degenerative changes of the left knee, and a "tiny" joint effusion may have been present. However, the examiner noted no significant effusion was evident. Based on these findings, the examiner opined that the Veteran's chronic bilateral knee condition would impact the Veteran's ability to function in a physical work environment. During the October 2020 VA examination, the Veteran had normal flexion and extension in his left knee. He reported left knee pain at rest/non-movement. The examiner indicated the Veteran did not have pain with weight-bearing, localized tenderness of the soft tissue or joints, or crepitus. The Veteran performed repetitive use testing without additional functional loss or reduction in ROM. The Veteran continued to report that his bilateral knee pain worsened over the past several months, but he indicated his knee function was essentially unchanged since the last VA examination. Despite the Veteran's account, the examiner noted the Veteran denied flare-ups and concluded the Veteran did not have functional loss or occupational impairment due to his knee condition. As noted above, the examiner's conclusions and opinions have limited probative value. From July 5, 2013 to July 16, 2014, the Veteran's left knee disorder manifested with daily knee pain and difficulty standing and walking. Since the July 2014 VA examination, the Veteran's left knee disorder manifested with constant pain; flare-ups; knee extension limited to 15 degrees and additional limitation of 20 degrees after repetitive use testing; painful ROM; pain with active and passive ROM; pain with weight bearing and non-weight bearing; and additional functional loss during flare-ups and after repetitive use, including reduced mobility and balance, difficulty standing and walking, and occasional buckling. Based on DC 5261, the Veteran's limited extension of 15 degrees would warrant a 20 percent rating. 38 C.F.R. § 4.71a, DC 5261. However, given the Veteran's painful ROM, additional functional loss during flare-ups, and additional limitation of extension to 20 degrees after repetitive use over time, the next highest rating of 30 percent is warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59, Deluca, supra. A rating of more than 10 percent is not warranted before July 16, 2014 because the evidence does not show that the Veteran had limited extension prior to that date. As indicated above, the evidence is in relative equipoise with respect to knee instability. Clinical testing at all three VA examinations indicated normal knee joint stability and muscle strength, however the Veteran reported a history of slight recurrent subluxation during the October 2018 examination. He has also reported occasionally using a knee brace and sometimes walking with a limp. Additionally, VA examiners have noted the Veteran has some difficulty with balance, mobility, standing and walking. Given these symptoms, the Board will resolve all doubt in the Veteran's favor and grant a separate 10 percent rating for "patellar instability" of the left knee under DC 5257. See 38 C.F.R. § 4.71a, DC 5257. A rating of more than 10 percent for left knee instability is not warranted. Although the Veteran reported his left knee buckled more than his right, regardless, neither knee has required surgical intervention. See DC 5257 ((noting the next highest rating (20 percent) requires recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker)). Further, the Veteran has only reported occasional use of a knee brace, and he has consistently demonstrated normal joint stability and muscle strength during clinical testing. A rating of more than 10 percent for "recurrent subluxation or instability" under DC 5257 is not warranted because the record does not demonstrate that the Veteran has a "sprain, incomplete ligament tear, or repaired complete ligament tear," or an "unrepaired or failed repair of a complete ligament tear" that causes persistent instability. See DC 5257. The remaining DCs applicable to the knee do not warrant any additional separate ratings. A separate rating under DC 5256 is not warranted because no medical provider has found evidence of ankylosis and the Veteran has consistently demonstrated a range of motion in both knees. 38 C.F.R. § 4.71a, DC 5256. A separate rating under DC 5258 for dislocated semilunar cartilage (meniscus) is not warranted because the evidence does not show that the Veteran had or has a meniscal condition with frequent episodes of locking, pain, and effusion into the knee joint. See 38 C.F.R. § 4.71a, DC 5258. A separate rating under DC 5259 for removal of semilunar cartilage is not warranted because the Veteran has not been diagnosed with any meniscal condition during the appellate period. 38 C.F.R. § 4.71a, DC 5259. A separate rating under DC 5260 for limitation of flexion is not warranted because the Veteran has not had flexion limited to 60 degrees or lower. 38 C.F.R. § 4.71a, DC 5260. A separate rating under DC 5262 for tibia or fibula impairment is not warranted as there was no evidence of nonunion or malunion of the tibia or fibula. 38 C.F.R. § 4.71a, DC 5262. A separate rating under DC 5263 is not warranted because the Veteran has never had genu recurvatum. 38 C.F.R. § 4.71a, DC 5263. For these reasons, the Board will award a 30 percent rating under DC 5261 for limited extension of the left knee. Additionally, the Board will award a separate 10 percent rating for left knee instability under DC 5257. The effective date of these ratings is July 16, 2014, the date of the VA examination where the Veteran reported a worsening of symptoms that warranted these ratings. See Hart v. Mansfield, supra. REASONS FOR REMAND 1. The issue of entitlement to an initial rating of more than 10 percent for a right wrist disorder is remanded. 2. The issue of entitlement to a TDIU is remanded. 1. BACKGROUND FOR THE RO ADJUDICATOR: The Veteran contends his right wrist disorder warrants a higher evaluation than the currently assigned 10 percent rating. The RO denied the claim because the Veteran does not have ankylosis of the wrist, and therefore he has not met the criteria for a rating of more than 10 percent under the applicable diagnostic code. However, the Veteran has consistently reported severe symptoms that raise extraschedular consideration. Specifically, the Veteran reports painful flare-ups of wrist pain during weather changes and after handwriting for a short period of time. He reports that he is unable to write or use other tools with his right hand during these flare-ups. Given these symptoms, the Board will remand the claim to the VA Director of Compensation and Pension Services for an opinion regarding whether extra-schedular compensation is warranted. The TDIU claim is intertwined with the remanded claim and will be deferred until the increased rating issue is adjudicated. 2. REMAND DIRECTIVES: Send the Veteran an additional Individual Unemployability form (VA Form 21-8940) to assist in developing his TDIU claim. The Veteran is again advised that failure to complete this form may result in the denial of his TDIU claim. He is further advised that while the law places a duty on VA to assist veterans in developing claims, the duty is not a one-way street. The Veteran must actively participate in developing his claim. If the Veteran fails to return the completed form(s) or otherwise fails to assist the RO in developing the claim, the Board will decide the claim based on the evidence of record. AFTER COMPLETING THE ACTIONS ABOVE AND ASSOCIATING ANY OUTSTANDING OR NEWLY-SUBMITTED EVIDENCE WITH THE CLAIM FILE: Refer the claim for an increased initial rating for a right wrist disorder to the VA's Director of Compensation (Director) for extra-schedular consideration. The Director has an independent responsibility to review the entire record for pertinent evidence, however, attention is called to: * July 2013 Statement in Support of Claim where the Veteran reported experiencing daily right wrist pain, especially when writing. He also reported having a "clicking" sensation or crepitus, when moving his wrist. See "VA 21-4138 Statement in Support of Claim," received July 5, 2013. *The February 2015 VA wrist disorders examination report where the Veteran reported limited movement, pain, and crepitus in his right wrist. The VA examiner found evidence of crepitus during the examination but concluded the Veteran did not have any functional impairment of the right wrist. See "C&P Exam," received February 27, 2015. * The Veteran's May 2015 Notice of Disagreement (NOD) where he continued to report daily wrist pain at "4/10" in severity. He also reported flare-ups with pain increased to "8/10" during weather changes and after handwriting for short periods of time. The Veteran indicated he could only write for a short time without having to stop due to pain, and had additional difficulty lifting and using tools with his right hand. He stated he was forced to attempt to use his left hand to complete these activities. See "Correspondence," received May 15, 2015. *April 2016 Statement in Support of Claim where the Veteran continued to report painful flare-ups of right wrist pain, inability to write, and difficulty with other tasks such as opening lids. See "VA 21-4138 Statement in Support of Claim," received April 17, 2016. *October 2020 VA examination report where the Veteran continued to report flare-ups and functional loss after repeated use over time. The VA examiner concluded the Veteran did not have any functional limitations due to a wrist disability, but did not explain that conclusion. See "C&P Exam," received October 19, 2020. Following the review and any additional development deemed necessary, readjudicate the claims. If the claims are not granted in their entirety, issue a supplemental statement of the case (SSOC) and forward the claims to the Board for adjudication. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (Continued on next page) This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Hiaasen 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.