Citation Nr: 21031684 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 10-16 640 DATE: May 24, 2021 ORDER Entitlement to increased ratings for left knee limitation of motion (associated with left knee hyperextension injury with osteochondritis dissecans), currently rated 20 percent disabling on the basis of limitation of extension, is denied. Entitlement to increased compensation for left knee disability (associated with left knee hyperextension injury with osteochondritis dissecans) on an extraschedular basis is denied. Entitlement to service connection for left vastus medialis obliquus atrophy and muscle impairment, secondary to service-connected left knee disability, is granted. REMANDED The issue of entitlement to total disability rating based upon individual unemployability (TDIU), raised in connection with rating the service-connected left knee disability, is remanded. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's left knee disability has not been manifested by flexion limited to 45 degrees, nor extension limited to the 20 degree position. 2. The Veteran's left knee symptoms and severity are contemplated by the rating schedule and do not present an exceptional disability picture that renders the rating schedule inadequate. 3. Resolving reasonable doubt in the Veteran's favor, the evidence shows that the Veteran has experienced, during the pendency of this appeal, left vastus medialis obliquus atrophy and muscle impairment proximately due to or the result of his service-connected left knee disability. CONCLUSIONS OF LAW 1. Throughout the rating period on appeal, the criteria for a disability rating in excess of 20 percent for left knee limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261, and 5299 (as in effect prior to February 7, 2021), and 4.71a, Diagnostic Codes 5260, 5261, and 5299 (as in effect from February 7, 2021). 2. The criteria for referral for an extraschedular rating for the Veteran's left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Codes 5256 to 5263 (as in effect prior to February 7, 2021), and 4.71a, Diagnostic Codes 5256 to 5263 (as in effect from February 7, 2021). 3. The criteria for entitlement to service connection for left vastus medialis obliquus atrophy and muscle impairment are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from December 2004 to July 2005, with a period of active duty for training from February 1987 to September 1987. This matter comes before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). This matter originally came to the Board on appeal from an August 2008 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). That decision granted service connection for the left knee disability at issue, effective from the May 9, 2008, date of claim. The Veteran presented testimony before the undersigned at a Travel Board hearing in March 2014, and a transcript of the hearing is associated with the claims-file. In July 2016, the Board issued a decision that denied entitlement to a rating in excess of 20 percent for left knee disability. The Veteran appealed this determination to the Court. In September 2017, the Office of General Counsel for the Department of Veterans Affairs and the Veteran's representative before the Court (hereinafter the parties) filed a Joint Motion for Remand (Joint Motion) that was granted by the Court in September 2017. The July 2016 Board decision was vacated, and the case was returned to the Board for further consideration in accordance with the terms of the Joint Motion. In November 2017, the Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for development actions to ensure compliance with the directives of the Court-endorsed Joint Motion. The Board addressed this appeal again in decisions/remands in March 2019 and October 2020; the Board resolved portions of the appeal to the extent possible at those times, and the Board remanded to the AOJ the remaining portions of the appeal for needed additional development. The case has now returned to the Board for further appellate review. The Court recently held in Bailey v. Wilkie, 33 Vet. App. 188 (2021), that in addition to considering entitlement to increased benefits, VA must consider entitlement to any additional benefits due to complications from the disability, and it is not necessary that the Veteran file a formal claim for service connection for such additional disability. In this case, the Veteran's appeal for greater compensation for his service-connected left knee disability has raised the question of potential entitlement to service connection for left vastus medialis obliquus atrophy and muscle impairment as secondary to service-connected left knee disability. Accordingly, the Board has considered the issue of entitlement to service connection for left vastus medialis obliquus atrophy and muscle impairment as part of the appeal for increased compensation for the left knee disability, explained in greater detail below (in connection with the analysis addressing entitlement to extraschedular rating consideration). Increased Rating 1. Entitlement to an increased rating for left knee limitation of motion (associated with left knee hyperextension injury with osteochondritis dissecans), currently rated 20 percent disabling on the basis of limitation of extension, is denied. Disability ratings are determined by comparing a Veteran's symptomatology during the pertinent period on appeal with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In every instance where the schedule does not provide a zero percent evaluation for a Diagnostic Code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence pertinent to the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all contents of the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran's disabilities prior to the rating period on appeal to see if the history supports a higher rating during the rating period on appeal. Additional references to the Veteran's service-connected disabilities are presented in evidence of record beyond that discussed below. Evidence of record includes medical records obtained from the Social Security Administration (SSA) as well as VA and private medical reports associated with the Veteran's treatment. The additional evidence of record does not present findings that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. Generally, in evaluating musculoskeletal disabilities, consideration must be given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Nonetheless, even when the background factors listed in § 4.40 or § 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Pain may be taken into consideration when rating functional loss. However, pain on motion is not, itself, functional loss, but may result in functional loss only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination[, or] endurance." 38 C.F.R. § 4.40. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (citing 38 C.F.R. § 4.40). 38 C.F.R. § 4.40 (functional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded); see Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170. In Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court addressed the adequacy of medical opinions that decline to present clear estimations by citing that such estimations would be mere speculation. The Court explained that case law and VA guidelines do not require direct observation of functional impairment after repetitive use or during a flare-up as a prerequisite to offering a DeLuca opinion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, it is not expected that such observation will usually occur; therefore, VA examiners should offer opinions based on estimates derived from information procured from all relevant sources, including the lay statements of Veterans. VA examiners have a duty to elicit information from the Veteran when attempting to describe functional loss associated with pain during unobserved exacerbations. If a non-speculative opinion still cannot be offered, the VA examiner must explain the basis for this conclusion. It must be apparent that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large and not a limitation (whether based on lack of expertise, insufficient information, or unprocured testing) of the individual examiner. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, arthritis established by X-ray findings is rated on the basis of limitation of motion of the affected joints. When, however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, however, arthritis is rated as 10 percent disabling when shown by X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, or as 20 percent disabling when shown by x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. Finally, it is the intention of the VA rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran contends that he is entitled to a higher rating for his left knee disability, asserting that the impairment has been more severe than the assigned 20 percent rating reflects. This appeal arises from the Veteran's disagreement with the initial rating determination associated with the grant of service connection for the left knee disability. Accordingly, the rating period for consideration begins with the May 9, 2008, effective date for the grant of service connection for the left knee disability. However, the Board furthermore notes that the rating period includes multiple short periods during which the Veteran has already been awarded a maximum 100 percent rating on a temporary basis for periods of convalescence and/or rating provisions for the Veteran's recent total knee replacement surgery. Those periods for which a 100 percent rating for the left knee disability is already in effect are not the subject of this appeal. Those periods are (1) May 9, 2008, to October 1, 2008; (2) February 5, 2009, to May 1, 2009; and (3) February 3, 2021, to April 1, 2022 (for the total knee replacement). Because the Veteran is currently in receipt of a 100 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5055 for knee replacement, effective from the date of the knee replacement surgery, this Board decision is being issued during a period that is not subject to the appeal. Although the AOJ has suggested a placeholder preliminary rating assignment to come into effect following the current temporary 100 percent, this is not within the scope of the appeal before the Board at this time, and the Board shall not otherwise discuss 38 C.F.R. § 4.71a, Diagnostic Code 5055 in this decision; the provisions of that Diagnostic Code do not apply to any of the rating periods for consideration in this case, as they all predate the occurrence of the Veteran's left knee replacement surgery. During the pendency of the instant appeal, VA promulgated new regulations governing ratings for musculoskeletal system and muscle disabilities, effective February 7, 2021. See 85 Fed. Reg. 76,453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. For the rating periods for consideration in this case, the Veteran's left knee disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5261, for disability manifested by impairment expressed in terms of limitation of extension of the leg. The Board notes that 38 C.F.R. § 4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint, and the Veteran is already in receipt of a greater than minimum compensable rating for the left knee disability throughout the rating period for consideration. With regard to schedular rating analysis, the only aspects of the Veteran's left knee disability rating claim on appeal are those involving limitation of motion of the joint as contemplated by 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. The Board's application of schedular rating provisions in this decision shall accordingly be limited to these Diagnostic Codes pertaining to limitation of motion. Flexion of the leg limited to 60 degrees warrants a 0 percent rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Extension limited to 5 degrees warrants a 0 percent rating, extension limited 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, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Flexion of the knee to 140 degrees is considered full and extension to 0 degrees is considered full. 38 C.F.R. § 4.71, Plate II. These provisions are unchanged by the new regulations effective February 7, 2021. The Board finds that the preponderance of the evidence weighs against a rating in excess of 20 percent for the left knee disability during any rating period for consideration in this appeal. On VA examination in June 2008, the Veteran complained of left knee swelling, and of pain if he had to sit or stand for too long a period of time. He reported that flare-ups occurred every morning. On examination, he had a slight limp on the left, and mild swelling. His left knee lacked 15 degrees of extension. He had well healed arthroscopy portals. Left knee flexion was to 105 degrees. He had pain at the endpoints of left knee flexion and extension, and no additional limitation of motion after 3 repetitive motions. There was no lateral instability. In September 2008, the Veteran indicated that he stopped working full time in March 2008 due to his left knee. He reported 4 years of college, plus Law Enforcement Training Academy and National Builder Certification Training. In January 2009, he indicated that he was only seeking a temporary total rating due to convalescence, not TDIU. On private evaluation June 2009, the Veteran's left knee range of motion was from 0 to 140 degrees of flexion, and there was no evidence of instability, but there was vastus medialis obliquus atrophy, with his left thigh circumference being 52.5 cm at 10 centimeters above the patella as compared to 54 centimeters on the right. On private evaluation in August 2009, the Veteran's left knee range of motion was from 0 to 135 degrees of flexion, and there was no evidence of instability. In September 2009, left knee range of motion was from 0 to 125 degrees and there was a large effusion but no instability. On VA examination in December 2009, the Veteran reported chronic pain rather than intermittent flare-ups. He had pain in particular when walking over uneven surfaces and on ascending or descending steps. He was a full time student. On examination, he moved somewhat slowly with a limp. He used a cane in his right hand and wore a left knee brace. Left knee surgical scars were well healed. There was slight left knee swelling. Left knee extension was to 0 degrees and left knee flexion was to 130 degrees. There was no additional limitation of motion after repetitive motion, and no ligamentous instability was noted. In April 2010, the Veteran indicated that he wanted at least a 50 percent rating for his service-connected left knee disability. On VA evaluations in October 2010, following arthroscopy in September 2010, the Veteran had a full range of motion of his left knee and was bearing most of his weight on both legs. There was slight effusion and less than +1 effusion. He was stable to varus and valgus stressors. In November 2010, the Veteran indicated that he felt he should have a rating in excess of 20 percent for his left knee disability based on continued pain, loss of balance, swelling, and pain when flexing or bending his knee. He also reported that he was on crutches for a few weeks following knee surgery in September 2010. On VA evaluation in November 2010, following diagnostic arthroscopy with plica excision in September 2010, the Veteran was without complaint except for generalized swelling, which would occur especially when he stood on his left lower extremity for an extended period of time. Popping and locking pain which he had before was now gone and was much better. There was no internal derangement to surgically address. In March 2011, the Veteran stated that one of his doctors has indicated that his left knee disability will likely get worse with time. On VA examination in April 2012, the Veteran reported that flare-ups occurred on first arising or after extended periods of weightbearing. Left knee flexion was to 125 degrees, with no objective evidence of painful motion. Left knee extension was to 5 degrees. The Veteran was able to perform repetitive use testing with 3 repetitions, with no additional limitation in the range of motion of the left knee following such testing. Left knee flexion and extension strength was 4/5. Anterior, posterior, and medial-lateral stability was normal. The Veteran had had no meniscal conditions. None of his left knee scars were painful or unstable and they did not have an area of greater than 39 square centimeters/ 6 square inches. An X-ray from February 2012 was noted to reveal a suspected osteochondral defect of the left medial femoral condyle, and mild degenerative medial compartment narrowing. The Veteran was working full time for the state capital police and had been for the past year. He would work through any pain in order to perform his job duties. During the Veteran's March 2014 hearing before the undersigned, he described pain which he had even after surgeries, and indicated that he continued to have pain as well as weakness and swelling. He testified that he had returned to work in 2009 or early 2010. On VA examination in September 2014, the Veteran displayed a mildly antalgic gait favoring the left knee. He stated that he was now on private disability from his job with the police department. He reported daily chronic pain and did not have flare-ups. Left knee flexion was to 110 degrees, with pain beginning at 90 degrees. Left knee extension was to minus 10 degrees. There was no additional limitation in range of motion of the knee following repetitive use testing. Muscle strength was 5/5 for left knee flexion and extension. The Veteran's left knee was normal or stable anteriorly, posteriorly, and on medial-lateral stability testing. He had never had a meniscal condition. None of his left knee scars were painful or unstable or in excess of 39 square centimeters/ 6 square inches. The examiner stated that the Veteran's left knee condition would make squatting, walking, running, and climbing/descending stairs difficult, but that he could easily function in a sedentary position. The September 8, 2014, VA examiner noted that the Veteran has been receiving injections for the left knee with the last injection in July 2013 and without subsequent left knee VA treatment records. VA treatment records two days later noted that the Veteran reported left knee swelling. Musculoskeletal assessment was that his gait was normal with mild swelling in the left knee. On VA examination in February 2018, the Veteran reported "that he is taking Diclofenac 2 times a day for pain," and experienced "swelling, weakness." He reported that flare-ups "mainly happen if I am standing, sitting to[o] long and it will start swelling, that[ i]s when it gets really unstable, usually if I take medication lay down and elevate it will go down in 3-4 hours, the flare up depends on activities it could be multiple times a day." The Veteran further reported that "its hard to get through a day, I can't do anything stren[u]ous, walk long distance, definitely cannot run anymore." Left knee range of motion measurements upon clinical testing show flexion to 120 degrees and extension to a fully normal 0 degree position. The VA examiner found "Pain noted on exam and causes functional loss," with the pain evident on both flexion and extension. The VA examiner noted pain with weight bearing and localized tenderness or pain on palpation. There was no change in the clinically observed ranges of motion on repetitive use testing. The February 2018 VA examiner found that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time, and described the functional impairment in such circumstances as Flexion "-10 to 110 degrees," and Extension "110 to -10" degrees. The Board has carefully considered how to interpret this report with attention to the indication of extension to -negative- 10 degrees. Within the frame of reference of the normal range of motion of a knee joint from the 0 degree extended position to the 140 degree flexed position, a report of extension to the -negative- 10 degree position can be understood as indicating excess range of extension beyond the 0 degree position. The Board finds that it is reasonable to interpret the report as indicating that the VA examiner estimated that extension of the left knee was limited to the 10 degree position due to pain during pertinent exacerbations. The February 2018 VA examiner provided the same estimate of left knee ranges of motion (flexion to 110 degrees and extension to "-10") to describe impairment due to "pain, weakness" during flare-ups. Again, the Board finds that it is reasonable to interpret the February 2018 VA examiner's findings as indicative of an estimated functional limitation of left knee extension to the 10 degree position. The February 2018 VA examiner otherwise noted that the Veteran's left knee disability interfered with "lifting, bending." Muscle strength was reduced to a level of "4/5." The VA examiner noted that the Veteran made "Constant" use of a brace as a locomotion-assistive device for the left knee. The VA examiner identified functional impairment of "walking, standing, kneeling, climbing for long periods of time, and squatting." The VA examiner explained that "[w]hen this veteran returns to his usual day to day environment/activities, the Veteran could potentially have further limitation in range of motion, potentially have an increase in the amount of pain and potentially have further decrease in range of motion, functional capacity during flare ups and/or with repetitive motion/use over time." A February 2018 private medical report (added to the record in November 2020) shows that the Veteran reported "severe" left knee pain at "10/10" intensity, made worse with "kneeling, sitting, stairs, twisting, moving, running, walking, engaging in athletics, standing and lifting." The Veteran's symptoms included "swelling, numbness, stiffness, limping, clicking, weakness and giving way." Range of motion was "0-135 with some pain in deep flexion." Testing revealed "[s]ensations intact to light touch." On VA examination in December 2019, the Veteran described "chronic knee pain that is aggravated by standing on hard surfaces, walking for extended periods of time, or climbing stairs, which he avoids; he does not run, or engage in other high impact activities." The Veteran report that "he will wear hinged knee braces," and that he "has used a cane...." The Veteran described "Aggravated pain" on flare-ups. Furthermore, the Veteran reported that he "cannot run, o[r] engage in high impact activities; he cannot squat and arise, lifting heavy loads." Left knee range of motion measurements upon clinical testing show flexion to 120 degrees and extension to 0 degrees. The VA examiner stated that the limitation of motion "Limits squatting," and that pain noted on the examination causes functional loss, specifically with regard to flexion. There was pain with weight bearing and localized tenderness or pain on palpation. There was no change in the range of motion measurements following repetitive use testing. The VA examiner noted that "Yes," the examination was conducted "immediately after repetitive use over time," and then estimated that "Pain, Weakness, Lack of endurance" further limit the Veteran's flexion to 115 degrees and extension to 0 degrees. The VA examiner found that the "examination is medically consistent with the Veteran's statements describing functional loss during flare-ups," and described that "Pain, Weakness, Lack of endurance" limit the Veteran's flexion to 110 degrees and extension to 5 degrees. The VA examiner noted that there was evidence of pain on passive motion and in non-weight bearing. The December 2019 VA examiner described that the left "[k]nee stiffens, when Veteran sits for extended periods of time, making it difficult to arise quickly." The report notes that the Veteran made "Regular" use of a brace and "Constant" use of a cane as locomotion-assistive devices, and remarks that "[t]he Veteran wears off-loading braces and ambulates with a cane." The VA examiner states: "The Veteran's chronic knee conditions would prevent work demanding strenuous physical labor, such as that entailing climbing and squatting to lift loads, as well as that requiring running, or walking significant distances, or standing for extended periods of time...." An October 2020 private medical report shows that the Veteran reported "[p]ain is severe with a rating of 10/10." There was "[g]ood full range of motion today 0-135 with pain in deep flexion." A January 2021 VA medical opinion based upon a review of the evidentiary record presents retrospective estimations of functional impairment at the times of the examination reports of record. The January 2021 VA examiner explains that "the following are estimations of the ranges of motion of the Veteran's left knee in active motion, passive motion, weight bearing, [and] non-weight bearing ... at each time the left knee was previously examined with range of motion testing for rating purposes." The VA examiner explained that "History obtained at the examinations and collateral treatment reports ... were included in the determination of the estimates." The January 2021 VA examiner's review of the June 2008 VA examination report resulted in an estimate of functional impairment limiting flexion to 105 degrees and extension to the 15 degree position for the left knee in active motion, passive motion, weight-bearing, and non-weight-bearing. Estimated functional impairment following repeated use further reduced flexion to 90 degrees without further affecting extension. Estimated functional impairment during flare-ups further reduced flexion to 85 degrees without further affecting extension. The January 2021 VA examiner's review of the December 2009 VA examination report resulted in an estimate of functional impairment limiting flexion to 130 degrees and extension to the 0 degree position for the left knee in active motion, passive motion, weight-bearing, and non-weight-bearing. Estimated functional impairment following repeated use further reduced flexion to 125 degrees without further affecting extension. Estimated functional impairment during flare-ups further reduced flexion to 120 degrees and limited extension to 5 degrees. The January 2021 VA examiner's review of the April 2012 VA examination report resulted in an estimate of functional impairment limiting flexion to 125 degrees and extension to the 5 degree position for the left knee in active motion, weight-bearing, and non-weight-bearing (with notation of 4/5 strength on flexion and extension). Estimated functional impairment of passive motion reduced flexion to 130 degrees and extension to the 5 degree position. Estimated functional impairment following repeated use further reduced flexion to 120 degrees without further affecting extension. Estimated functional impairment during flare-ups further reduced flexion to 115 degrees and limited extension to 5 degrees. The January 2021 VA examiner's review of the September 2014 VA examination report resulted in an estimate of functional impairment limiting flexion to 110 degrees and extension to "-10 degrees" for the left knee in active motion and weight-bearing. Estimated functional impairment of passive motion and non-weight-bearing reduced flexion to 115 degrees and extension to "-10 degrees." Estimated functional impairment following repeated use further reduced flexion to 100 degrees without further affecting extension. Estimated functional impairment during flare-ups reduced flexion to 105 degrees without further affecting extension. The January 2021 VA examiner's review of the February 2018 VA examination report resulted in an estimate of functional impairment limiting flexion to 120 degrees and extension to the 0 degree position for the left knee in active motion, weight-bearing, and non-weight-bearing (with notation of 4/5 strength on flexion and extension). Estimated functional impairment of passive motion reduced flexion to 125 degrees and extension to the 0 degree position. Estimated functional impairment following repeated use or during flare-ups further reduced flexion to 110 degrees and limited extension to "-10 degrees," with the January 2021 VA examiner simply repeating and citing the estimates entered by the February 2018 VA examiner. The January 2021 VA examiner's review of the December 2019 VA examination report resulted in an estimate of functional impairment limiting flexion to 120 degrees and extension to the 0 degree position for the left knee in active motion and weight-bearing. Estimated functional impairment of passive motion and non-weight-bearing (with notation of 4/5 strength on extension) reduced flexion to 125 degrees and extension to the 0 degree position. Estimated functional impairment following repeated use further reduced flexion to 115 degrees without further limitation of extension, with the January 2021 VA examiner simply repeating and citing the estimate entered by the December 2019 VA examiner. Estimated functional impairment during flare-ups further reduced flexion to 110 degrees and extension to the 5 degree position, with the January 2021 VA examiner simply repeating and citing the estimate entered by the December 2019 VA examiner. The January 2021 VA examiner additionally prepared a report regarding "the nature and extent of any functional impairment attributable to symptoms of atrophy, deformity, effusion, and swelling of the left knee from May 2008 to the present in this case," and additionally "whether these factors have caused any manner of functional impairment beyond that reflected in measurements of range of motion, joint stability, and muscle strength of the left knee." Regarding the June 2008 VA examination report, the January 2021 VA examiner states: "extension of deformity of the Left knee is noted on examination. This factor should not cause any additional manner of functional impairment that is not already accounted for in the ranges of motion, joint stability testing and muscle strength testing of the left knee." Additionally: "The examiner notes a history of swelling reported by the Veteran. There was evidence of Swelling (Effusion) on physical examination. It would not be expected that this would cause any additional functional impairment beyond that reflected in measurements of range of motion, joint stability and muscle strength of the left knee." Regarding the December 2009 VA examination report, the January 2021 VA examiner states: "There was evidence of Swelling (Effusion) on physical examination. It would not be expected that this would cause any additional functional impairment beyond that reflected in measurements of range of motion, joint stability and muscle strength of the left knee." Regarding the April 2012 VA examination report, the January 2021 VA examiner states: "extension deformity of the left knee is noted on examination. This factor should not cause any additional manner of functional impairment that is not already accounted for in the ranges of motion, joint stability testing and muscle strength testing of the left knee." Additionally: "The examiner noted Swelling (Effusion) as a factor causing functional impairment. This factor should not cause any additional manner of functional impairment that is not already accounted for in the ranges of motion, joint stability testing and muscle strength testing of the left knee." Regarding the September 2014 VA examination report, the January 2021 VA examiner states: "The extension deformity of the Left knee is noted on examination. This factor should not cause any additional manner of functional impairment that is not already accounted for in the ranges of motion, joint stability testing and muscle strength testing of the left knee." Additionally: "The examiner noted Swelling (Effusion) as a factor causing functional impairment. This factor should not cause any additional manner of functional impairment that is not already accounted for in the ranges of motion, joint stability testing and muscle strength testing of the left knee." Regarding the February 2018 and December 2019 VA examination reports, the January 2021 VA examiner states: "The Veteran had no evidence of Atrophy on examination; no evidence of Deformity on examination; and no evidence of Swelling/Effusion on examination." With consideration of all of the evidence, including both the clinical measurements of ranges of motion and the medical estimations and assessments of functional ranges of motion in all pertinent contexts and exacerbations, the Board finds that none of the evidence of record shows limitation of left knee flexion to 45 degrees at any time during any of the rating periods on appeal. Accordingly, the Board is unable to find that the criteria for a schedular compensable rating for limitation of flexion have been met in this case. The Board notes that while the Veteran has consistently experienced significantly painful motion in both flexion and extension of the left knee, he is already in receipt of greater than the minimum compensable rating for limitation of motion of the joint (on the basis of extension). With consideration of all of the evidence, including both the clinical measurements of ranges of motion and the medical estimations and assessments of functional ranges of motion in all pertinent contexts and exacerbations, the Board finds that none of the evidence of record shows limitation of left knee extension to the 20 degree position at any time during any of the rating periods on appeal. The Veteran's current rating of 20 percent for limitation of left knee extension under Diagnostic Code 5261 contemplates limitation of extension to the 15 degree position. The Board is unable to find that the criteria for a schedular rating in excess of 20 percent for limitation of flexion have been met in this case. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to a schedular rating in excess of 20 percent for limitation of motion of the left knee for any rating period on appeal. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. In the remaining sections below, this Board decision addresses the Veteran's contentions raising questions of entitlement to extraschedular ratings for the left knee disability and consideration of entitlement to service connection for complications of the left knee disability such as muscle atrophy / impairment. Aside from these matters, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record in connection with the disabilities for consideration in this appeal. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to increased compensation for left knee disability (associated with left knee hyperextension injury with osteochondritis dissecans) on an extraschedular basis is denied. 3. Entitlement to service connection for left vastus medialis obliquus atrophy and muscle impairment, secondary to service-connected left knee disability, is granted. The September 2017 Joint Motion asserted that the Board's July 2016 decision "determined that referral for extraschedular consideration was not warranted .... However, the Board did not explain how it considered evidence that Appellant experienced symptoms of atrophy, deformity, effusion, and swelling." The Board has considered whether an increased rating on an extraschedular basis for the Veteran's left knee disability is warranted. See 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires the Board to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. Thun step one is not a "mechanical test;" thus, it is not automatically satisfied just because a certain symptom or functional effect is not expressly listed in a diagnostic code. See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2016) (holding that the rating criteria for hearing loss contemplated the full range of symptoms related to decreased hearing, even though the diagnostic code failed to list any symptoms but relied solely on audiometric tests). If the Board determines that a Veteran's disability is exceptional, the second element requires the Board to "determine whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Long v. Wilkie, No. 16-1537, U.S. App. Vet. (Dec. 30, 2020). Finally, if the first two elements are met, the final element mandates that the Board refer the claim to the Director of Compensation Service (Director) for a determination as to whether an extraschedular rating is warranted. Id.; see also 38 C.F.R. § 3.321(b). The Board finds that the Veteran's left knee disability is not exceptional. The Board has considered the facts of this case and whether the Veteran's disability picture as a whole (i.e., full symptomatology) presents an impairment that is so exceptional that the rating schedule is not capable of assessing it in the first instance. The Veteran is already in receipt of schedular disability ratings for limitation of motion, instability, and scarring associated with the left knee disability. These impairments are fully contemplated by the applicable rating criteria. Furthermore, the Board notes that pain is contemplated in the rating criteria for all musculoskeletal disabilities, and it does not need to be identified in each individual code to indicate its inclusion. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that § 4.59 applies to "joint pain in general" and is not limited to joint pain due to arthritis). In addition, weakness and lack of endurance are contemplated in the ratings for all orthopedic disabilities. See 38 C.F.R. §§ 4.40, 4.45, see also Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). The Board has further considered the Joint Motion's attention to "symptoms of atrophy, deformity, effusion, and swelling." Of these identified symptoms, the January 2021 VA medical opinion provided a retrospective medical assessment of the "deformity, effusion, and swelling" of the left knee. For each of these, the expert author of the January 2021 VA medical opinion, informed by review of the record, found that the shown symptomatology is not medically assessed to have caused any additional manner of functional impairment that is not already accounted for in the ranges of motion, joint stability testing, and muscle strength testing of the left knee. The Veteran's impairments accounted for in ranges of motion and joint stability testing have already been assigned schedular ratings and are within the capabilities of conventional rating means; they cannot be deemed exceptional. Remaining for consideration is the Veteran's symptomatology associated with atrophy and muscle weakness; both of these aspects of disability were referenced by the Joint Motion in different sections of its discussion. The Board finds that there is a reasonable basis for concluding that muscle atrophy that arose in connection with the Veteran's left knee disability has not been fully contemplated by assigned disability ratings. In this regard, the January 2021 VA medical opinion stated: "Based on the February 2018 and December 2019 examinations, the Veteran did not have evidence of atrophy. Hence, the assumption would be that the exams prior to these exams had no evidence of atrophy." However, the Board's review of the evidence reveals that a June 2009 private medical record shows that there was vastus medialis obliquus atrophy, with his left thigh circumference being 52.5 cm at 10 centimeters above the patella as compared to 54 centimeters on the right. The Board notes that this is evidence of atrophy during a rating period on appeal (it comes after the expiration of the temporary total disability rating in May 2009). Additionally, the Board observes that muscle strength testing in subsequent VA examination reports shows, at times, reduced muscle strength associated with the left knee movement. Muscle impairments, including around the knee, are contemplated by the rating schedule. See 38 C.F.R. § 4.73. Muscle impairments are capable of evaluation by conventional means, and cannot be deemed exceptional. The Court recently held in Bailey v. Wilkie, 33 Vet. App. 188 (2021), that in addition to considering entitlement to increased benefits, VA must consider entitlement to any additional benefits due to complications from the disability, and it is not necessary that the Veteran file a formal claim for service connection for such additional disability. Moreover, VA's duty to maximize benefits requires it to exhaust all schedular alternatives, to include secondary service connection, for rating a disability before the extraschedular analysis is triggered. Morgan v. Wilkie, 31 Vet. App. 162, 164 (2018). In this case, the Veteran's appeal for greater compensation for his service-connected left knee disability has raised the question of potential entitlement to service connection for a muscle disability involving atrophy of the left vastus medialis obliquus. Very briefly, the Board is reasonably satisfied that the Veteran's clinically observed atrophy of the vastus medialis obliquus 10 centimeters above the left knee patella in June 2009 is sufficiently shown to be etiologically linked to the service-connected left knee disability and the February 2009 left knee surgery that proximately preceded the June 2009 evidence (for which a temporary 100 percent rating expired in May 2009). Accordingly, the Board finds that service connection for left vastus medialis obliquus atrophy and muscle impairment (as secondary to the service-connected left knee disability) is warranted in this case. To this extent, the Veteran's appeal is granted. 38 C.F.R. § 3.310. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The AOJ shall now process the Board's grant of service connection for the Veteran's left vastus medialis obliquus atrophy and muscle impairment (as secondary to the service-connected left knee disability) and issue a determination regarding the disability rating and effective date for that disability in the first instance. The Board notes that the Veteran included the word "numbness" in his description of left knee symptoms recorded in a February 2018 private medical report. The private medical doctor assessed the Veteran's sensation at that time and found it to be intact, and there is otherwise no clear indication of neurological impairment or other pathology associated with numbness in this case. The Board does not find that the record indicates an impairment or pathology to raise a question of entitlement to secondary service connection, nor does the Board otherwise find that such reported numbness suggests an impairment beyond the capabilities of conventional rating means. Sensory and neurological impairments are contemplated by the rating schedule. See 38 C.F.R. § 4.124a. Application of the rating schedule is not indicated here because this instance of the Veteran referring to "numbness" is followed by his doctor's assessment that sensation was intact, and the evidence of record does not otherwise indicate a functional impairment or pathology. The Board finds that the Veteran's reference to "numbness" appears to be an aspect of his sensory disruption associated with the consistently shown severe pain and swelling of his left knee, rather than a distinct pathology or impairment. In the absence of any showing of functional impairment that is not already accounted for in the ranges of motion, joint stability testing, and muscle strength testing contemplated in the established entitlements to service connection for left knee limitation of motion, left knee instability, left knee scarring, and left vastus medialis obliquus atrophy and muscle impairment (as secondary to the service-connected left knee disability), the Board finds no basis for concluding that the Veteran's left knee disability is exceptional. Because the left knee disability is capable of evaluation by conventional means, it cannot be deemed exceptional. As such, the rating schedule is adequate to evaluate the Veteran's left knee disability, and referral for consideration of an extraschedular rating is not warranted. REASONS FOR REMAND 1. The issue of entitlement to TDIU, raised in connection with rating the service-connected left knee disability, is remanded. The development and outcome of the forthcoming initial rating determination when the AOJ effectuates the Board's grant of entitlement to service connection for left vastus medialis obliquus atrophy and muscle impairment (as secondary to the service-connected left knee disability) could affect the outcome of the Veteran's claim of entitlement to TDIU. Accordingly, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the Board cannot complete a final appellate review of the TDIU issue until the initial rating determination for the newly service-connected left vastus medialis obliquus atrophy and muscle impairment has been completed. Furthermore, the Board finds that other development of the evidence is necessary to adequately inform appellate review of the TDIU issue in this case. The Veteran submitted a VA Form 21-8940 "Application for Increased Compensation Based on Unemployability" in September 2008, and at that time he reported that he "became too disabled to work" on "3/11/2008." Clarification and updated information is necessary regarding the Veteran's employment / employability over the 13 years that have passed since that filing. For instance, the April 2012 VA examination report assessing the Veteran's left knee disability states that the Veteran "Works full time for the State Capitol Police for the past one year." Additionally, a January 2021 note from the Veteran's private doctor regarding his recent knee surgery stated that the Veteran's "[t]entative return to work date will be 5.3.21." The AOJ should provide the Veteran with another VA Form 21-8940, "Veteran's Application for Increased Compensation Based on Unemployability," for completion in order to provide updated information as to his employment and education. The Board recognizes, as discussed in prior Board decisions including the October 2020 remand of this issue, that the Veteran contacted the AOJ in January 2009 and stated that he no longer wanted to pursue a TDIU claim, but instead wanted to claim a temporary total rating based on convalescence. However, when the Veteran appealed the July 2016 Board decision to the Court, the Veteran's representative expressed the Veteran's disagreement regarding TDIU, stating that the Veteran "requests that the Court reverse the Board's determination that the issue of entitlement to TDIU was not reasonably raised by the record," accompanied by arguments to this effect. The Board is compelled to find that the issue of entitlement to TDIU has been raised in this case in connection with the left knee rating issue, and the Board shall accordingly proceed with the development necessary to adequately inform appellate review. The matters are REMANDED for the following action: 1. Associate with the claims-file any outstanding pertinent treatment records, including any additional VA treatment records (such as those that may have been created since the last such update of the claims-file). Additionally, ask the Veteran to complete a VA Form 21-4142 for any new or outstanding records from private providers of pertinent medical treatment of his disabilities on appeal that the Veteran may wish VA to assist him in obtaining for the record. 2. Provide the Veteran with another VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for completion in order to provide updated information as to his employment and education. 3. After completion of the above-directed development and completion of the initial rating determination in effectuating the grant of entitlement to service connection for left vastus medialis obliquus atrophy and muscle impairment, readjudicate the TDIU issue on appeal. If any benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Barone, 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.