Citation Nr: 1716005 Decision Date: 05/11/17 Archive Date: 05/22/17 DOCKET NO. 11-23 786 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent from February 12, 2010, to September 27, 2011, and in excess of 40 percent thereafter, for a left knee disorder, characterized as strain and partial tear of the anterior cruciate ligament (ACL), strain of medial meniscus, focal tear of the free edge of the lateral meniscus, and arthritis. 2. Entitlement to a rating in excess of 20 percent since December 14, 2011, for a right (dominant) shoulder disorder, characterized as acromioclavicular (AC) separation with impingement syndrome and arthritis and tears of the right biceps, labrum, and infraspinatus/supraspinatus. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. E. Miller, Associate Counsel INTRODUCTION The Veteran served in the U.S. Army from July 1974 to July 1978. This matter came before the Board of Veterans' Appeals (Board) on appeal from July 2010 and April 2012 decisions of the Milwaukee, Wisconsin, Regional Office (RO). In January 2016, the Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge. A hearing transcript is in the record. In May 2016, the Board remanded the appeal to the RO for additional action. The issue of entitlement to service connection for depression has been raised by the record in a February 2017 claim, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2016). FINDINGS OF FACT 1. During the period from February 12, 2010, to September 27, 2011, the Veteran's left knee disability has been shown to be manifested by no more than pain, stiffness, instability, swelling, fullness, guarding, tenderness to palpation, positive McMurray's test, mild effusion, locking, meniscus tear, osteoarthritis, extension to 0 degrees with pain, and flexion to 115 degrees with pain. 2. Since September 27, 2011, the Veteran's left knee disability has been shown to be manifested by constant pain; constant swelling; weakness; flare-ups three times per week; tenderness; decreased muscle strength; quadriceps atrophy; weakened movement; excess fatigability; pain on movement and weight-bearing; disturbance of locomotion; an antalgic gait; history of recurrent effusion; flexion limited to 70 degrees with pain and extension limited to 30 degrees with pain. 3. Since December 14, 2011, the Veteran's right shoulder disability has been shown to be manifested by no more than pain, flare-ups, less movement than normal, pain on movement, weakened movement, tenderness to palpation, guarding, crepitus, tenderness of the right trapezius, flexion to 60 degrees, abduction to 50 degrees, internal rotation to 20 degrees, and external rotation to 30 degrees with pain. 4. The Veteran's service-connected disability makes him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent, from February 12, 2010, to September 27, 2011, for left knee limitation of motion have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 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, Diagnostic Codes 5003, 5261 (2016). 2. The criteria for a rating in excess of 40 percent, since September 27, 2011, for left knee limitation of motion have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 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, Diagnostic Codes 5003, 5261 (2016). 3. The criteria for a rating of 20 percent since February 12, 2010, for left knee meniscus tear causing locking, pain, and effusion have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 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, Diagnostic Code 5258 (2016). 4. The criteria for a rating of 30 percent since December 14, 2011, for right shoulder limitation of motion have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 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, Diagnostic Codes 5003, 5201, 5203 (2016). 5. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.16 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and to Assist VA has a duty to notify claimants about the claims process and a duty to assist them in obtaining evidence in support of their claim. VA has issued several notices to the Veteran including March 2010 and January 2012 notices which informed him of the evidence generally needed to support his claims; what actions he needed to undertake; and how VA would assist him in developing his claims. The March 2010 and January 2012 notices were issued to the Veteran prior to the July 2010 and April 2012 decisions, respectively, from which the instant appeal arises. Additionally, where, as here, with the appeal for an initial compensable rating following the grant of service connection, no additional VCAA notice is required with respect to the downstream issue of the initial rating assigned to the now service-connected disability. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003. All identified and available relevant documentation has been secured to the extent possible and all relevant facts have been developed. There remains no question as to the substantial completeness of the claims. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). For these reasons, the Board finds that the VA's duties to notify and to assist have been met. II. Analyses Disability evaluations are determined by comparing the Veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2016). Traumatic arthritis is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2016). Degenerative arthritis, established by X-ray, will be rated on the basis of limitation of motion under the appropriate diagnostic criteria for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 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, a 10 percent rating is warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups; a 20 percent rating is warranted if there are also occasional incapacitating exacerbations. Note (1) states: The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) states: The 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2016). 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. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). A. Left Knee Diagnostic Code 5261 provides ratings based on limitation of the extension of the leg. Limitation of extension to 5 degrees warrants a noncompensable 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. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2016). The average normal range of motion of the knee is flexion from 0 to 140 degrees and extension from 140 to 0 degrees. 38 C.F.R. § 4.71, Plate II. In his February 2010 claim for service connection, the Veteran stated that he had left knee symptoms of pain, tenderness, stiffness, instability, and swelling. A March 2010 magnetic resonance imaging (MRI) study indicated that the Veteran had a strain/partial thickness tear of the caudal one-half of the ACL, strain of the meniscal capsular attachment along the posteromedial aspect of the medial meniscus, and a possible focal tear of the free edge of the body of the lateral meniscus. In June 2010, the Veteran was afforded a VA examination. He reported constant pain, stiffness, swelling, difficulty using stairs, difficulty driving, difficulty being in the same position for a prolonged period of time, and that he could stand for about five minutes and walk up to one-and-a-half blocks. He used a knee brace and often used a cane. On examination, he had fullness on the medial side of the knee, tenderness to palpation, positive McMurray's test, full extension, flexion limited to 120 degrees, and excessive pain on repeated use. He was diagnosed with strain or partial tear of the ACL, strain of the medial meniscus, and a focal tear of the free edge of the lateral meniscus. June 2010 VA treatment records indicate that the Veteran fell approximately 7-10 days prior when his knee gave out; he was diagnosed with left knee meniscal disease and osteoarthritis. During a follow-up appointment with his physician, he had range of motion from zero to 130 degrees with pain throughout, guarding, and tenderness. He was diagnosed with degenerative disease and medial compartment meniscal tears. A June 2010 physical therapy record notes range of motion from zero to 115 degrees with pain. In a September 2010 telephone call to VA, the Veteran reported that his knee pain was constant, he had been receiving cortisone injections, and he was contemplating surgery. A March 2011 VA treatment record states that the Veteran had mild effusion, minimal lateral joint line tenderness, and range of motion from zero to 130 degrees; he was diagnosed with a meniscus tear. On September 27, 2011, the Veteran was afforded a VA examination. Diagnoses of knee strain/partial ACL tear, medial meniscus strain, lateral meniscus tear, and degenerative joint disease were noted. The examiner stated that the Veteran's fall in June 2010 was a result of his left knee locking. The Veteran reported pain flare-ups resulting from rainy or damp weather and increased activity. On examination, he exhibited flexion to 70 degrees with pain; extension ending at 20 degrees with pain; tenderness to palpation; decreased muscle strength; and functional loss resulting in less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. He had no patellar subluxation or dislocation, no tibial and/or fibular impairment, and the examiner was unable to test the Veteran's knee for instability. The examiner indicated that the Veteran had a meniscal tear and frequent episodes of joint pain. He regularly used a knee brace and a cane. In August 2014, the Veteran was afforded a VA examination. The Veteran reported daily flare-ups lasting from a few minutes to one hour and caused by prolonged weight-bearing activities, climbing stairs, kneeling or squatting, and changes to the weather. He wore a brace daily and used a cane during flare-ups. On examination, he exhibited flexion limited to 110 degrees with pain, extension to zero degrees with no pain, functional loss following repeated use testing resulting in weakened and painful movement, tenderness to palpation, decreased muscle strength, no instability, and no patellar subluxation or dislocation. The Veteran had not had a meniscectomy or other knee surgery. A November 2014 written statement from the Veteran's spouse, who is a VA nurse, indicates that the Veteran had weak limbs and the he was unable to extend them. A March 2015 VA treatment record states that the Veteran had a Baker's cyst. A June 2015 X-ray study indicated patellar tendon ossifications but no evidence of effusion. In November 2015, the Veteran was treated at the emergency medical department after falling down the stairs when his knee locked up. A December 2015 VA treatment record states that the Veteran did not have knee swelling, deformity, or effusion, but that he did have moderate to severe pain with squatting. The record states that he may have injured his meniscus. A January 2016 VA physical therapy note indicates that the Veteran had an antalgic gait in his left lower extremity with limited knee flexion and extension and locking. He was not using a cane at that time. He had range of motion from zero to 90 degrees with pain. He reported difficulty climbing into his truck, climbing stairs, squatting, walking, and that he could not run. During a January 2016 Board hearing, the Veteran reported daily use of a knee brace and cane and decreased range of motion following his November 2015 fall. A February 2016 MRI indicated minimal early degenerative changes within the medial compartment but otherwise indicated no meniscal tenderness or ligamentous tear. In July 2016, the Veteran was afforded a VA examination. The Veteran reported flare-ups 2-3 times per week resulting in increased pain and swelling and that he used a brace constantly. On examination, he exhibited flexion to 120 degrees with pain and extension to zero degrees with no pain. There was no pain on weight-bearing, no tenderness to palpation, and no evidence of crepitus. He was able to perform repeated use testing with no additional functional loss or limitation of motion. Muscle strength and instability testing were normal, there was no ankylosis, no history of recurrent subluxation or recurrent effusion noted, and no tibial and/or fibular impairment. The examiner wrote that an X-ray study was normal. In a September 2016 statement, the Veteran wrote that his fall in November 2015 has resulted in an inability to pivot or make certain turns or movements. He reported constant pain, difficulty walking prolonged distances, and constant swelling. An October 2016 VA treatment record indicates that the Veteran was treated for complaints of pain, weakness, and difficulty raising his knee. He reported a recent fall. On examination, he exhibited no swelling or effusion, extension to 90 degrees with pain, and no instability. In November 2016, the Veteran was afforded a VA examination. The Veteran reported daily pain and swelling and that he could stand or sit for approximately 30 minutes, walk approximately 2 blocks, had pain when using the stairs, and could not kneel, squat, or run. He regularly used both a brace and a cane. He reported functional loss resulting in weakness and decreased range of motion. On examination, he exhibited flexion limited to 90 degrees with pain, extension limited to 30 degrees with pain, and functional loss due to fatigue. He had pain on weight-bearing, tenderness to palpation, objective evidence of crepitus, an inability to squat, quadriceps atrophy, decreased muscle strength, no instability, a history of recurrent effusion, and no tibial and/or fibular impairment. An X-ray study indicated degenerative changes involving the tibial plateau and patellar facets, mild medial tibiofemoral and lateral patellofemoral joint space narrowing, dorsal patellar enthesophytes, and no joint effusion. The examiner noted that his quadriceps atrophy caused weakness and prevented him from standing on the left leg alone if the knee is flexed and that he is unable to get up from a squatting position without assistance. November 2016 and January 2017 VA treatment records indicate complaints of knee pain and range of motion from 15 to 95 degrees with pain. A January 2017 written statement from the Veteran's spouse indicates that the Veteran had swelling, stiffness, pain, and weakness. A January 2017 written statement from the Veteran indicates knee pain and weakness. During the period from February 12, 2010, to September 27, 2011, the Veteran's left knee disability has been shown to be manifested by no more than pain, stiffness, instability, swelling, fullness, guarding, tenderness to palpation, positive McMurray's test, mild effusion, locking, difficulty using stairs, difficulty driving, difficulty being in the same position for a prolonged period of time, an ability stand for about five minutes and walk up to one-and-a-half blocks, strain or partial tear of the ACL, meniscus tear, osteoarthritis, extension to zero degrees with pain, and flexion to 115 degrees with pain. He required the use of a brace and a cane, required cortisone injections, and had fallen. Since September 27, 2011, the Veteran's left knee disability has been shown to be manifested by no more than constant pain; constant swelling; weakness; flare-ups 2-3 times per week; tenderness; decreased muscle strength; quadriceps atrophy; weakened movement; excess fatigability; pain on movement and weight-bearing; disturbance of locomotion; an antalgic gait; difficulty climbing into his truck and climbing stairs; an inability to stand or sit for more than 30 minutes, walk more than 2 blocks, run, squat, or stand on the left leg alone if the knee is flexed; an ACL tear; a meniscus tear; arthritis; a Baker's cyst; crepitus; locking; a history of recurrent effusion; flexion limited to 70 degrees with pain; extension limited to 30 degrees with pain; use of a brace and cane; and resulting in a fall. Given these facts, the Board finds that the current 10 percent rating from February 12, 2010, to September 27, 2011, and 40 percent rating thereafter, adequately reflects the Veteran's limitation of motion during the relevant period. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board also finds that an additional 20 percent rating is warranted for locking, pain, and effusion since February 12, 2010. 38 C.F.R. § 4.71a, Diagnostic Code 5258. In making these determinations, the Board has considered, along with the schedular criteria, the Veteran's functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45 (2016); DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). B. Right Shoulder Arm limitation of motion is rated under diagnostic code 5201. A 20 percent rating is warranted for limitation of motion of the major arm to the shoulder level. A 30 percent rating is warranted for limitation of motion of the major arm to a point midway between the side and shoulder level. A 40 percent disability evaluation requires that motion of the major arm be limited to a point 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The average normal range of motion of the shoulder is forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; external rotation from zero to 90 degrees; and internal rotation from zero to 90 degrees. When the arm is held at the shoulder level, the shoulder is in 90 degrees of either forward elevation (flexion) or abduction. 38 C.F.R. § 4.71, Plate I. A 10 percent disability evaluation is warranted for malunion of the clavicle or scapula or for nonunion without loose movement. A 20 percent disability evaluation is warranted for nonunion of clavicle or scapula with loose movement or for dislocation. Impairment of the clavicle or scapula can alternatively be rated on impairment of function a contiguous joint. 38 C.F.R. § 4.71a, Diagnostic Code 5203. In January 2012, the Veteran was afforded a VA examination. The Veteran reported flare-ups whenever he used his arm for lifting, pulling, or any overhead activity. On examination, he exhibited flexion to 80 degrees with pain and abduction to 90 degrees with pain. He had no additional limitation of motion following repeated use testing, but did have less movement than normal, pain on movement, and weakened movement. He had tenderness to palpation and guarding, normal muscle strength, no ankylosis of the joint, was positive for impingement, had dislocation and tenderness of the AC joint, and arthritis. In December 2012, the Veteran was afforded a VA examination. The Veteran reported pain and flare-ups one time per week. The examiner noted that the Veteran had received steroid injections in his shoulder. On examination, he exhibited internal rotation from zero to 20 degrees, external rotation from zero to 60 degrees, flexion limited to 80 degrees with pain, and abduction limited to 90 degrees with pain. He had no additional limitation of motion following repeated use testing but did have pain on movement. He had normal muscle strength, no ankylosis of the joint, and was positive on tests for impingement, supraspinatus tear, infraspinatus tear, subscapularis tear, and AC joint pathology. He was diagnosed with osteoarthritis, AC joint injury, biceps tendon rupture, labrum injury, infraspinatus injury, and supraspinatus injury. In January 2015, the Veteran was afforded a VA examination and was diagnosed as having a bicipital tendon tear, rotator cuff tendonitis, labral tear including SLAP, glenohumeral joint osteoarthritis, AC joint osteoarthritis, and AC joint separation. The Veteran reported flare-ups resulting from weather change and use and described functional impairment limiting motion and lifting. On examination, he exhibited flexion to 90 degrees with pain, abduction to 80 degrees with pain, external rotation to 30 degrees with pain, and internal rotation to 60 degrees with pain. He had tenderness to palpation, functional loss due to pain and weakness, flare-ups, decreased muscle strength, and no muscle atrophy or joint ankylosis. He was positive for impingement; external rotation/infraspinatus strength testing and lift-off subscapularis testing were unable to be performed. The examiner indicated that shoulder instability, dislocation, or labral pathology was suspected, that the AC joint was dislocated, that there was tenderness on palpation of the AC joint, and that cross-body adduction testing was positive. The examiner also stated that the Veteran had rupture of the biceps muscle, tenderness of the right trapezius without radiation or numbness, his right elbow exhibited a positive Tinel's test with numbness to the forearm, and he had a negative Tinel's test at the wrist. The examiner stated that the Veteran had arthritis and objective evidence of crepitus. A January 2015 MRI indicated AC joint separation, degenerative changes of the AC and glenohumeral joints, complete tear and retraction of the long head of the biceps tendon, mild anterior downsloping of the acromion and mildly narrowing of the acromiohumeral distance, mild atrophy of the supraspinatus muscle, mild tendinosis of the infraspinatus tendon, SLAP tear, and tears of the anterior and posterior labrum. A February 2016 VA treatment record states that the Veteran had flexion from zero to 115 degrees, abduction from zero to 110 degrees, internal rotation from zero to 30 degrees, and external rotation from zero to 70 degrees. In July 2016, the Veteran was afforded a VA examination. Diagnoses of rotator cuff injury with complete tear and retraction of the long head of the biceps, bicipital tendon tear, rotator cuff tendonitis, rotator cuff tear, labral tear including SLAP, glenohumeral joint osteoarthritis, and AC joint osteoarthritis were advanced. The Veteran reported weakness, pain, and flare-ups with increased activity. On examination he exhibited flexion to 90 degrees, abduction to 80 degrees with pain, external rotation to 40 degrees, and internal rotation to 35 degrees with pain. The examiner noted that the Veteran was unable to lift his arm above his head. He had tenderness to palpation, no functional loss following repeated use testing, decreased muscle strength but no muscle atrophy, and no ankylosis. Testing for impingement and rotator cuff pathology was positive. There was no evidence of instability, dislocation, or labral pathology. The examiner stated that the Veteran had arthritis. In November 2016, the Veteran was afforded another VA examination. The examiner listed diagnoses of impingement syndrome, bicipital tendon tear, rotator cuff tendonitis, rotator cuff tear, labral tear including SLAP, glenohumeral joint osteoarthritis, and AC joint osteoarthritis. The examiner noted that the Veteran had pain with weight-bearing, objective evidence of crepitus, and that he could not use his arm over his head without pain. Following repeated use testing, the Veteran had functional loss due to pain, fatigue, weakness, and lack of endurance, and had limitation of flexion to 60 degrees, abduction to 50 degrees, external rotation to 70 degrees, and internal rotation to 30 degrees. He had decreased muscle strength but no muscle atrophy and the examiner noted that the rupture of the biceps has resulted in an unusual degree of flexion and weakness in the right arm. Tests for impingement, rotator cuff pathology, and subscapularis tendinopathy or tear were all positive. Instability, dislocation, or labral pathology was suspected, AC joint osteoarthritis was noted, and cross-body adduction testing was positive. The examiner noted that the Veteran regularly used a sling. A January 2017 statement from the Veteran's spouse indicates that the Veteran had constant pain, weakness, decreased range of motion, and difficulty sleeping due to his disorder. Since December 14, 2011, the Veteran's right shoulder disability has manifested by no more than pain, flare-ups, less movement than normal, pain on movement, weakened movement, tenderness to palpation, guarding, an inability to lift his arm over his head, difficulty sleeping, decreased muscle strength, crepitus, use of a sling, regular steroid injections, impingement, rotator cuff injury with complete tear and retraction of the long head of the biceps, bicipital tendon tear, rotator cuff tendonitis, rotator cuff tear, labral tear including SLAP, glenohumeral joint osteoarthritis, and AC joint osteoarthritis, AC joint separation, rupture of the biceps muscle, tenderness of the right trapezius, flexion to 60 degrees, abduction to 50 degrees, internal rotation to 20 degrees, and external rotation to 30 degrees with pain. Given these facts, the Board finds that a 30 percent rating most closely approximates the Veteran's limitation of motion and functional impairment during the relevant period. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In making this determination, the Board has considered, along with the schedular criteria, the Veteran's functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). The disability does not warrant assignment of a separate compensable rating for impairment of the clavicle or scapula as such an evaluation would constitute pyramiding. 38 C.F.R. § 4.14. Total Disability Rating - Individual Unemployability The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) has been raised under Rice v. Shinseki, 22 Vet. App. 447 (2009). VA regulations allow for the assignment of TDIU when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, and the veteran has certain combinations of ratings for service-connected disabilities. If there is only one such disability, that disability must be ratable at 60 percent or more. If there are two or more disabilities, there must be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran has at least one disability rated at 40 percent or more and currently has an overall rating of 90 percent. Therefore, he meets the schedular criteria for a TDIU. The Veteran owns a landscaping business but has provided evidence that he can only work a very limited number of hours per week. The Veteran and his spouse have both provided evidence that his service-connected disabilities prevent him from securing or following a substantially gainful occupation. Therefore, a TDIU is warranted. ORDER A rating in excess of 10 percent from February 12, 2010, to September 27, 2011, for left knee limitation of extension is denied. A rating in excess of 40 percent since September 27, 2011, for left knee limitation of extension is denied. A rating of 20 percent since February 12, 2010, for left knee meniscus tear causing locking, pain, and effusion is granted. A rating of 30 percent since December 14, 2011, for right shoulder limitation of motion is granted. TDIU is granted. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs