Citation Nr: 1804971 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 07-27 771A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased disability rating in excess of 60 percent for a left knee disability, status-post total knee replacement, for the period from September 1, 2015. 2. Entitlement to a separate disability rating for a left knee scar, status-post total knee replacement. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Patricia A. Talpins, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1984 to January 1992. For the record, this appeal has a long history with a number of staged disability ratings. These matters initially came to the Board of Veterans' Appeals (BVA or Board) on appeal from an October 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida in which the RO, among other things, granted service connection for posttraumatic arthritis of the left knee (left knee disability) and assigned a 10 percent disability rating effective March 28, 2006. The Veteran timely appealed for, among other things, a higher initial rating for his service-connected left knee disability. In appealing the RO's October 2006 rating decision, the Veteran stated in his September 2007 VA Form-9/Substantive Appeal that he experienced chronic instability of the knees. The RO construed this statement as an informal claim of entitlement to service connection for left knee instability. After assisting in the development of the Veteran's claim and affording him a June 2010 VA examination, the RO denied service connection for left knee instability in July 2010. In April 2011, the Veteran testified before a Veteran's Law Judge during a BVA Travel Board hearing. At that time, the Veteran's testimony regarding instability of his left knee was viewed to constitute a notice of disagreement (NOD) to the July 2010 rating decision. A transcript of the April 2011 BVA Travel Board proceeding has been associated with the claims file. Subsequently, the Veteran underwent his first of two left knee total knee replacements. In an April 2011 rating decision, the RO assigned a temporary total disability rating for the Veteran's left knee disability beginning March 24, 2011 and ending on April 30, 2012. Thereafter, the Veteran's left knee disability rating was increased from 10 percent to 30 percent effective May 1, 2012. During the above-referenced time frame, the Board issued a decision in September 2011 in which it recharacterized the issues on appeal as claims of entitlement to (1) an initial evaluation in excess of 10 percent for posttraumatic osteoarthritis of the left knee, (2) service connection for left knee instability and (3) an increased rating for a service-connected right knee disability. The Board remanded all three issues to the RO for additional development, and also remanded the additional issue of entitlement to a TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Then, in a September 2012 rating decision, the RO increased the Veteran's left knee disability rating from 30 percent to 60 percent effective August 2, 2012. That same month, the RO issued a statement of the case (SOC) related to the issue of entitlement to a separate disability rating for left knee instability prior to March 24, 2011 (the date he was first assigned a temporary total evaluation). The Veteran did not submit a VA Form-9/Substantive Appeal to the SOC. Thereafter, the Veteran underwent a second left knee total knee replacement. In a series of rating decisions dated in December 2012, March 2015, and May 2015, the RO assigned the Veteran a temporary total rating from February 6, 2013 to August 31, 2015. Effective September 1, 2015, the Veteran's left knee disability was assigned a 60 percent disability rating. The Veteran continued his appeal to the Board. In an April 2015 decision, the Board (among other things) denied an initial rating in excess of 10 percent for the Veteran's left knee disability from March 28, 2006, to March 23, 2011. For the same time period, the Board noted in the body of its decision that a separate rating for instability of the left knee could not be assigned because the Veteran failed to perfect an appeal to the July 2010 rating decision that denied service connection for left knee instability. See BVA decision, pgs. 18-21. Thereafter, the Board recharacterized the Veteran's left knee disability to reflect his undergoing a total knee replacement (posttraumatic osteoarthritis of the left knee, status-post total knee replacement). In addressing the time period from May 1, 2012, to February 5, 2013, the Board awarded a 60 percent disability rating from May 1, 2012, to August 1, 2012, but denied a rating in excess of 60 percent from May1, 2012, to February 5, 2013. In the body of the opinion, the Board also found that the preponderance of the evidence was against assigning a separate rating for instability of the left knee based upon the medical evidence of record. Id., pgs. 21-26. The above-referenced issues are no longer before the Board. In the remand portion of the April 2015 BVA decision, the Board sought additional development regarding the issues of entitlement to an increased disability rating for a left knee disability from February 6, 2013, forward and entitlement to a TDIU. The Veteran was subsequently assigned a temporary total rating from February 6, 2013, to August 31, 2015. See rating decisions dated in December 2013, March 2015, and May 2015. In a May 2015 rating decision, the RO assigned a 60 percent disability rating for the Veteran's left knee, effective September 1, 2015. The appeal was then returned to the Board. In April 2016, the Board remanded the above-referenced claims once again due to a procedural error. See May 2015 supplemental statement of the case; April 2016 BVA decision; June 2016 supplemental statement of the case. Subsequently, the Veteran's Law Judge who presided over the Veteran's April 2011 Travel Board hearing left the Board. The Veteran was notified via letter of the departure of the Veterans Law Judge and given the opportunity for a new BVA hearing. See letter dated in February 2017. The Veteran requested a new BVA hearing; and thereafter testified before the undersigned Veteran's Law Judge in August 2017. A transcript of this hearing has been associated with the claims file. Finally, for the record, the Board notes that this appeal was processed using the Veterans Benefits Management System (VBMS), Caseflow Reader, and Legacy Content Manager Documents. FINDINGS OF FACT 1. Since September 2015, the Veteran's left knee disability, status-post total knee replacement, has been manifested by chronic severe painful motion or weakness of the left lower extremity, and by pain; thigh amputation of the left lower extremity is not demonstrated. 2. Since September 2015, the preponderance of the evidence is against finding that the Veteran's left knee disability, status-post total knee replacement, has been manifested by instability of the left knee. 3. The most persuasive and credible evidence of record reveals that the Veteran has a painful scar on his left knee, status-post total knee replacement; however, the scar is not deep, unstable or nonlinear; does not cover an area of at least 6 square inches (39 sq. cm); is not located on the Veteran's head, face or neck; nor is it shown to result in any disabling effects. 4. The Veteran's last formal place of employment was as a pastor. 5. Since he stopped working as a pastor, the Veteran's service-connected disabilities have not precluded obtaining and sustaining substantially gainful employment. CONCLUSIONS OF LAW 1. Since September 2015, the criteria for an increased rating in excess of 60 percent for posttraumatic osteoarthritis of the left knee, status-post total knee replacement, are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5055, 5260 (2017). 2. The preponderance of the evidence is against the assignment of a separate disability rating for instability of the left knee. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.27, 4.3, 4.7, 4.27, 4.40, 4.59, 4.71a, Diagnostic Code 5257 (2017). 3. The criteria for an initial compensable evaluation of 10 percent, but no higher, for a painful surgical scar of the left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.27, 4.118, Diagnostic Codes 7800-7805 (2017). 4. The preponderance of the evidence is against the assignment of a total rating based upon individual unemployability. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Overview of Increased Ratings Claims Disability ratings are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The Rating Schedule sets forth diagnostic criteria (via diagnostic codes) that are utilized as a tool in evaluating the severity of service-connected diseases, injuries and conditions. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In determining a disability rating, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function are expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In increased rating claims, staged ratings are appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The factors involved in evaluating and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. In DeLuca v. Brown, 8 Vet. App. 202, 205 (1995), the United States Court of Appeals for Veterans Claims (Court) held that, for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45 pertaining to functional impairment. The Court instructed that in applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of knee pain. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. However, when a condition is specifically listed in the rating schedule, it may not be rated by analogy under a different diagnostic code. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). Rating in Excess of 60 Percent for a Left Knee Disability As set forth in the Introduction portion of this decision, the Veteran was initially granted service connection for posttraumatic osteoarthritis of the left knee pursuant to Diagnostic Code 5260 (limitation of motion of the knee). When the Veteran underwent his initial total knee replacement, the RO changed the description of the Veteran's left knee disability to posttraumatic osteoarthritis of the left knee, status-post total knee replacement, and evaluated the disability in accordance with Diagnostic Codes 5010-5055 (arthritis due to trauma - knee replacement (prosthesis)). Among other rating criteria, VA's rating schedule includes eight diagnostic codes applicable to evaluating knee and leg disabilities, six diagnostic codes for rating disabilities involving prosthetic implants and several diagnostic codes related to amputations of the lower extremity. See, 38 C.F.R. § 4.71a, diagnostic codes 5256 to 5263, 5051 to 5056, and 5160 to 5173. As mentioned above, the Veteran's left knee disability has been rated pursuant to Diagnostic Code 5055, the diagnostic criteria specifically applicable to knee replacement (prosthesis). Under that code, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. (The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30). Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. In a December 2013 rating decision, the RO increased the Veteran's left knee disability rating to 100 percent pursuant to Diagnostic Code 5055 in light of the Veteran undergoing a second left knee total knee replacement. The effective date of this increase was February 6, 2013. Thereafter, due to extenuating circumstances, the Veteran's 100 percent disability rating was continued until August 31, 2015. See rating decision dated in March 2015. Thereafter, in a May 2015 rating decision, the RO assigned a 60 percent rating disability for the Veteran's left knee effective September 1, 2015. A 60 percent rating is the highest disability rating available under Diagnostic Code 5055. Because Diagnostic Code 5055 in VA's rating schedule pertains specifically to evaluations of total knee replacement disabilities, the Veteran's disability cannot be rated by analogy to any of the other diagnostic codes. See Copeland, 27 Vet. App. at 337. However, even if it were possible to rate by analogy, the Veteran's left knee disability would remain at 60 percent since, other than the assignment of a temporary 100 percent evaluation for one year following the implantation of a prosthesis, a 60 percent disability rating is the highest rating that can be assigned pursuant to the eight diagnostic codes applicable to the evaluation of knee and leg disabilities, in addition to the six diagnostic codes for rating disabilities involving prosthetic implants. See 38 C.F.R. § 4.71a, diagnostic codes 5256 to 5263 and 5051 to 5056. As for Diagnostic Codes 5160 to 5173 pertaining to disabilities involving amputations of the lower extremities, the evidence of record fails to show the Veteran has had a thigh amputation of the left lower extremity. Given the foregoing, the Board finds that a disability rating in excess of 60 percent from September 1, 2015, for posttraumatic osteoarthritis of the left knee, status-post total knee replacement, is denied. Separate Rating for Instability of the Left Knee from September 1, 2015 In addition to seeking an increased rating for his left knee disability pursuant to Diagnostic Code 5055, the Veteran seeks the assignment of a separate disability rating for instability of the left knee pursuant to Diagnostic Code 5257. Disabilities of the knee and leg are generally evaluated under Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5257 ("other impairment of the knee"), Diagnostic Code 5258 (semilunar, dislocated cartilage), Diagnostic Code 5259 (the removal of symptomatic, semilunar cartilage), Diagnostic Code 5260 (limitation of flexion of the leg), Diagnostic Code 5261 (limitation of extension of the leg), Diagnostic 5262 (impairment of the tibia and fibula) and/or Diagnostic Code 5263 (genu recurvatum). As set forth above, VA's rating schedule also provides for disabilities that pertain to the knee or leg under sections where they are deemed to be more applicable, such as Diagnostic Code 5055 (for disabilities involving a prosthetic implant of the knee/knee replacement) and Diagnostic 5164 (for disabilities in which amputation is not improvable by prosthesis controlled by regular knee action). As set forth above, the Veteran's service-connected left knee disability has been rated under Diagnostic Code 5055. If an injury or disease manifests with two different disabling conditions, then two separate ratings should be awarded; it is improper to assign a single rating with a hyphenated diagnostic code under such circumstances. Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006); 38 C.F.R. § 4.27. Separate ratings may be assigned for distinct disabilities from the same injury if the symptomatology for the conditions is not duplicative or overlapping; however, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); 38 C.F.R. § 4.14. For instance, VA's General Counsel has held that knee arthritis and instability may be rated separately under 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Further, the General Counsel has held that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint; and that separate evaluations may also be assigned for limitation of motion and for instability. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998); VAOGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). Diagnostic Code 5055 refers to chronic residuals consisting of painful motion or weakness. Although that criteria does necessarily encompass any other description of disability resulting from painful motion and weakness, reasonably including fatigue and any incoordination due to weakness or pain, it does not encompass instability, a manifestation that could exist without pain or weakness. Therefore, a rating under Diagnostic Code 5055 does not preclude a separate additional rating under Diagnostic Code 5257 for instability. See e.g. Thomas v. Nicholson, 20 Vet. App. 448 (Table); 2006 WL 322032, * 1-2 (2006) (nonprecedential)(reversing the Board's finding that 38 C.F.R. § 4.14 prohibited the assignment of separate ratings under Diagnostic Code 5257 and Diagnostic Code 5055); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (finding that a nonprecedential decision of the Court, while not binding, "may be cited or relied upon, however, for any persuasiveness or reasoning it contains"). As mentioned previously, Diagnostic Code 5257 provides the rating criteria for disabilities related to "other impairment of the knee," specifically recurrent subluxation (partial dislocation of the kneecap) and lateral instability of the knee. This code allows for the assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability of the knee, a 20 percent rating when there is moderate recurrent subluxation or lateral instability of the knee, and a 30 percent evaluation for severe recurrent subluxation or lateral instability of the knee. Prior to discussing the evidence in this case, the Board observes for the record that the Veteran has already been denied a separate rating for instability of the left knee prior to September 1, 2015. See April 2015 BVA decision, p. 21 (due to his failure to timely appeal a July 2010 rating decision that denied service connection for left knee instability, "a separate rating for instability cannot be assigned."); April 2015 BVA decision, p. 23 ("a separate rating is not warranted for instability as the examiners found no evidence thereof"). Thus, the issue before the Board is whether the assignment of a separate disability rating for instability of the knee is warranted for the time period beginning September 1, 2015. Turning to the evidence in this case, the Board observes that the Veteran has reported recurrent problems with instability of his left knee. See e.g. June 2010 VA examination (the Veteran reported a medical history of giving way, instability, pain, stiffness, weakness, and swelling); April 2011 BVA hearing transcript ((the Veteran testified that his left knee gave out on him on many occasions); August 2017 BVA hearing transcript (the Veteran testified that his knee buckled and gave way without notice). However, just as consistently, medical examination records document various instances during which the Veteran's instability tests have been found to be normal (i.e., the Veteran has been found medically not to have instability of the knee according to tests undertaken to diagnose that condition). See e.g. June 2010 VA examination (examination of the left knee in June 2010 revealed crepitus, tenderness, and guarding of movement but no instability or other joint abnormality); February 2012 VA examination report (examination joint stability testing was found to be normal, with examiner also noted finding no evidence of recurrent patellar subluxation or dislocation); VA medical records dated in May 2012 (x-ray of the left knee demonstrated stable components without apparent fracture or complication). Although the Veteran's post-service medical records appear to focus on instability of his right knee rather than his left knee, the Board observes that during a March 2015 VA examination, the Veteran underwent joint stability tests. In the pertinent section of the report that addressed joint stability tests, the examiner indicated "no" in the box that asked if the Veteran had joint instability. The Veteran's Lachman test (anterior instability) was reported as normal, his posterior drawer test (posterior instability) was also reported as normal. Additionally, the Veteran's medial instability test and lateral instability test were marked as normal. A May 2015 VA examination report, conducted and prepared by a different medical provider than the Veteran's previous examiner, also notes that the Veteran's anterior instability test (Lachman test) and posterior instability test (posterior drawer test) were normal; the Veteran's medial instability and lateral instability tests were also marked normal. In addition, the examiner was essentially asked if the Veteran's joint stability testing revealed joint instability - the answer to which was no. Thus, the evidence is contradictory in terms of whether the Veteran actually has the medical condition of instability of the left knee. Although the Veteran is certainly competent to report and testify that he has fallen and believes he has fallen because of instability of the left knee rather than another cause (i.e., such as weakness of the knee), he is not competent to actually diagnose himself as having an unstable left knee for rating purposes. Lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. In this case, the issue of whether the Veteran's left knee buckles beneath him because of instability or some other cause is one that relates to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet). Such a finding is supported by the fact that when attempting to determine if a person suffers from joint instability, medical providers use several joint stability tests before providing an opinion as to whether or not a joint is unstable. Thus, although the Board finds that the Veteran's testimony is competent and credible in terms of the fact that the Veteran feels that what he suffers from is instability of the left knee, the medical and other probative evidence of record does not support such a diagnosis. Therefore, a separate disability rating for instability of the left knee is denied. Separate Rating for a Painful Scar on the Left Knee During his April 2017 BVA hearing, the Veteran testified that he has a scar on his left knee as a result of his left knee total knee replacement. He testified that this scar is painful. The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. The Board notes that on September 23, 2008, VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The amendments are only effective for claims filed on or after October 23, 2008. The Veteran initially raised the issue of a separate rating for a scar during his May 2017 BVA hearing. As such, only the amended regulations are applicable to these claims. Reviewing the evidence of record in this case, the Board observes that the Veteran's scar symptomatology does not meet the requirements set forth in any of the following: Diagnostic Code 7800 (scars of the head, face and neck), Diagnostic Code 7801 (scars that are deep and nonlinear in an area at least 6 square inches), Diagnostic Code 7802 (scars that are superficial and nonlinear in an area of at least 144 square inches), and Diagnostic Code 7805 (scars that result in disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804). However, VA's rating schedule provides for the assignment of a 10 percent disability rating under Diagnostic Code 7804 upon a showing of evidence that a veteran suffers from one or two scars that are either unstable or painful. Although a February 2012 VA examination report reflects the Veteran having a scar of the left knee, it also notes that the scar was not painful, unstable or greater than 39 square cm. VA examination reports dated in March 2015 and May 2015 also note a scar of the Veteran's left knee that was reported not to be painful. The March 2015 examination report reflects that the Veteran's scar was 10cm in length and 1 cm in width; while the May 2015 VA examination report indicates that the Veteran's scar was in the vertical midline knee area 23 cm x 0.4 cm. The examiner noted that the scar was well-healed, stable, without keloids, inflammations or adhesions and caused no functional limitation. Despite the lack of information in the Veteran's VA medical records and the VA examiners report notations that the Veteran's scar has not been found to be painful, the Board finds that doubt should be resolved in the Veteran's favor in light of his July 2017 BVA testimony that he has a painful left knee scar. Therefore, the Board finds that a separate, 10 percent disability for a painful scar on the Veteran's service-connected left knee disability is warranted pursuant to Diagnostic Code 7804. Extraschedular Consideration In a November 2016 post-remand brief, the Veteran's representative argued that the Veteran's left knee disability should be given extraschedular consideration. Initially, the Board observes that its findings set forth above are based on the rating schedule. Generally, it must be remembered that the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. In this regard, the basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. See 38 C.F.R. § 4.10. Moreover, the rating schedule is based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. 38 C.F.R. § 4.15. To afford justice in exceptional situations, however, an extraschedular rating may also be assignable. 38 C.F.R. § 3.321(b). The Board may not, in the first instance, assign an increased rating on an extraschedular basis, but may determine whether referral for extraschedular consideration is warranted, provided that it articulates the reasons or bases for that determination. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). An extraschedular determination must follow a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, the level of severity and symptomatology of a veteran's service-connected disability must be compared with the established criteria found in the rating schedule for that disability. Id. If the rating criteria reasonably describe a veteran's disability level and symptomatology, the disability picture is contemplated by the rating schedule. Therefore, the assigned schedular evaluation is adequate and no referral is required. Id. If the schedular evaluation does not contemplate the level of disability and symptomatology, and is found inadequate, the second step of the inquiry requires the Board to determine whether the exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-16. If analysis of the first two steps shows that the rating schedule is inadequate to evaluate the disability picture and that picture shows the related factors discussed above, the final step requires that the disability be referred to the Director of the Compensation Service for a determination of whether the disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. 111. Limiting referrals for extraschedular evaluation to considering a veteran's disabilities individually ignores the compounding negative effects that each individual disability may have on the veteran's other disabilities. 38 C.F.R. § 3.321(b)(1) performs a gap-filling function, accounting for situations in which a veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a veteran's disabilities are nonetheless inadequately represented. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Therefore, referral for extraschedular consider may also be made to consider the compound/combined impact of multiple service-connected disabilities in determining whether referral for extraschedular consideration is needed. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). In this case, the Board finds that referral for extraschedular consideration is not warranted. The Veteran's service-connected left knee disability both, prior to and after, his total knee replacements involve signs and symptoms, such as painful motion, weakness, and associated functional effects involving being precluded from prolonged standing/walking/kneeling, running or heavy lifting. These signs and symptoms, and their resulting functional impairments, are expressly contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the knee provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4. In fact, for all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Because the rating schedule was purposely designed to compensate for such functional effects of his disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in standing and walking for long periods. See 38 C.F.R. §§ 4.1, 4.10, 4.15. In short, there is nothing exceptional or unusual about the Veteran's left knee disability because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. For these reasons, referral for consideration of an extraschedular rating for this disability is not warranted. Entitlement to a TDIU If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of a service-connected disability/disabilities, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of non-service connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). All veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of a service-connected disability/disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). In cases where the schedular criteria are not met, an extraschedular rating is for consideration. 38 C.F.R. §3.321. The central inquiry of a TDIU is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Factors to be considered are the veteran's education, employment history, and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. Turning to the schedular criteria, the Board observes that the Veteran is currently service-connected for (1) posttraumatic osteoarthritis of the left knee, status-post total knee replacement at 60 percent effective from September 1, 2015; (2) right total knee replacement at 30 percent from March 1, 2011; and (3) peripheral neuropathy of the right lower extremity at 10 percent from May 17, 2010. The Veteran's individual disability evaluations combine to an overall 90 percent evaluation as of September 1, 2015. Therefore, he meets the criteria for consideration of the assignment of a TDIU. Turning to the issue is whether the Veteran is capable of performing the physical and mental acts needed for employability, the Board observes that the Veteran has testified that his prior profession was as a pastor at a church; and that he had to leave this position in 2007 because his knee surgeries and recoveries began to take too much time away from his church. Evidence of record reveals that the Veteran is currently enrolled in school. In this regard, the Veteran testified in April 2017 that he was about to graduate with a Master's in Business Administration. In seeking medical guidance as to the effects the Veteran's service-connected disabilities had on his employability, the Veteran was afforded two (2) VA examinations related to his knee conditions and his service-connected peripheral neuropathy. Both examinations were conducted by the same VA examiner. At that time, the VA examiner reviewed the Veteran's entire claims file, obtained a medical history from him, and conducted physical examinations. Thereafter, the examiner opined that the Veteran's service-connected right and left knee disabilities would limit his ability for prolonged standing, walking, kneeling, running, and heavy lifting. However, the examiner noted that the Veteran's service-connected knee disabilities should not preclude sedentary or light duty occupations, especially considering the Veteran's advance education. In regards to his service-connected right lower extremity peripheral neuropathy, the examiner opined that the condition might limit any occupation that required the Veteran to go barefoot because of hypersensitivity of his right sole. The examiner found no evidence of motor deficits and noted the Veteran had adequate sensory function for his daily activities. In favor of the TDIU claim is a letter in the claims file dated in August 2017 from the Veteran's site supervisor/Director of Veterans Services named K.D. This letter indicates that the Veteran began participating at a VA Work Study Program in December 2016. It reflects K.D.'s opinion that the Veteran was a suitable candidate for Individual Unemployability. In providing this opinion, K.D. gave information as to her background and experience in the letter as she stated she was basing her recommendation on her overall work experience and management of the Veteran. In the letter, K.D. reports that when the Veteran started working at the VA Work Study Program, he was very motivated and had a strong desire to do a good job. As time lapsed though, she observed the Veteran struggling with his health and emotional needs; and that this affected his work. She noticed that the Veteran began to make simple mistakes that could have affected his employment if he had been in a more formal employment position. Also, she stated that the Veteran's interactions with other staff had sometimes been strained, resulting in a less effective work environment. In summary, K.D. stated that the Veteran had a strong desire to do a good job and is very intelligent, but at the same time had challenges to overcome that appeared to affect him in his career goals. Viewing the evidence in total, to include the August 2017 letter from K.D. and the VA medical opinions set forth above, the Board finds that the preponderance of the evidence is against the assignment of a TDIU at this time. Although the Veteran may be unemployed, the dispositive issue is whether he is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The more probative and persuasive evidence of record reveals that the Veteran's service-connected disabilities, separately or together, do not preclude his ability to do work other than that of a pastor. In fact, there is no evidence in the claims file indicating that he will not be able to have a career in Business Administration when he graduates with his Master's degree. The August 2017 letter from K.D. does not indicate such, as her comments regarding the Veteran's work performance involved making minor mistakes that could affect his formal employment; and that his mistakes were due struggles with his health and emotional needs, in addition to problems that he had in communicating well with others. In light of the foregoing, the Board finds that the evidence does not show that the Veteran is unable to secure or maintain substantially gainful employment due to his service-connected disabilities alone. Therefore, the Veteran's claim for TDIU is denied. Conclusion In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. In doing so, the Board finds that the evidence supports the assignment of a separate 10 percent disability rating for the Veteran's left knee surgical scar; and therefore that claim is granted. However, the Board finds that the preponderance of the evidence is against the other claims. Because the preponderance of the evidence is against those claims, the benefit of the doubt doctrine is not applicable to them. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. ORDER An increased rating in excess of 60 percent for a left knee disability, status-post total knee replacement, for the period from September 1, 2015, is denied. A separate disability rating for left knee instability is denied. A separate disability rating of 10 percent for a painful scar on the left knee, as a result of status-post total knee replacement, is granted subject to the law and regulations governing the payment of monetary benefits. A total disability rating based on individual unemployability is denied. ____________________________________________ H.M. WALKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs