Citation Nr: 18139853 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 11-21 627 DATE: October 1, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression is denied. Entitlement to service connection for degenerative joint disease (DJD) or degenerative disc disease (DDD) of the lumbar spine, to include as secondary to service-connected low back strain is denied. Entitlement to an initial disability rating for low back strain in excess of 10 percent prior to May 25, 2018 and in excess of 20 percent thereafter is denied. Entitlement to an initial disability rating for chronic right knee strain and arthritis, with history of lateral and medial meniscal tears associated with low back strain (right knee disability) in excess of 10 percent is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The preponderance of the evidence indicates that the Veteran does not have a diagnosis of PTSD for VA purposes. 2. The evidence of record fails to demonstrate that an acquired psychiatric disorder, to include depression, is etiologically related to the Veteran’s active service. 3. The evidence of record fails to demonstrate that DJD or DDD of the lumbar spine is either etiologically related to the Veteran’s active service, or caused or aggravated by service-connected low back strain. 4. Prior to May 25, 2018, the Veteran’s low back strain did not result in forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; combined range of motion limited to 120 degrees or less; and muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 5. From May 25, 2018, the Veteran’s low back strain did not result in forward flexion of the thoracolumbar spine limited to 30 degrees or less or ankylosis. 6. For the entire period on appeal, the Veteran’s right knee disability has been manifested by, at worst, extension to 0 degrees and flexion to 90 degrees with pain; with no objective evidence of ankylosis, dislocated semilunar cartilage, symptomatic removal of semilunar cartilage, genu recurvatum, impairment of the tibia and fibula, instability or subluxation. 7. The Veteran’s service connected disabilities do not preclude him from obtaining or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. § 1101, 1110, 1131; 38 C.F.R. § 3.303, 3.304. 2. The criteria for service connection for DJD or DDD of the lumbar spine have not been met. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 3. The criteria for an initial disability rating in excess of 10 percent for low back strain prior to May 25, 2018 and a disability rating in excess of 20 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237. 4. The criteria for an initial disability rating in excess of 10 percent for right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4, 4.71, DC 5003-5260. 5. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1973 to January 1974 and from April 1976 to January 1983. These matters are before the Board of Veterans’ Appeals (Board) on appeal from April 2010, June 2011, and September 2013 rating decisions. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing in November 2015; a transcript of which is of record. These matters were previously before the Board in January 2016 and January 2018 when they were remanded for additional development. A rating decision dated July 2018 granted an increased rating of 20 percent for low back strain effective May 25, 2018. The rating decision also granted service connection for right knee arthritis effective October 25, 2010 and rated it together with the already service-connected right knee strain with history of meniscal tears, evaluated at 10 percent. As this represents a full grant of the benefits sought, the issue of service connection for right knee arthritis is not before the Board. Service Connection In general, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection also may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. §§ 3.310(a)-(b); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection for certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See Cohen v. Brown, 10 Vet. App. 128 (1997). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which simply mandates that, for VA purposes, all mental disorder diagnoses conform to the DSM-IV or DSM-V. See 38 C.F.R. § 3.304(f). The Board has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, 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. 1. DJD of the Lumbar Spine The Veteran contends that service connection is warranted for his current DJD of the lumbar spine, as it is related to an in-service armored personnel carrier (APC) accident and/or service-connected low back strain. The claims folder reflects the Veteran has current diagnoses for osteoarthritis and DJD/DDD of the lumbar spine. His service treatment records show in-service complaints of back pain in February 1977 and April 1980. The Board finds that the first two elements of a service connection claim, current disability and injury in-service, have been met. With regard to a nexus, VA examinations in November 2009, September 2010, November 2012, April 2016 are inadequate as they failed to note the Veteran’s consistent assertions of symptomatology since service and/or failed to provide an adequate rationale in determining whether DJD of the lumbar spine was due to service-connected low back strain. A May 2018 VA examiner opined that DJD/DDD of the lumbar spine is less likely related to the in-service APC injury and is less likely caused or aggravated by service-connected low back strain. The examiner explained that the Veteran was treated in service for muscle spasms and a sprained muscle, with no reports of disc problems. The examiner also explained that an in-service 1977 x-ray of the lumbar spine showed transitional vertebrae, which is a normal variant, with no spondylolysis or spondylolisthesis. Despite acknowledging the Veteran’s testimony and history of back pain, the examiner found that his lumbar spine disability is at least as likely related to the aging process. The examiner further explained that the Veteran had no abnormal spinal contour on the current and previous VA examinations due to his service-connected low back strain that would increase stress to the lumbar spine. There is no probative clinical opinion which supports a causal relationship between the DJD/DDD of the lumbar spine and active service or his service-connected low back strain. Thus, service connection is not warranted. Additionally, the claims folder does not reflect that the Veteran’s DJD of the low back strain manifested to a compensable degree within one year from him separating from active service. Thus, presumptive service connection for a chronic disease (arthritis) is not warranted here. 38 C.F.R. §§ 3.307, 3.309. The Board assigns little probative weigh to the statements of the Veteran and his girlfriend, as much as they attempt to provide etiology opinions to the claimed disability. Although a lay person is competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case in light of the education and training necessary to make a finding with regard to the complexities of degenerative arthritis or osteoarthritis of the left knee for VA purposes. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board has considered the doctrine of giving the benefit of the doubt to the Veteran, under 38 U.S.C. § 5107 and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 2. Acquired Psychiatric Disorder The Veteran avers that service connection is warranted for his alleged psychiatric disabilities, including PTSD and depression, as they are related to in-service stressors, including the APC accident discussed previously. The Veteran has diagnoses for PTSD and depressive disorder. (See June 2010 psychological evaluation and April 2016 and April 2018 VA psychological examinations) Although service records document an in-service APC accident, there is no evidence of any psychiatric complaints in service. The Veteran’s December 1982 separation examination shows a normal psychiatric clinical evaluation. An April 2016 VA examiner diagnosed the Veteran with unspecified depressive disorder, which he opined was not related to service. The examiner failed to comment as to whether the Veteran had other psychiatric disorders, including PTSD, which had resolved or was incorrectly diagnosed. An April 2018 VA examiner diagnosed other specified depressive disorder with recurrent brief depression. The examiner determined that the Veteran did not meet the full diagnostic criteria for a PTSD diagnosis. The examiner reported that VA treatment records showing a diagnosis of PTSD were made in error, as the Veteran did not endorse prominent symptoms of PTSD other than occasional dreams pertaining to the in-service APC accident with low frequency and severity. The examiner stated that the Veteran had some symptoms consistent with PTSD but had not consistently reported those symptoms across providers versus consistency in his description of depressive symptoms. The examiner also noted that the Veteran did not initially report psychiatric symptoms (i.e., depression) or enter into mental health treatment until 2009.The examiner concluded that PTSD symptoms typically present earlier in life associated with trauma. The examiner opined that depressive disorder is less likely as not related to service, as treatment and symptoms reportedly began in recent years. The examiner opined that depressive disorder is related to post-service events. Based on the evidence aforementioned, the Board finds that service connection for PTSD is not warranted, as a preponderance of the evidence is against a finding that he has a current diagnosis of PTSD. In addition, unspecified depressive disorder was not present until many years after service and is not etiologically to service. The Board notes that the Veteran asserts that he has diagnoses of PTSD, as shown in the June 2010 psychological evaluation and VA treatment records. However, the Board finds the April 2018 opinion to be highly probative, as it is based on examination of the Veteran and thorough review of his claims file. Moreover, the examiner provided a detailed rationale in support of the respective opinions provided, with clear conclusions, supporting data, and reasoned medical explanations. Accordingly, the opinion is entitled to greater probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). After careful consideration of the lay and medical evidence of record, the Board finds that the most probative evidence (i.e., April 2018 VA examination) is against a grant of service connection for the Veteran’s acquired psychiatric disorder. 38 C.F.R. § 3.303. In reaching such a conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. Increased Rating Right Knee Disability Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Here, the relevant evidentiary window begins one year before the Veteran filed her claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Hyphenated diagnostic codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The first four numbers reflect the diagnosed disability. The second four numbers after the hyphen identifies the criteria used to evaluate that disability. Under DC 5003, degenerative arthritis, the disability is evaluated based upon limitation of motion of the affected part. When limitation of motion is noncompensable, a 10 percent rating is warranted when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted where there is X-ray evidence of the involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. DCs 5256 through 5263 address disability ratings for the knee and leg. DC 5256 governs ankylosis of the knee and permits a 30 percent rating for favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees, while a 40 percent rating is called for with flexion between 10 and 20 degrees, and a 50 percent rating for flexion between 20 and 45 degrees. Extremely unfavorable ankylosis, with flexion at an angle of 45 degrees or more warrants a maximum 60 percent evaluation. Under DC 5257, a 10 percent rating will be assigned for slight recurrent subluxation or lateral instability of a knee; a 20 percent rating will be assigned for moderate recurrent subluxation or lateral instability; and a 30 percent rating will be assigned for severe recurrent subluxation or lateral instability. Under DC 5258, dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint warrants a 20 percent evaluation. Under DC 5259, symptomatic removal of semilunar cartilage warrants a 10 percent rating. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the knee to 60 degrees, a 10 percent rating will be assigned for limitation of flexion of the knee to 45 degrees, a 20 percent rating will be assigned for limitation of flexion of the knee to 30 degrees, and a 30 percent rating will be assigned for limitation of flexion of the knee to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for knee extension limited to 10 degrees, a 20 percent disability rating is assigned for extension limited to 15 degrees, a 30 percent disability rating is assigned for extension limited to 20 degrees, a 40 percent disability rating is assigned for extension limited to 30 degrees, and a 50 percent disability rating is assigned for extension limited to 45 degrees. Under DC 5262, impairment of the tibia and fibula warrants a 10 percent rating where there is malunion of the tibia and fibula with slight ankle or knee disability. A 20 percent rating is warranted where there is malunion of the tibia and fibula with moderate ankle or knee disability. A 30 percent rating is warranted where there is malunion of the tibia and fibula with marked ankle or knee disability. A maximum 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion, requiring brace. DC 5263 provides a 10 percent rating where there is evidence of acquired genu recurvatum or traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. The VA General Counsel held that a knee disability may receive separate ratings under diagnostic codes evaluating instability (DC 5257) and those evaluating range of motion (DCs 5003, 5010, 5256, 5260, and 5261). See VAOPGCPREC 23- 97. Additionally, the General Counsel held that separate ratings under Code 5260 (limitation of flexion of a knee) and Code 5261 (limitation of extension of a knee) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. For the thoracolumbar spine, normal range of motion on forward flexion is 0 to 90 degrees; backward extension, 0 to 30 degrees; lateral flexion and lateral rotation, 0 to 30 degrees. See 38 C.F.R. § 4.71a, Plate V. Back disabilities are rated under either the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome (IVDS) based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a. Disabilities of the spine (other than IVDS when evaluated on the basis of incapacitating episodes) are to be rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, DCS 5235-5243. These criteria are to be applied irrespective of whether there are symptoms such as pain (whether or not it radiates), stiffness, or aching in the affected area of the spine, and they “are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine.” 68 Fed. Reg. 51, 454 (Aug. 27, 2003). Any associated objective neurologic abnormalities including, but not limited to, bowel or bladder impairment, are to be rated separately from orthopedic manifestations under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1). The words “slight,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. Under the Formula for Rating IVDS, a 40 percent disability rating is assigned for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating is assigned for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. An incapacitating episode is defined as a period of symptoms due to IVDS that requires bedrest prescribed by a physician and treatment by a physician. Id. In order to warrant a higher rating under the Formula for Rating IVDS, there needs to be evidence of both IVDS and of incapacitating episodes due to symptoms of IVDS that requires bedrest prescribed by a physician. Under the General Rating Formula for Diseases and Injuries of the Spine, in relevant part, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; or, combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. A 40 percent rating is warranted if forward flexion of the thoracolumbar spine is 30 degrees or less; or, if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a maximum 100 percent disability rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Right Knee Disability The Veteran’s chronic right knee strain and arthritis is currently rated at 10 percent effective October 25, 2010 under DCs 5003-5260. During a January 2011 VA examination, the Veteran reported right knee pain for the last 20 years that was more severe with activities such as walking. He reported weakness, stiffness, tendency for locking, discomfort of the knee, and posture changes due to persistent back symptoms. He reported that he used a brace and a cane. Examination of the right knee revealed no redness, tenderness, definite hypertrophy or laxity of the medial or lateral collateral ligaments, effusion, or Drawer sign or McMurry’s test. The Veteran had mild soft tissue swelling. Flexion was to 100 degrees and extension to 0 degrees with painful motion. MRI findings showed lateral and medial meniscus tears. A May 2011 VA examination diagnosed degenerative arthritis of the right knee. On examination, no laxity was noted, but crepitus without swelling or effusion was noted. The Veteran had mild synovial hyperplasia of the right knee, indicative of degenerative arthritis. A November 2012 VA examination noted that the Veteran reported he was limited to walking three blocks due to pain, and denied any flare-ups of pain. On examination, flexion was limited to 90. degrees and extension was normal. Pain was elicited with range of motion testing and no additional functional loss was appreciated with repetitive testing. No tenderness of the knee on palpation or ligament instability were noted. An April 2016 VA examination showed flexion to 110 degrees with pain and extension to 0 degrees. No additional functional loss was appreciated with repetitive testing. Tenderness or pain on palpation was noted, but no instability or recurrent effusion was noted. A May 2018 VA examination showed flexion to 90 degrees with pain and extension to 0 degrees with pain. Upon repetition, there was no additional functional loss. The examiner estimated no additional functional loss with repeated use over time. There was no evidence of subluxation or instability, edema, warmth, or erythema. The examiner noted the Veteran’s history of right knee meniscal tear, resulting in frequent episodes of joint pain, to include right knee pain with standing, walking, and climbing stairs. The examiner also indicated a history of recurrent effusion. The examiner diagnosed right knee strain with meniscal tears and right knee degenerative joint disease (arthritis). The examiner opined that right knee arthritis was permanently aggravated beyond normal progression by service connected right knee strain. The examiner was unable to differentiate the symptoms related to right knee strain and right knee arthritis. In consideration of the medical and lay evidence, the Board finds that a rating in excess of 10 percent is not warranted under DCs 5003-5260. The evidence throughout the entire period on appeal shows flexion was, at worst, limited to 90 degrees with pain. Accordingly, only a 10 percent rating is warranted for painful limitation of motion. Moreover, the Veteran has had normal extension throughout the period on appeal; therefore, a separate rating based on limited extension is not warranted. After reviewing the medical evidence of record, the Board finds no ankylosis has been noted and thus a separate rating under DC 5256 is not warranted. The Board considered whether the Veteran was entitled to a separate rating under DC 5257, but stability tests were normal and diagnostic testing taken during the aforementioned VA examinations and did not reveal evidence of subluxation. Regarding entitlement to a separate rating under DC 5258, neither the medical nor lay evidence documents recurrent effusion nor locking. The Board acknowledges that the Veteran reported swelling in the May 2018 VA examination and the examiner found that he had a history of recurrent effusion; however, the evidence overwhelmingly shows a history of intermittent swelling. The Veteran had no edema, warmth, or erythema during the May 2018 VA examination. In addition, previous VA examiners did not note a history of recurrent effusion. While pain and tenderness have been related to the Veteran’s right knee disability, these symptoms are not sufficient to warrant a separate rating under DC 5258 and are contemplated by his 10 percent rating based on painful limitation of motion. Accordingly, the Board finds that a separate rating is not warranted under DC 5258. The Board finds that a separate rating is not warranted under DC 5259 because the Veteran has not undergone meniscal surgery or removal. Also, no instability or subluxation has been demonstrated and a separate rating under DC 5257 is not warranted. Further, there is no evidence of impairment of the tibia and fibula or acquired or traumatic genu recurvatum and thus, separate ratings under DC 5262 and 5263 are not warranted. The Board additionally considered whether the Veteran is entitled to a higher rating due to functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). In making this determination, the Board considered the Veteran’s testimony regarding his symptoms, VA examination reports, and VA treatment records. While the record shows knee pain, swelling, crepitus, and difficulty with prolonged exertional activities (e.g. standing and walking), the evidence does not show that his symptoms and flare-ups produce functional loss that is manifested by adequate evidence of disabling pathology for higher ratings. See 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 38. Indeed, the Veteran did not experience additional limitation of motion after repetitive use testing or during a flare up and his disability ratings are already based on the extent to which his symptoms reduce range of motion. In light of the Veteran’s reported symptoms and the medical evidence, the Board finds that the Veteran is not entitled to any higher ratings for his right knee disability. Low Back Strain The Veteran’s low back strain is currently rated at 10 percent disabled prior to May 25, 2018 and 20 percent disabled thereafter under DC 5237. Rating Higher than 10 percent prior to May 25, 2018 A November 2009 VA examination diagnosed the Veteran with lumbar strain while in the service as a result of his in-service APC accident and DJD of the lumbar spine, which was not related to the in-service injury. The examiner noted that the Veteran’s current back symptoms (i.e., loss of range of motion and increasing back pain) are due to DJD, and not caused by the lumbar strain. Flexion was to 85 degrees; extension, 10 degrees; right and left lateral flexion, 25 degrees; and rotation, 30 degrees. Combined range of motion is 215 degrees. Discomfort was noted with range of motion, but there was no additional limitation due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive movement. The Veteran denied flares and any impairment of bowel or bladder. Scoliosis was noted as congenital, as it had existed prior to the motor vehicle accident. There was no muscle spasm or guarding. Lower extremity strength, sensation, and reflexes were normal. A September 2010 VA examiner indicated that the Veteran’s chronic DJD/lumbar strain was unchanged since the last VA examination and that he concurred with the previous examiner’s opinion indicating that the Veteran’s current subjective complaints and objective findings of loss of motion were related to nonservice-connected degenerative changes. A November 2012 VA examination showed flexion to 60 degrees with pain; extension to 10 and extension with pain to 20; lateral flexion to 20; right and left lateral flexion to 20 degrees; and right and left lateral rotation to 15 degrees. Although there was pain on movement, there was no additional limitation in range of motion following repetitive movement. No tenderness or pain to palpation, guarding or muscle spasm, or muscle atrophy were noted. The examiner diagnosed DDD and osteoarthritis of the lumbar spine and found that the Veteran’s current symptoms were associated with his degenerative changes. An April 2016 VA examination, flexion to 75, extension to 10, right and left lateral flexion to 20, and right and left lateral rotation to 20. Pain was noted with range of motion, as well as tenderness. No additional loss of motion was noted after repetitive use. The Veteran had no guarding or muscle spasm, but had localized tenderness that did not result in abnormal gait or abnormal spinal contour. Reflexes, sensation, and muscle strength were normal. No neurologic deficits were noted. The examiner reported that the Veteran had a chronic lumbar strain in the service which continued after the service and remained stable. The Veteran’s complaints of constant back pain, exam findings of limitation in motion, limitations in ambulation and the use a cane are a result of the Veteran’s DJD/DDD. In this case, there is no medical evidence of record that documents any incapacitating episodes, at any point prior to May 25, 2018, and similarly, the Veteran has not been shown to have IVDS. Accordingly, as there is no evidence documenting any incapacitating episodes due to symptoms of IVDS, which required bedrest prescribed by a physician, the Board finds that a higher disability rating is not warranted at any point during the period on appeal under the Formula for Rating IVDS Based on Incapacitating Episodes. Even though a higher rating is not warranted under the Formula for Rating IVDS Based on Incapacitating Episodes, the Veteran must still be evaluated for a higher rating under the General Rating Formula for Diseases and Injuries of the Spine. Ultimately, the evidence of record does not approximate the criteria under DC 5237 for a rating higher than 10 percent disabling. There is no probative evidence that the Veteran’s low back strain has limited forward flexion in his thoracolumbar spine to 60 degrees or less or that it has limited the combined range of motion in this area of his spine to 120 degrees or less. Likewise, there is no evidence that muscle spasm or guarding has been so severe as to cause an abnormal gait or spinal contour. Moreover, even when considered in the light most favorable to the Veteran, the pain and limitation in the motion of his spine do not rise to the level of severity required for a rating of 20 percent or higher under DC 5237, as these symptoms are not attributed to his service-connected low back strain but to his nonservice-connected DJD/DDD. Pursuant to DeLuca, the Board has also considered whether weakness, pain, incoordination, or fatigability caused by repetitive use or flare-ups warrant a higher rating. However, there is no competent medical evidence appearing in the record to suggest that flare-ups or repetitive use of his lumbosacral spine would cause the degree of functional limitation that would warrant a rating of 20 percent or higher. In fact, the Veteran denied flare-ups and no additional limitation due to pain, fatigue, weakness, lack of endurance or incoordination following repetitive movement were noted on any examinations prior to May 25, 2018. Accordingly, the Board concludes that the Veteran’s low back strain has been no higher than 10 percent disabling prior to May 25, 2018. Rating Higher than 10 percent from May 25, 2018 A May 2018 VA examination showed limited range of motion with painful motion, as flexion was to 65; extension, 15; right lateral flexion, 25; left lateral flexion, 20; and, right and left lateral rotation, to 30. Flexion was estimated to decrease to 50 degrees with repeated use over time. The examiner stated that during a flare-up, there would be no additional loss of motion. There was no evidence of muscle spasm or guarding resulting in abnormal gait or abnormal spinal contour. The examiner was unable to delineate findings between the service-connected low back strain and the non-service connected degenerative changes; thus, all findings were considered part of the service-connected low back strain. After reviewing the competent medical evidence of record, the Board finds that a rating higher than 20 percent is not warranted under DC 5237 from May 25, 2018, because, there is no probative evidence of demonstrated forward flexion of the thoracolumbar spine to 30 degrees or less or any ankylosis. Pursuant to DeLuca, the Board has also considered whether weakness, pain, incoordination, or fatigability caused by repetitive use or flare-ups warrant a higher rating. However, there is no competent medical evidence appearing in the record to suggest that flare-ups or repetitive use of his lumbosacral spine would cause the degree of functional limitation that would warrant a rating of 40 percent or higher. In fact, flexion was only estimated to decrease to 50 degrees, which approximates a 20 percent rating under DC 5237. There is no additional loss of motion during a flare-up. Accordingly, the Board concludes that the Veteran’s low back strain has been no higher than 20 percent disabling from May 25, 2018.] TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and that, if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). If, however, the veteran does not meet these required percentage standards set forth in 38 C.F.R. § 4.16(a), he still may receive a TDIU on an extraschedular basis if it is determined that he is unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities. 38 C.F.R. § 4.16(b); See also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, there must be a determination as to whether there are circumstances in this case, apart from any non-service connected conditions and advancing age, which would justify a total rating based on unemployability. See Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). Being unable to maintain substantially gainful employment is not the same as being 100 percent disabled. “While the term ‘substantially gainful occupation’ may not set a clear numerical standard for determining a TDIU, it does indicate an amount less than 100 percent.” Roberson v. Principi, 251 F.3d 1378 (Fed Cir. 2001). Assignment of a TDIU evaluation requires that the record reflect some factor that “takes the claimant’s case outside the norm” of any other veteran rated at the same level. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Id. The Board is precluded from assigning an extraschedular rating in the first instance. See Bagwell, 9 Vet. App. 237, 238-9; Floyd, 9 Vet. App. 88, 96. Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer, 22 Vet. App. 242; see also Shipwash, 8 Vet. App. 218, 227. In this case, the Veteran is service connected for low back strain at 20 percent disabling and chronic right knee strain and arthritis at 10 percent disabling, for a combined evaluation of 30 percent disabling. 38 C.F.R. §§ 4.16(a), 4.25. Accordingly, the Veteran does not meet the schedular percentage requirements for eligibility for TDIU. Therefore, the Board must consider whether he has nevertheless demonstrated that he is unable to secure or follow a substantially gainful occupation as a result of his service connected disabilities. As, discussed below, the Board finds that referral for extraschedular consideration of a TDIU is not warranted. In February 2016, the RO notified the Veteran and requested that he complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability in support of his claim. As of date, VA has not received a completed VA Form 21-8940 from the Veteran. During the pendency of his appeal, the Veteran claimed unemployability due to his service connected disabilities. The Veteran reported to the November 2009 and September 2010 VA spine examiners that he worked in security until 2008 or July 2009, when he quit, as he was unable to walk and climb stairs due to his back and bilateral knee problems. The Veteran reported he could not do anything that required prolonged walking and standing, repetitive bending, or lifting more than 50 pounds because of his back condition. However, the November 2009 and September 2010 VA examiners reported that the Veteran did not have any functional limitations due to lumbar strain. A May 2011 VA examiner reported that the Veteran’s nonservice-connected DDD of the lumbar spine and degenerative arthritis of the right knee caused difficulty performing physical work, but would not prevent performing a sedentary-type work. A November 2012 VA examiner reported that the Veteran’s right knee disability limited his walking to three blocks at a time. His nonservice-connected DDD and osteoarthritis of the lumbar spine limited walking and standing. An April 2016 VA examiner reported that the Veteran’s chronic lumbar strain and DJD/DDD caused back pain that would limit lifting, walking, and standing. A May 2018 VA examination showed that the Veteran’s right knee disability was less likely to impact sedentary employment. This case has not been submitted for extra-schedular consideration because the evidence of record fails to suggest that the Veteran is unable to obtain or maintain substantially gainful employment due to service connected disabilities (38 C.F.R. 4.16). The evidence of record indicates that the Veteran’s right knee disability limits his ability to walk no more than three blocks at a time. The Veteran’s low back strain, at worst, would limit lifting, walking, and standing. All other limitations to the back are the result of nonservice-connected degenerative changes to the lumbar spine. Moreover, even when considering the functional limitations of the Veteran’s service-connected and nonservice-connected disabilities, he is able to perform sedentary work. The Board finds that the Veteran’s service connected disabilities do not render him unemployable. The Board acknowledges that the Veteran is competent to report symptoms of his service connected disabilities to include back pain. See Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, he is credible to report symptoms of their effects on his activities. However, he is not competent to identify a specific level of disability of his conditions according to the diagnostic code or to assess whether the symptoms preclude employment. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Such competent evidence concerning the nature and extent of the Veteran’s service-connected disabilities, and in particular his limitations from his service connected disabilities, has been provided by medical professionals who have examined him. While the Board does not wish to minimize the nature and extent of the Veteran’s overall disability, the evidence of record does not support his claim that his service-connected disabilities alone is sufficient to prevent him from obtaining or maintaining substantially gainful employment. The Board does not find that the Veteran’s service-connected disabilities would prevent him from obtaining or maintaining substantially gainful employment. Accordingly, TDIU on an extraschedular basis is not warranted. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Norwood, Associate Counsel