Citation Nr: 18148295 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 04-18 519 DATE: November 7, 2018 ORDER An increased disability rating in excess of 10 percent for limitation of motion associated with degenerative joint disease of the left knee is denied. An increased disability rating in excess of 10 percent for instability associated with degenerative joint disease of the left knee is denied. A separate, increased disability rating of 20 percent for a meniscal tear with frequent episodes of locking, pain and effusion into the left knee joint effective September 29, 2015 is granted. A total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s degenerative joint disease of the left knee was manifested by limitation of extension of no more than 10 degrees. Limitation of flexion has been no more than 90 degrees. 2. Throughout the appeal period, the Veteran’s left knee instability was assessed to be no more than slight. 3. The evidence of record establishes the Veteran’s meniscal tear of the left knee was manifested by frequent episodes of locking, pain and effusion into the left knee joint. 4. From January 1, 2013, while the evidence of record establishes the Veteran’s service-connected disabilities do not preclude sedentary employment, his work experience is limited to physically demanding positions in law enforcement, which had not equipped him with sufficient transferrable job skills to enable him to secure or follow a substantially gainful sedentary occupation. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating in excess of 10 percent for limitation of extension associated with degenerative joint disease of the left knee have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5261 (2017). 2. The criteria for an increased disability rating in excess of 10 percent for instability of the left knee associated with degenerative joint disease of the left knee have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.40, 4.45, 4.71a, DC 5271 (2017). 3. The criteria for a separate, increased disability rating of 20 percent for a meniscal tear with frequent episodes of locking, pain and effusion into the left knee have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.40, 4.45, 4.71a, DC 5258 (2017). 4. The criteria for entitlement to TDIU have been met effective January 1, 2013. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19, 4.25 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1981 to March 1988. Increased Rating 1. The issues of entitlement to an increased disability rating in excess of 10 percent for limitation of motion associated with degenerative joint disease of the left knee; and an increased disability rating in excess of 10 percent for instability of the left knee associated with degenerative joint disease of the left knee. The Veteran contends that he is entitled to an increased disability rating in excess of 10 percent for limitation of motion of the left knee and an increased disability rating in excess of 10 percent for instability of the left knee. See November 2010 Statement in Support of Claim; March 2015 Board Hearing Transcript. More specifically, during the March 2015 travel Board hearing, the Veteran testified that his knees were bone to bone. March 2015 Board Hearing Transcript at 4. He relayed that his knees locked up and gave out. Id. at 13. As a result, he had issues with his knees buckling when he goes to stand up and falling. Id. at 13, 9. However, he reported falling down only on one occasion. Id. at 13. He also reported experiencing popping in his knees. While extending his leg straight out was not an issue in terms of range of motion (ROM), bending his knees was difficult due to pain. Id. at 14. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. While the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, and lateral instability and recurrent subluxation of the knee. The Board will explore all possibilities in this case. Preliminarily, the Board addresses the issue of entitlement to an increased disability rating in excess of 10 percent for limitation of motion of the left knee. In this regard, the Board notes the applicable DCs are 5260 and 5261. DC 5260 rates based on limitation of flexion. When flexion of the leg is limited to 60 degrees, a noncompensable rating is warranted. When flexion is limited to 45 degrees, a 10 percent rating is warranted. Flexion limited to 30 degrees warrants a 20 percent rating, while flexion limited to 15 degrees warrants the maximum 30 percent rating. Under DC 5261, a non-compensable disability rating is warranted if extension is limited to five degrees. A 10 percent disability rating is warranted if extension is limited to 10 degrees. When limitation of extension is at 15 degrees, a 20 percent rating is warranted. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Lastly, extension limited to 45 degrees warrants the maximum, 50 percent rating. Further, when evaluating musculoskeletal disabilities such as knee disabilities, 38 C.F.R. § 4.40 recognizes the primary concern is the inability to perform the normal working movements of the body with normal excursion, strength, speed coordination, or endurance. Thus, when evaluating musculoskeletal disabilities on the basis of limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors that may not be reflected upon ROM testing during flare-ups or with repeated use over time. In that regard, VA must also consider factors such as: more or less movement than normal; weakened movement; excess fatigability; incoordination; and pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Instability of station, disturbance of locomotion, and interference with sitting, standing and weight-bearing are related considerations as well. 38 C.F.R. § 4.45. Nevertheless, even when such factors are present, a separate of higher disability rating is not appropriate based on those factors alone. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Rather, the disability rating assigned is based on the extent to which motion is limited as a result of these factors. As in this instance, where an increase in the rating assigned is at issue, the primary concern is the Veteran’s present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994); cf. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, if factually ascertainable, the effective date assigned may be up to one year prior to the date the application for increase was received. 38 U.S.C. § 5110 (2012). Here, the relevant timeframe for consideration is from December 18, 2008 to the present. December 2009 Statement in Support of Claim (the Veteran initiated informal claims for an increased disability rating for degenerative joint disease and instability of the left knee, which was received by the VA on December 18, 2009). A review of the Veteran’s VA treatment records reveals the pertinent medical evidence begins in 2009. Throughout 2009, he consistently complained of bilateral knee pain and intermittently complained of swelling in the knees bilaterally. See generally VA Preventive Medicine Notes from 2009; December 2009 VA Preventative Medicine Nursing Note. Although the VA treatment records during this period recorded his pain ratings fluctuated between zero to nine out of 10 on the pain scale, with 10 being the most severe, during these assessments his pain ratings were not limited to his left knee alone. Similarly, although he further described the general nature of his pain, exacerbating factors as well as its effects, he did not describe his left knee disability with any specificity. Consequently, these VA treatment records have little probative value in assessing the severity of his degenerative arthritis of the left knee other than confirming the presence of pain. Throughout the appeal period VA Preventive Medicine Notes, Preventative Medicine Nursing Notes, Pain Medicine Nursing Evaluation and Management Notes and VA Nurse Practitioner Notes continued to include similar complaints of pain in the knees generally, without further information pertaining to the left knee. In 2009, a VA Orthopedic Surgery Consult documented the Veteran’s continued complaint of swelling in the knees bilaterally. September 2009 VA Orthopedic Surgery Consult. At that time, he also reported experiencing some crunching and popping in knees when standing after sitting and climbing stairs. Upon examination, the VA treatment provider observed he ambulated with a normal gait without antalgia. However, the VA treatment provider noted femoral anteversion during extension in swing and early stance phases. The VA examiner determined there was retropatellar dysphoria with quad contraction in extension, which was accompanied by either reflex inhibition or voluntary cogwheeling. Even so, ROM testing showed he could achieve 90 degrees of flexion and 10 degrees of extension bilaterally with active ROM. With passive ROM, he demonstrated 110 degrees of flexion and 10 degrees of extension bilaterally. His stress testing was stable. Further, the VA treatment provider found evidence of genu valgum bilaterally, but the right knee was worse than the left. The VA treatment provider’s findings are silent as to any crunching or popping associated with his left knee. These findings were reiterated in an October 2009 VA Orthopedic Surgery Outpatient Note and thereafter in a January 2010 VA Orthopedic Surgery Consult. The next relevant evidence of record is an April 2010 VA Orthopedic Surgery Outpatient Note, which recorded the Veteran’s statement that he continued to experience some crunching and popping in knees when standing after sitting as well as climbing stairs. Following examination, the VA treatment provider again observed that he ambulated with a normal gait without antalgia. He continued to demonstrate femoral anteversion during extension in swing and early stance phases. During this examination, he could achieve 100 degrees of flexion and 10 degrees of extension bilaterally with active ROM. With passive ROM, he demonstrated 110 degrees of flexion and 10 degrees of extension bilaterally. His stress testing remained stable. This time, while the VA examiner noted there was no dysphoria, there was evidence of voluntary cogwheeling with quad contraction in extension. Further, contrary to his lay reports, the VA treatment provider expressly found no evidence of crepitation, grinding or popping. Subsequently, a June 2010 VA Orthopedic Surgery Outpatient Note largely reiterated these findings. A VA Joints examination was conducted in July 2010. As an initial matter, the Board acknowledges this examination was conducted prior to the decision in Correia v. McDonald. Correia v. McDonald, 28 Vet. App. 158 (2016). Although a review of the July 2010 Joints VA Examination Report suggests it did not fully comply with the all the Correia mandates, as the Regional Office based its grant of a 10 percent disability rating for degenerative joint disease of the left knee on the basis of limitation of extension and a separate disability rating for instability of the left knee on the July 2010 VA examiner’s findings, the Board must address it. At the time of the July 2010 examination, the Veteran averred that he continued to suffer from swelling, popping and pain in his left knee. July 2010 Joints VA Examination Report. While he used a brace to help with stability, it did not help relieve the pain. He avowed his daily living activities were affected because it was difficult to put his socks and shoes on. He denied experiencing any flare-up episodes. Although he reported missing 260 hours of work in the past two years due to his knees and other health issues, he did not indicate how much work was missed due to his left knee disability alone. Upon ROM testing, the Veteran was able to achieve flexion of 120 degrees and extension of 10 degrees. Although there was increased pain with repetitive use testing, there was no additional limitation of motion or function. In addition, the VA examiner found evidence of crepitus, which was greater at the lateral joint lines than the medial joint lines or the patellofemoral compartment. There was evidence of effusion with synovitis as well as mild lateral instability with varus stress. Further, the VA examiner noted the Veteran exhibited a limping gait. Based on the findings, the VA examiner determined that neither incoordination, fatigue, weakness or lack of endurance were contributing factors of his left knee disability. During an October 2010 VA Physical Therapy Consult, the Veteran relayed that he continued to suffer from constant pain in his knees bilaterally, which he rated at an eight out of 10. Nonetheless, he stated that he continued to go to the gym, lift weights, walk and bike. He continued to experience swelling, especially after exercising. He also continued to wear knee braces. After examination, the VA physical therapist observed he ambulated without acute distress. His active ROM was within normal limits with both flexion and extension. There was evidence of mild swelling bilaterally, which was greater in the right knee than the left. His muscle tone was good bilaterally. In a March 2011 VA Orthopedic Surgery Note, a VA treatment provider documented the Veteran’s report of bilateral knee pain. At that time, the VA treatment provider indicated ROM testing revealed flexion to approximately 150 degrees bilaterally and he “lacked a few degrees” of extension bilaterally, without recording specific measurements. The VA treatment provider confirmed he demonstrated some discomfort with ROM as well as evidence of crepitus bilaterally. A June 2011 T.H.H.M. Hospital Therapy Services Department Treatment Note documented the Veteran had decreased tolerance for squatting, stooping and climbing in the bilateral extremities. In particular, he had difficulty squatting 12 inches from the floor safely. There was evidence moderate tenderness to his bilateral knees. Even still, his bilateral lower extremities were found to be grossly within functional limits. He could sit for eight hours at a time and stand for two hours. His balance was within normal limits. He denied suffering from any falls in the past 12 months. He ambulated independently without assistive devices, despite a jerky gait. He demonstrated full weight-bearing bilaterally. Notably, no ROM measurements for the lower extremities were included. The T.H.H.M. Hospital occupational therapist noted he exhibited significant limitations because of his bilateral knee pain. In the end, the T.H.H.M. Hospital occupational therapist opined his functional abilities were consistent with his reported pain levels. Once again, the medical evidence of record in 2012 is limited. A December 2012 VA Physical Therapy Consult is the lone VA treatment record bearing on the relevant diagnostic criteria. The December 2012 VA treatment provider logged the Veteran’s report of bilateral knee pain, which he rated at an eight out of 10. However, he denied experiencing any pain in a non-weight bearing position. He reported popping, catching, locking, grating, giving way as well as stiffness. Following examination, the VA physical therapist noted he exhibited full weight-bearing and did not rely on any assistive devices. The VA physical therapist determined he was able to demonstrate flexion of 108 degrees with the left knee as well as extension of three degrees. Although there was reduced muscle strength in all respect, which was rated at a 4/5, there was no evidence of muscle atrophy. December 2012 VA Physical Therapy Consult; see also August 2015 Knee and Lower Leg Conditions VA Examination Report (noting that muscle strength was score from 0/5, indicating no muscle movement, to 5/5, indicating normal strength; 4/5 indicated active movement against some resistance). There was evidence of tenderness at the bilateral knee joints. December 2012 VA Physical Therapy Consult. Even though the VA physical therapist found no evidence of joint instability, the lateral meniscus test was positive indicating the presence of a tear. In a February 2014 VA Physical Medicine Rehab Consult, the treatment provider recorded the Veteran’s report of increased difficulty with ambulation due to pain. Even so, he admitted he could climb 15 steps at home with the assistance of a rail. He relayed falling down in March 2013 after his knees gave way, but he did not disclose any subsequent falls. Upon examination, the VA physical therapist concluded he had full ROM for ambulation with a single point cane, but specific ROM measurements for flexion and extension were not included. Further, while the VA physical therapist observed his gait was slow, it was steady and his balance was good. In 2015, the Veteran underwent two VA examinations; first in August 2015, then in September 2015. August 2015 Knee and Lower Leg Conditions VA Examination Report; September 2015 Knee and Lower Leg Conditions VA Examination Report. During the August 2015 examination, the Veteran relayed experiencing bilateral knee pain with recurrent effusion in the right only. He stated the pain increased with prolonged standing, sitting, walking, squatting and kneeling. However, he did not describe any limitation of motion or function attendant with the increased pain. Of note, he denied experiencing any flare-up episodes. He reported that he stopped working in 2012 due to multiple orthopedic issues, not just limited to his left knee disability. Following ROM testing, the VA examiner documented flexion of 120 degrees and extension of zero degrees. There was pain noted with both motions. The VA examiner determined that limitation of motion contributed to functional loss, specifically it prevented squatting. There was no additional limitation of motion or function after repetitive use testing. Aside from ROM, the VA examiner found evidence of generalized tenderness and crepitus. However, the Veteran’s muscle strength was normal, without any evidence of muscle atrophy. There was no evidence of ankylosis. There was also no history of recurrent left knee effusion. The VA examiner found there was a history of slight left knee lateral instability and joint stability testing at the time of examination was positive for lateral instability of the left knee, which was scored at 1+ on a scale ranging from normal to 3+. Further, the VA examiner observed that he required the constant use of a brace and cane due to the pain in his knees. No other pertinent physical findings, complications, conditions, signs or symptoms were noted. Based on the foregoing, the VA examiner concluded the only additional contributing factor was decreased movement due to pain and adhesions. In the end, the VA examiner opined the findings were neither medically consistent with or inconsistent with the Veteran’s lay statements describing function loss with repeated use over time. Given the examination was not conducted immediately following repeated use over time, the VA examiner stated it would constitute mere speculation to express additional limitation of motion due to pain, weakness, fatigability or incoordination in terms of degrees of ROM. In terms of functional impact on the Veteran’s ability to work, the VA examiner determined that while he would be unable to engage in prolonged standing and walking, he would be able to engage in sedentary employment. The Board finds the VA examiner’s opinion is adequate for rating purposes. Although the Veteran asserted he experienced increased pain with prolonged standing, sitting, walking, squatting and kneeling, he did not detail any limitation of motion or function attendant with the increased pain. The examination itself revealed no additional limitation of motion or function following repetitive use testing. Further, the VA treatment records addressing exacerbation of the left knee do not provide information related to any resulting limitation of motion or function or do not distinguish between the severity of his left knee disability from his other physical ailments. Thus, the Board finds there was no other procurable and assembled data for the VA examination’s consideration. Just one month later, the Veteran was examined by the VA again. September 2015 Knee and Lower Leg Conditions VA Examination Report. At that time, in addition to pain, he averred that he experienced locking, popping, clicking, fatigue, stiffness, cramping, grinding and swelling. He asserted that he was unable to walk or stand for prolonged periods of time. He reported suffering flare-up episodes, which consisted of pain and swelling. However, he did not describe any limitation of motion or function attendant with the increased pain and swelling. ROM testing revealed the Veteran could achieved flexion of 100 degrees and extension of zero degrees. Pain was noted with both motions as well as with weight-bearing. The VA examiner concluded his limitation of motion contributed to functional loss in that he was unable to stand for prolonged periods or squat. There was no additional limitation of motion or function following repetitive use testing. Other than ROM, the VA examiner found evidence of moderate to severe tenderness or pain on palpation of the patella and crepitus. His muscle strength was reduced, scoring 4/5, indicating active movement against some resistance, in all respects. Even so, there was no evidence of muscle atrophy. There was no evidence of ankylosis. This VA examiner also confirmed there was a history of slight left lateral instability. Again, upon joint stability testing, he was positive for left lateral instability. The VA examiner also determined the meniscal tear of the left knee was now manifested by frequent episodes of joint locking, constant joint pain and joint effusion requiring drainage. The VA examiner observed he required the constant use of a brace as well as regular use of a pillow and transcutaneous electrical nerve stimulation unit. As a result of repairs of the left meniscal tear and debridement in 1994 and 2008, the VA examiner noted three porthole scars on the left knee. None of the scars were unstable or painful. Further, they did not cover a total area equal to or greater than 39 square centimeters. Based on the above, the VA examiner found other contributing factors of the left knee disability were weakened movement, instability of station, disturbance of locomotion and interference with standing. In the end, the VA examiner opined the findings were medically consistent with the Veteran’s lay statements describing functional loss during flare-up episodes and with repetitive use over time. Although the VA examiner determined that pain, fatigue, weakness, lack of endurance and incoordination significantly limited functional ability during a flare-up and with repeated use over time, they were unable to describe it terms of ROM without resorting to mere speculation because pain thresholds are too variable. In terms of functional impact on the Veteran’s ability to work, the VA examiner determined that while he would be unable to stand, squat, walk, run or climb stairs. The Board finds this VA examiner’s opinion is also adequate for rating purposes. Although the Veteran asserted that he was unable to walk or stand for prolonged periods of time and that his flare-ups consisted of pain and swelling, he did not describe the duration of time he could walk or stand, any limitation of motion or function attendant with the increased pain and swelling, or the frequency thereof. Again, the VA treatment records addressing exacerbation of the left knee do not provide information related to any resulting limitation of motion or function or do not distinguish between the severity of his left knee disability from his other physical ailments. Therefore, the Board finds there was no other procurable and assembled data for the VA examination’s consideration. As another matter, the Board acknowledges both the August 2015 and September 2015 Knee and Lower Leg Conditions VA Examination Reports were produced prior to the decision in Correia. See Correia, supra. However, a review of both examinations as delineated above establishes they are adequate for rating purposes. In contemplating the above, the Board finds the preponderance of the evidence does not warrant an increased disability rating in excess of 10 percent at any time during the appeal period for degenerative joint disease of the left knee, rated on the basis of limitation of extension. Although until the July 2010 VA examination, the Veteran demonstrated limitation of extension of 10 degrees, which met the diagnostic criteria for a 10 percent disability rating, following the July 2010 examination, his limitation of extension improved. In October 2010, a VA treatment provider found he exhibited full extension. A March 2011 VA treatment provider indicated he only lacked a few degrees of extension. In December 2012, another VA treatment provider noted he demonstrated extension of three degrees. Thereafter, in August and September 2015, he demonstrated full extension. Notwithstanding the improvement, the Board declines to reduce the present disability rating assigned as 38 C.F.R. § 4.59 allows for the assignment of at least a minimum compensable disability rating for a joint due to painful motion, when limitation of motion itself is non-compensable. 38 C.F.R. § 4.40, 4.59, 4.71a, DC 5003 (2017). The Board’s inquiry does not end here. The Board must also consider increased evaluations under other potentially applicable DCs. Other DCs pertaining to the knee are DC 5256 for ankylosis; DC 5257 for impairment of the knee due to subluxation or lateral instability; DC 5258 for dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; DC 5259 for removal of the semilunar cartilage with residuals; DC 5260 for limitation of flexion; DC 5262 for impairment of the tibia and fibula; and DC 5263 for genu recurvatum. At this juncture, the Board addresses the issue of an increased disability rating in excess of 10 percent for instability of the left knee. In contemplating the above, the Board finds the preponderance of the evidence does not warrant an increased disability rating in excess of 10 percent at any time during the appeal period for instability of the left knee. Cf. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; cf. also Fagan, supra; Hart, supra. Under DC 5257, a 10 percent disability rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent disability rating is warranted for severe recurrent subluxation or lateral instability. The words “slight,” “moderate,” and “severe” are not defined in the VA’s Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. Part 4, § 4.71a, DC 5257 (2017). As such, rather than applying a mechanical formula, the Board must evaluate all of the evidence for an “equitable and just decision.” 38 C.F.R. § 4.6. The evidence of records reveals that during the appeal period the Veteran relied on the constant use of knee braces for instability and pain. However, this information alone is insufficient to determine the severity of his left knee instability. Although in February 2014, he reported falling once in March 2013 after his knees gave way, he did not provide any further details to assess the severity of the instability associated with his left knee alone. Moreover, the evidence of record reveals only one fall. Significantly, each time his left knee instability was assessed, it was found to be slight, scoring at worst 1+ upon examination. With respect to DC 5256, there is no evidence of ankylosis. As such, a separate increased disability under DC 5256 is impermissible. With respect to DC 5258 for dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, although there is evidence of frequent episodes of locking, joint pain, and joint effusion, these symptoms were associated with a meniscal tear rather than a meniscal dislocation. Nevertheless, the Board notes no other DC considers the symptoms of frequent episodes of locking, joint pain, and joint effusion. Accordingly, the Board finds the evidence (specifically the September 2015 VA knee and lower leg conditions examination) supports a separate, increased disability rating of 20 percent under DC 5258 for the meniscal tear with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. A separate, increased disability rating under DC 5259 for removal of the semilunar cartilage with residuals is inapplicable because the Veteran has not undergone a meniscotomy of the left knee. Under DC 5260, a non-compensable disability rating is warranted if flexion is limited to 60 degrees. A 10 percent disability rating is warranted if flexion is limited to 45 degrees. In this instance, while there is evidence of limitation of flexion of record, at worst, the Veteran exhibited limitation of flexion of 90 degrees, which is 45 degrees more than the minimum limitation of flexion required for a compensable disability rating under DC 5260. Consequently, a separate, increased disability rating under DC 5260 may not be assigned. With respect to DC 5262, there is no evidence of any impairment of the tibia and fibula. For this reason, DC 5262 is impermissible. With respect to DC 5263, there is no evidence of genu recurvatum. Thus, DC 5263 is also impermissible. The only other symptom raised by the record are the scars of the left knee following the Veteran’s repairs of the meniscal tear and debridement in 1994 and 2008. As noted above, the September 2015 VA examiner found there were three porthole scars on the left knee. However, none of the scars were unstable or painful. Further, they did not cover a total area equal to or greater than 39 square centimeters (six square inches). The DCs pertaining to scars are DC 7800, 7801, 7802, 7804, and 7805. 38 C.F.R. § 4.118. DC 7800 applies to burn scars, other scars, or disfigurement of the head, face, or neck. As the scar is not located on the head, face, or neck, DC 7800 is not applicable. DC 7801 applies to deep, non-linear burn scars, other scars, or disfigurement not of the head, face, or neck. However, in order for the minimum compensable disability rating of 10 percent to be assigned, the scar must cover an area(s) of at least six square inches. As the September 2014 determined the scars covered a total area less than six square inches, DC 7801 is also not applicable. DC 7802 applies to burns or scars due to other causes not of the head, face, or neck, that are superficial and non-linear. However, in order for the minimum compensable disability rating of 10 percent to be assigned, the scar must at least cover an area of 144 square inches. Once more, as the September 2014 determined the scars covered a total area less than six square inches, DC 7802 is inapplicable. DC 7804 applies to unstable or painful scars. Given there is no evidence of record demonstrating the scar is unstable or painful, DC 7804 is also inapplicable. DC 7805 applies to other scars, including linear scars, and the effects of scars evaluated under DC 7800, 7801, 7802, and 7804 not considered in the diagnostic criteria. Under DC 7805, the scar is evaluated under the diagnostic criteria associated with the disabling effect. Here, the evidence of record discloses no other disabling effects stemming from the scar. Consequently, a separate, increased disability rating under DC 7805 is impermissible. 2. The issue of entitlement to TDIU. The Veteran contends that he has been unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. July 2010 Veteran’s Application for Increased Compensation Based on Unemployability. The Board notes the Veteran expressly raised the issue of entitlement to TDIU in a July 2010 Veteran’s Application for Increased Compensation Based on Employability during the pendency of this appeal. As such, the issue of TDIU became a part and parcel of the increased disability rating claims herein. See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Ordinarily, the relevant timeframe for consideration is from December 18, 2008 to the present. See December 2009 Statement in Support of Claim. However, the evidence of record establishes he was employed until December 31, 2012. See May 2014 Social Security Administration (SSA) Disability Determination and Transmittal; May 2014 SSA Work History Report; August 2015 Knee and Lower Leg Conditions VA Examination Report (the Veteran reported that he stopped working in 2012); November 29, 2012 VA Orthopedic Surgery Outpatient Note (noted the Veteran’s Report that he was still working in law enforcement, but would be retiring due to problems with his hands and knees). During the pertinent time period, in addition to the above, the Veteran has been service-connected for stomach ulcers, with a 30 percent disability rating effective February 8, 2008; instability of the right knee, with a 10 percent disability rating effective February 25, 1991; degenerative joint disease of the right knee, with a 10 percent disability rating effective January 1, 2005; torn semilunar cartilage with frequent locking and effusion of the right knee associated with degenerative joint disease of the right knee, with a 20 percent disability rating effective February 28, 2002; the residuals of a right ankle sprain with degenerative joint disease, with a 20 percent disability rating effective February 28, 2002; residuals of a left ankle injury, with a 20 percent disability rating effective August 29, 2006; and an ingrown toenail of the right foot, with a non-compensable disability rating effective August 29, 2006. See October 2016 Rating Decision Codesheet. Consequently, throughout out the relevant time period he met the minimum disability rating percentage threshold for schedular TDIU consideration. 38 C.F.R. § 4.16(a). A review of the claims file shows the Veteran is presently unemployed. However, the sole fact that he is unemployed or has difficulty obtaining employment is insufficient for TDIU purposes. The evidence must show that he is incapable of performing the physical and/or mental acts required by employment by reason of his service-connected disabilities. 38 C.F.R. § 4.16(b); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this context, other appropriate factors for consideration are his employment history, educational and vocational attainment, and any other factors having a bearing on the issue. 38 C.F.R. § 4.16(b); see also Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). Based on the medical evidence detailed above, the evidence of record establishes the Veteran’s service-connected right and left knee disabilities would preclude physical employment. Thus, the Board must determine whether his employment history, educational and vocational attainment, and any other relevant factors would prevent him from securing or following a substantially gainful sedentary occupation. 38 C.F.R. § 4.16(b); see also Ferraro, supra. In terms of educational and vocational attainment, the Board notes the Veteran has a Bachelor’s degree in criminal justice. July 2010 Veteran’s Application for Increased Compensation Based on Unemployability; 2011 T.H.H.M. Hospital Therapy Service Department Treatment Note. Although his educational attainment suggests a capacity to engage in sedentary employment, in application, his entire employment history post-separation has been in law enforcement in physically demanding positions, such as a corrections/detention officer, police officer or a security officer. May 2014 SSA Work History Report. There is no evidence of record suggesting he has acquired jobs skills that would be transferrable to a substantially gainful sedentary position. Based on the above, the Board finds the preponderance of the evidence supports entitlement to TDIU given the Veteran’s physical limitations and lack of jobs skills that would be transferrable to a substantially gainful sedentary occupation. 38 C.F.R. § 4.16(a). BETHANY L. BUCK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Suh, Associate Counsel