Citation Nr: 18148331 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 10-40 329 DATE: November 7, 2018 ORDER Entitlement to an initial increased evaluation for residuals of right wrist volar ganglion, rated as noncompensably disabling prior to September 7, 2017, and 10 percent disabling thereafter, is denied. Entitlement to an initial increased evaluation in excess of 10 percent for residuals of left lateral meniscectomy with osteoarthritis for the period from April 1, 2008, to December 1, 2008, and February 1, 2009, to January 22, 2014, is denied. Entitlement to an initial increased evaluation for residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty (previously rated as residuals of left lateral meniscectomy with osteoarthritis), rated 30 percent disabling from March 1, 2015 to September 6, 2017, and 60 percent disabling thereafter, is denied. Entitlement to a total disability based on individual unemployability beginning October 29, 2015, is granted. REMANDED Entitlement to a total disability based on individual unemployability prior to October 29, 2015, is remanded. FINDINGS OF FACT 1. For the period prior to September 7, 2017, the Veteran’s residuals of right wrist volar ganglion manifested pain and limitation of motion to 70 degrees without ankylosis. 2. For the period beginning September 7, 2017, the Veteran’s residuals of right wrist volar ganglion manifested pain and limitation of motion to 20 degrees without ankylosis. 3. For the period from April 1, 2008, to December 1, 2008, and February 1, 2009, to January 22, 2014, residuals of left lateral meniscectomy with osteoarthritis manifested limitation of flexion to 90 degrees. 4. For the period from March 1, 2015 to September 6, 2017, the Veteran’s residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty (previously rated as residuals of left lateral meniscectomy with osteoarthritis) has been manifested by no more than intermediate degrees of residual weakness, pain, or limitation of motion. 5. For the period beginning September 7, 2017, the residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty (previously rated as residuals of left lateral meniscectomy with osteoarthritis), manifest chronic residuals consisting of severe painful motion or weakness. 6. For the period beginning October 29, 2015, the Veteran’s service-connected disabilities preclude him from performing gainful employment for which his education and occupational experience otherwise qualify him. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial increased evaluation for residuals of right wrist volar ganglion, rated as noncompensably disabling prior to September 7, 2017, and 10 percent disabling thereafter, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5214, 5215. 2. The criteria for entitlement to an initial increased evaluation in excess of 10 percent for residuals of left lateral meniscectomy with osteoarthritis for the period from April 1, 2008, to December 1, 2008, and February 1, 2009, to January 22, 2014, are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5260. 3. The criteria for entitlement to an initial increased evaluation of 30 percent from March 1, 2015 to September 6, 2017, for residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty (previously rated as residuals of left lateral meniscectomy with osteoarthritis), have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 4. The criteria for entitlement to an initial increased evaluation of 60 percent from September 7, 2017, for residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty (previously rated as residuals of left lateral meniscectomy with osteoarthritis), have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 5. The criteria for an award of a total disability evaluation based on individual unemployability (TDIU) are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1966 to June 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision. The Veteran testified at a June 2013 Travel Board hearing; a transcript of the hearing is associated with the record. These matters were previously before the Board in April 2014 and August 2017. Increased Rating Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code (DC), the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran’s entire history is reviewed when making disability ratings. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already 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). In cases where, as here, the question for consideration is the propriety of the initial disability rating assigned, however, an evaluation of the medical evidence since the grant of service connection and a consideration of the appropriateness of a “staged rating” is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). A staged rating compensates the veteran for variations in the disability’s severity since the effective date of his award. When weighing evidence, lay statements that describe the features or symptoms of an injury or illness are considered competent evidence. Falzone v. Brown, 8 Vet. App. 398 (1995). A lay person is also competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Once evidence is determined competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”)). 1. Entitlement to an initial increased evaluation for residuals of right wrist volar ganglion, rated as noncompensably disabling prior to September 7, 2017, and 10 percent disabling thereafter A September 2008 rating decision granted service connection for residuals of a volar ganglion of the right wrist. A noncompensable evaluation was assigned effective April 1, 2008. The Veteran filed another claim for the right wrist with additional evidence in March 2009, and a July 2009 rating decision continued the noncompensable rating. The Veteran filed a November 2009 notice of disagreement (NOD). In an April 2018 rating decision, a 10 percent evaluation for residuals of a volar ganglion cyst of the right wrist was granted, effective September 7, 2017. The Veteran contends that a higher rating is warranted. First, the Board will consider the period prior to September 7, 2017. After reviewing the evidence, the Board finds that a compensable evaluation is not warranted for this period. The Veteran’s residuals of a volar ganglion cyst of the right wrist are rated under DC 5212 for limitation of wrist motion. This DC provides for maximum 10 percent ratings for limited palmar flexion (palmar flexion limited in line with forearm) and limited dorsiflexion (dorsiflexion less than 15 degrees). 38 C.F.R. § 4.71a, DC 5215. A June 2008 private medical note reported that the Veteran had “problems” with his wrist when he “lift[ed] things with his right hand” or “put [his] wrist in certain positions.” Another June 2008 private medical note recorded “moderate” symptoms of “pain with grasping, pain with twisting, pain with range of motion, tingling with activity, tenderness.” The first measurements of the effect on range of motion were in September 2008. A September 2008 private medical note reported no limitation of range of motion of the right wrist. A September 2008 VA examination noted both dorsiflexion and volar (palmar) flexion from zero to 70 degrees. No pain, fatigue, weakness, or incoordination were found. In contrast, a November 2008 private medical note recorded that the Veteran’s wrist pain had worsened and “now the entire wrist hurts all around, having trouble with any ROM [range of motion].” At a July 2009 VA examination, the Veteran reported pain and weakness of the right wrist but not instability, stiffness, giving way, incoordination, dislocation, or subluxation. The Veteran’s right wrist range of motion at the July 2009 VA examination was zero to 70 degrees dorsiflexion and zero to 80 degrees palmar flexion. The July 2009 VA examination also indicated that the Veteran used a brace on his right wrist; this was confirmed in the Veteran’s November 2009 NOD. In the November 2009 NOD, the Veteran reported that his wrist “ache[d] all the time” and he could not “lift over 10 pounds with it.” At the June 2013 hearing, the Veteran testified that he could only pick up eight to 10 pounds with his right wrist. He also reported “pain, popping” and giving way of the wrist in addition to loss of motion. He testified that he is right-handed and had to compensate for his right wrist with his left wrist. At a December 2014 VA examination, the Veteran did not report flare-ups of the right wrist and no pain was noted on examination. The Veteran’s right wrist dorsiflexion was zero to 70 degrees and palmar flexion was zero to 80 degrees. No additional loss of function or range of motion was noted after repetitions and the “Veteran was observed to use RUE [right upper extremity] for taking off shoes, socks, unzipping lower part of gym trousers, all activities performed without observable difficulty or pain.” Considering this evidence as a whole, the Board finds the Veteran’s residuals of right wrist volar ganglion most closely approximate a noncompensable rating for the period prior to September 7, 2017. Although the November 2008 private medical note found “trouble” with any range of motion, this was not expressed in terms of range of motion lost, and the remaining evidence shows that the Veteran maintained dorsiflexion and plantar flexion at worst to 70 degrees. This rules out a higher rating under DC 5214 (ankylosis of wrist). Similarly, a higher rating is not available for degenerative arthritis. Although the VA medical center (VAMC) records (such as a July 2013 VAMC record) reference wrist pain “felt to be due to arthritis,” and the December 2014 VA examination indicated that the Veteran had arthritis of the right wrist, there are no x-ray findings showing this. The only x-ray report associated with the record, dated September 2017, did not find arthritis, and a September 2017 VA examination found there was no arthritis. Under DC 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved and a 10 percent rating is applicable where the limitation of motion is noncompensable under the appropriate diagnostic code for each major joint or group of minor joints affected. 38 C.F.R. § 4.71a. In this case, however, this 10 percent rating is not appropriate because there is no x-ray evidence establishing arthritis. Accordingly, a noncompensable evaluation is the appropriate rating for the Veteran’s right wrist disability for the period prior to September 7, 2017. For the period beginning September 7, 2017, a 10 percent evaluation is appropriate. The September 2017 VA examination noted flare-ups in which the Veteran “reports difficulty with mobility due to pain. He states he usually does not lift more than 10 [pounds] around the house.” At the September 2017 VA examination, the Veteran’s dorsiflexion and palmar flexion both ranged from zero to 20 degrees, with no pain noted on examination and no additional loss with repetition. Again, the Veteran had range of motion and therefore a higher rating under DC 5214 for ankylosis is not appropriate. The September 2017 VA examination and x-ray found no arthritis of the wrist. Thus, a 10 percent evaluation is warranted for the period beginning September 7, 2017. 2. Entitlement to an initial increased evaluation in excess of 10 percent for residuals of left lateral meniscectomy with osteoarthritis for the period from April 1, 2008, to December 1, 2008, and February 1, 2009, to January 22, 2014 In the September 2008 rating decision, a 10 percent evaluation was assigned effective April 1, 2008, for residuals of left lateral meniscectomy with osteoarthritis. This was increased to 100 percent from December 2, 2008, to January 31, 2009; beginning February 1, 2009, the evaluation was returned to 10 percent. On January 22, 2014, the Veteran underwent a total knee replacement surgery. The temporary period of 100 percent is not at issue because the Veteran was receiving the maximum evaluation for that period. Thus, the Board will consider the Veteran’s contention for a higher rating for the period from April 1, 2008, to December 1, 2008, and February 1, 2009, to January 22, 2014. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Limitation of flexion of a leg warrants a 10 percent evaluation if flexion is limited to 45 degrees; a 20 percent evaluation is assigned if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees is evaluated as 30 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Veteran is in receipt of a 10 percent evaluation for limitation of flexion for the period from April 1, 2008, to December 1, 2008, and February 1, 2009, to January 22, 2014. At an August 2008 private medical appointment, the Veteran stated that he “had some instability episodes which have actually made him fall over the last two to three months” but physical examination found “Negative anterior drawer, Lachman’s, varus and valgus stress test.” Range of motion at the September 2008 VA examination was flexion from zero to 115 degrees, with “mild” pain beginning at 110 degrees. There was no change with repetition and no fatigue, weakness, or incoordination found. The Veteran reported pain “present all the time,” pain at night, and pain when he stood more than four to six minutes at a time; he also reported he could “walk four blocks.” The VA examination conducted Lachman’s, anterior drawer, and posterior drawer tests and found negative results for each. At the July 2009 VA examination, the Veteran’s flexion results were zero to 115 degrees, where pain began. The examination noted the Veteran’s use of a cane. The Veteran reported instability, pain, weakness, incoordination, and locking episodes “[d]aily or more often” with “[r]epeated” effusions; the Veteran denied deformity, giving way, stiffness, and episodes of dislocation or subluxation. The July 2009 VA examination found no instability and no meniscus abnormality. The Veteran reported in a November 2009 statement that the bones in his knee “scrub[], lock[] and pop[]” on use and “constantly hurt and ache[].” The Veteran stated in a November 2009 NOD that he used a knee brace and cane. At a January 2011 VA examination, the Veteran’s flexion results were zero to 90 degrees, where pain began. The Veteran reported no giving way, no instability, no stiffness, no weakness, no incoordination and no episodes of dislocation or subluxation. The Veteran did note pain (“9/10 pain level”), pops and clicks, and locking episodes “at least 12 [times] a day.” The Veteran reported standing limitations of “[about] 7 minutes” and functional limitations on walking as “[about] 40 feet”; the Veteran reported use of a cane and a brace “always.” The January 2011 VA examination found clicks, snaps, and grinding as well as abnormal patellar tracking but did not find crepitation or instability. In a May 2011 statement, the Veteran apparently disputed the findings of the January 2011 VA examination, reporting that the VA examination did not use any instruments to measure range of motion. The Veteran also declared that the VA examination was incorrect in stating that he denied having deformity, giving way, instability, stiffness, incoordination, decreased speed of joint motion, dislocation, or subluxation. The Veteran instead reported that he had “[a]ll of the above.” A November 2012 VAMC record noted that the Veteran reported continued pain in his knee, aggravated by weightbearing activity; the Veteran estimated that he could walk “60 [to] 70 yards without having to stop.” The Veteran also noted “increased swelling in the knee which has diminished over the last few days.” In a January 2013 VAMC record, the Veteran reported left knee pain, swelling, instability, locking, popping, “lateral pain dull achy, worse [when] walking.” In June 2013 the Veteran testified at a Board hearing that he had lost motion in his knee and could not “make long steps like I was able to do a few years ago.” In a June 2013 VAMC record, the Veteran noted left knee pain and intermittent swelling and giving way. At a July 2013 VAMC appointment, the Veteran reported similar symptoms, including “severe” pain, constant pain worse with prolonged weightbearing, and “some popping and giving way of the left knee.” The VAMC provider found that Lachman’s, anterior drawer, and poster drawer tests were all negative. A January 2014 VAMC provider also found negative Lachman’s, anterior drawer, and posterior drawer tests. Considering the results of the Veteran’s range of motion tests throughout this period, the Board finds a rating higher than 10 percent is not warranted for limitation of flexion. At worst the Veteran’s flexion ranged from zero to 90 degrees in January 2011. The Board notes the Veteran’s contention that the VA examiner at that time did not use an instrument to measure his range of motion. Treating this claim as true, the Board still finds that an estimated 90 degree flexion is sufficiently far from flexion limited to 30 degrees, which would be required for a 20 percent rating, that the results can be believed to a degree of certainty to be greater than 30 degrees. Thus a 20 percent rating is not warranted during this period for flexion of the left knee. The Board has considered whether there is any other schedular basis for granting a higher or separate rating. The Board has found no basis for granting a higher or separate rating. The Veteran has not demonstrated knee ankylosis or impairment of the tibia and fibula, so DCs 5256 and 5262 are not for application. The VA examinations also showed normal extension of the left leg, which excludes a separate rating for limitation of extension. The Board notes that the Veteran has repeatedly reported giving way and instability of the left knee, such as at the August 2008 private medical appointment, the July 2009 VA examination, and the June 2013 Board hearing. The August 2008 private medical appointment tested for instability and physical examination found negative anterior drawer, Lachman’s, varus, and valgus stress tests. Similar results — lack of instability — were found on testing in the September 2008 VA examination, July 2009 VA examination, January 2011 VA examination, July 2013 VAMC record, and January 2014 VAMC record. Although the Veteran is competent to report symptoms such as his knee giving way and being unstable, and the Board finds him credible, the Board gives greater weight to the medical evidence that performed multiple tests over the entire period at issue to determine no instability was present. Finally, a higher rating under DC 5258 is not warranted because the record does not demonstrate dislocated cartilage with frequent episodes of locking, pain, and effusion or symptomatic removal of cartilage. The Board notes that the Veteran consistently reported pain, at times noted locking of his knee, and sometimes had effusions of the knee, but there is no indication that these occurrences were related to dislocated semilunar cartilage. In sum, a rating in excess of 10 percent for the Veteran’s residuals of left lateral meniscectomy with osteoarthritis is not warranted for the period from April 1, 2008, to December 1, 2008, and February 1, 2009, to January 22, 2014. 3. Entitlement to an initial increased evaluation for residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty (previously rated as residuals of left lateral meniscectomy with osteoarthritis), rated as 30 percent disabling from March 1, 2015, to September 6, 2017, and 60 percent disabling thereafter The Veteran underwent left total knee arthroplasty on January 22, 2014. A 100 percent rating was assigned for this condition from January 22, 2014, to February 28, 2015. A 30 percent rating was then granted effective March 1, 2015. Finally, in an April 2018 rating decision, the rating for residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty, was increased to 60 percent effective September 7, 2017. The Veteran’s residuals of left lateral meniscectomy with osteoarthritis, status post left total knee arthroplasty, are currently rated under 38 C.F.R. § 4.71a, DC 5055. This DC provides for a 30 percent minimum rating. A 60 percent rating is warranted for a total knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. A higher 100 percent rating is only assigned for one year following the implantation of a knee prosthesis. Intermediate degrees of residual weakness, pain, or limitation of motion (i.e., a level of disability in between those contemplated by the 30 and 60 percent ratings) are rated by analogy to DCs 5256, 5261, or 5262. Id. The rating schedule does not define the terms “intermediate” or “severe” as they used in DC 5055. Instead, adjudicators must evaluate all of the evidence and render a decision that is equitable and just. 38 C.F.R. § 4.6. Clinicians’ use of terminology such as severe, although an element that the Board will consider, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. A December 2014 VA examination noted flexion from zero to 115 degrees, with no limit to extension; no pain was noted on examination and there was no additional range of motion lost after repetitions. The Veteran reported at the December 2014 VA examination that he had limited motion and constant pain in the left knee. He stated he could not “stand too long” or “go more than 30 or 35 feet before I get pain in my left knee.” The December 2014 VA examination also noted that the Veteran used a brace and cane with “regular” frequency. A March 2015 VAMC record noted the Veteran’s report that his knee joint would give way but stated that it was “avoided mostly” by use of the Veteran’s brace. In April 2016 VAMC record the Veteran stated he had “persistent pain, weakness in left [knee],” and that his knee “occasionally” gives way. An October 2016 VAMC record noted reports of ongoing left knee pain and instability. In a December 2016 statement, the Veteran reported that he had “unbearable” pain in the left knee, that the knee was unstable, that he was unable to stand for long periods of time, and could only walk “forty to fifty feet without having to take a break because of the pain in the knee.” Considering this evidence together, the Board finds that an evaluation in excess of 30 percent is not warranted for the period from March 1, 2015, to September 6, 2017. The Veteran’s flexion was limited to 115 degrees and his extension was normal during this period; thus, the DCs associated with these measurements of range of motion would not provide a higher rating than 30 percent. Diagnostic Code 5055 is meant to compensate the Veteran for symptoms such as pain and disability associated with a total replacement of the knee. Despite the Veteran’s subjective complaints, objective testing failed to demonstrate that the Veteran suffers from any symptomatology of the left knee above and beyond that considered by DC 5055. In the present case, to assign a separate rating in addition to the 30 percent rating assigned under Diagnostic Code 5055 for pain would result in pyramiding, and as such, is to be avoided. 38 C.F.R. § 4.25(b). For the period beginning September 7, 2017, the Veteran’s 60 percent evaluation is the highest possible rating for residuals of a left knee arthroplasty after the year period following implantation of a prosthesis. Pursuant to the September 2017 VA examination, the Veteran’s disability is productive of chronic residuals including left knee instability and falling, knee pain which radiates to the ankle, decreased mobility, and knee swelling. The Veteran also described flare-ups of pain and weakness in which he was unable to walk or stand for extended periods of time. These flare-ups happened “more than once weekly” and lasted several minutes. Additionally, the Board finds that it need not consider ratings by analogy to DCs 5256, 5261, or 5262, as the Veteran’s disability most nearly approximates chronic residuals and severe painful motion rather than intermediate degrees of residual weakness, pain, or limitation of motion. A higher rating is not possible under DC 5055 (or any other criteria for rating the knee). Finally, the Board finds that a rating for subluxation or lateral instability under DC 5257 is not warranted for the period beginning March 1, 2015. The Veteran repeatedly reported giving way and instability, such as at a December 2016 statement and the September 2017 VA examination. The December 2014 and September 2017 VA examinations performed joint stability tests (Lachman’s, posterior drawer, medial instability, and lateral instability) whose results were all normal. Although the Veteran is competent to report symptoms such as his knee giving way and being unstable, and the Board finds him credible, the Board gives greater weight to the medical evidence that performed multiple tests over the entire period at issue to determine no instability was present. 4. Entitlement to a total disability based on individual unemployability beginning October 29, 2015, is granted. The Veteran contends that he is unemployable due to his service-connected left knee and right wrist conditions. VA will grant a TDIU when the evidence shows that the Veteran is precluded — by reason of his service-connected disabilities — from obtaining or maintaining “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91. For the period beginning October 29, 2015, the Veteran meets the schedular criteria for an award of TDIU based on a combined rating of at least 70 percent and a 40 percent rating for urge incontinence/voiding dysfunction. See 38 C.F.R. § 4.16(a). With regard to his employment history, the Veteran worked as an assistant teacher, a supervisor at a service for the mentally challenged, an administrator, and a correctional officer. Veteran received an associate degree in social work and a bachelor’s degree in criminal justice. After reviewing the evidence, the Board finds that the Veteran is entitled to a TDIU for the period beginning October 29, 2015. A July 2009 VA examination reported that the Veteran’s left knee and right wrist disabilities had “Significant Effects” on the Veteran’s usual occupation because of “Decreased mobility” and “pain.” In August 2009 the Social Security Administration found the Veteran disabled due to his osteoarthritis of the left knee and residuals of right wrist ganglion cyst beginning June 1, 2008. A January 2011 VA examination noted “Significant Effects” of the Veteran’s knee on his employment, stating it caused “Decreased concentration, Poor social interactions, Problems with lifting and carrying, [and] Pain.” This was supported by the Veteran’s testimony at the June 2013 Board hearing, in which the Veteran testified that his left knee and right wrist caused him to retire because he was unable to “stand [and] move around as good as [he] used to.” A December 2014 VA examination found the Veteran’s knee condition “may limit prolonged standing [continuous, several hours] or running” (brackets in original). The September 2017 VA examination for the Veteran’s knee stated that his knee impacts his ability to perform occupational tasks because “Veteran reports problems with prolonged standing and walking due to knee pain and decreased mobility. Veteran unable to climb or complete tasks which require significant bending of the knee.” The VA examination stated that “Any given occupation” would be difficult for the Veteran, “especially one that requires significant amounts of walking and weightbearing.” The September 2017 VA examination for the Veteran’s wrist found that the right wrist also impacted the Veteran’s ability to perform occupational tasks because he was unable to lift more than 10 pounds and had “Difficulty with pain from typing and writing.” Considering this evidence together, the Board finds that the Veteran’s left knee, right wrist, and remaining service connected disabilities prohibit the Veteran from securing or following a substantially gainful occupation because he is unable to lift more than 10 pounds, engage in prolonged standing or walking, or significantly bend the left knee. His right wrist also limits his ability to type and write because of pain. Thus, a TDIU is warranted for the period beginning October 29, 2015. REASONS FOR REMAND 1. Entitlement to TDIU for the period prior to October 29, 2015, is remanded. The Board finds that additional development is necessary with respect to the claim for entitlement to TDIU prior to October 29, 2015. Although the Veteran does not meet the schedular percentage requirements for an award of TDIU under 38 C.F.R. § 4.16(a), the Social Security Administration found the Veteran disabled as of June 1, 2008, because of his service-connected osteoarthritis of the left knee and right wrist ganglion cyst. Considering these records in light of the Board’s duty to “fully and sympathetically develop the veteran’s claim,” the Board finds sufficient evidence to warrant extraschedular consideration by the Director of Compensation Service in accordance with 38 C.F.R. § 4.16(b). See McGee v. Peake, 511 F.3d 1352, 1357 (Fed. Cir. 2008) (citation omitted). The Board itself may not assign an extraschedular rating in the first instance. Bowling v. Principi, 15 Vet. App. 1, 10 (2001) (recognizing that “the [Board] is not authorized to assign an extraschedular rating in the first instance under 38 C.F.R. § 3.321(b)” or § 4.16(b)). The matter is REMANDED for the following action: 1. Refer the issue of entitlement to a TDIU prior to October 29, 2015, on an extraschedular basis to VA’s Director, Compensation Services, per 38 C.F.R. § 4.16(b). M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD W. Ripplinger, Associate Counsel