Citation Nr: 18156246 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 14-06 033 DATE: December 7, 2018 ORDER Entitlement to an increased rating for plica syndrome, left knee, status post excision (left knee disability), currently rated as 10 percent disabling on the basis of limitation of flexion is denied. Entitlement to an increased rating of 20 percent, but no higher, from March 27, 2018 for plica syndrome, left knee, status post excision (left knee disability), on the basis of limitation of extension is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an increased rating of 20 percent, but no higher, from March 27, 2018 for plica syndrome left knee status post excision (left knee disability), on the basis of instability is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to an increased 40 percent rating, but no higher, for degenerative arthritis, thoracolumbar spine is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a 30 percent rating, but no higher, from September 11, 2015 for carpal tunnel syndrome (CTS) of the right upper extremity is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a 20 percent rating, but no higher, from September 11, 2015 for carpal tunnel syndrome (CTS) of the left upper extremity is granted, subject to controlling regulations governing the payment of monetary awards. FINDINGS OF FACT 1. The limitation of motion of left knee flexion did not more nearly approximate 30 degrees, to include consideration of functional loss. 2. Prior to March 27, 2018, left knee extension did not more nearly approximate 10 degrees, to include consideration of functional loss. 3. From March 27, 2018, left knee extension more nearly approximated 15 degrees with consideration of functional loss; at no time did it more nearly approximate 20 degrees, to include consideration of functional loss. 4. Prior to March 27, 2018, the Veteran's left knee instability did not more nearly approximate moderate instability. 5. From March 27, 2018, the Veteran's left knee instability more nearly approximate moderate instability; severe instability is not more nearly approximated at any time. 6. The evidence is at least evenly balanced as to whether the Veteran's lumbar spine disability more nearly approximated flexion to 30 degrees or less with consideration to functional impairment, but it did not more nearly approximate ankylosis or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 7. Prior to September 11, 2015, the Veteran’s service-connected right and left CTS more nearly approximated mild incomplete paralysis of the median nerve; moderate incomplete paralysis for either right or left CTS was not more nearly approximated. 8. From September 11, 2015, the Veteran’s service-connected right and left CTS more nearly approximated moderate incomplete paralysis of the median nerve; severe incomplete paralysis for either right or left CTS was not more nearly approximated. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent rating for left knee flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 2. Resolving reasonable doubt in the Veteran's favor, the criteria for an increased rating of 20 percent, but no higher, for the left knee extension have been met from March 27, 2018; prior to that date, the criteria for a separate compensable rating were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261. 3. Resolving reasonable doubt in the Veteran's favor, the criteria for an increased rating of 20 percent, but no higher, for the left knee instability have been met from March 27, 2018; prior to that date, the criteria for a rating higher than 10 percent were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1-4.10, 4.71a, DC 5257. 4. Resolving reasonable doubt in the Veteran’s favor, the criteria for a 40 percent increased rating, but no higher, for degenerative arthritis, thoracolumbar spine have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71(a), DC 5242. 5. Resolving reasonable doubt in the Veteran's favor, the criteria for a 30 percent rating, but no higher, from September 11, 2015 for right CTS have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.69, 4.124a, DC 8515. 6. Resolving reasonable doubt in the Veteran's favor, the criteria for a 20 percent rating, but no higher, from September 11, 2015 for left CTS have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.69, 4.124a, DC 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1984 to September 1984 and September 1987 to June 2007. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In March 2017, the Veteran had a videoconference hearing before the undersigned Veterans Law Judge. The hearing transcript is of record. In November 2017, the Board granted service connection for diabetes mellitus and remanded the remaining issues for additional development. The development has been completed and the issues have returned to the Board. In September 2018, the Veteran submitted a waiver of consideration of additional evidence by the Agency of Original Jurisdiction (AOJ). The Board may consider the additionally received evidence in the first instance. I. Duty to notify and assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, the VCAA requires VA to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b). An April 2011 letter notified the Veteran about the information and evidence needed to substantiate his increased rating claims. The duty to notify is satisfied. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claims. This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (c)(4). VA treatment records, private clinician’s letter and VA examinations, with the most recent being in March 2018, are of record. To the extent any portion of the VA examination reports is not fully compliant with the most recent Court decisions relating to orthopedic examinations, any error in this regard is not prejudicial. See Shinseki v. Sanders, 556 U.S. 396, 409-10 (2009); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). Ankylosis or severe joint deformity, such as malunion or non-union that would suggest a single disability warranting a total rating or independently causing unemployability, is not shown for any joint at issue. See March 2018 VA-contract examination report. The Board has made partial grants to account for functional impairment. For left knee flexion, the Veteran has demonstrated range of motion (ROM) significantly greater than next higher rating criteria and additional motion loss was not found upon repetitive ROM testing. The Veteran’s flare-up or repetitive use reports concern generalized left knee pain as opposed to left leg flexion motion loss. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of 38 C.F.R. § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Overall, the record does not include any indication that a request for additional information would assist in the substantiation any of these claims. Id.; see Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). The decision is also in substantial compliance with the November 2017 Board remand for these claims and the Veteran is not prejudiced by any remand deficiency. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required); see also Shinseki v. Sanders, 556 U.S. at 409-10 (discussing prejudicial error). The Veteran was afforded appropriate VA examinations in March 2018. The RO readjudicated the claim with consideration to the newly associated evidence in September 2018. In sum, where appropriate, the Board has granted additional ratings based on the Veteran’s reports of functional impairment and the additional ratings result in a 100 percent combined rating. Another remand for an additional medical opinion regarding motion loss during flare-ups would raise no reasonable possibility of additional compensation to the Veteran. Id.; 38 C.F.R. §§ 3.350, 4.25. Consequently, the Board finds that the Veteran is not prejudiced by any VA opinion inadequacy with respect to orthopedic functional impairment and that another remand for additional orthopedic examinations would not benefit the Veteran. See Lamb v. Principi, 22 Vet. App. 227, 234 (2008) (remand not required when it would serve no useful purpose); Winters v. West, 12 Vet. App. 203, 208 (1999) (en banc) ("[A] remand is not required in those situations where doing so would result in the imposition of unnecessary burdens on the [Board] without the possibility of any benefits flowing to the appellant."); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that "[a] veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution"). For the reasons set forth above, the Board finds that VA has substantially complied with the notification and assistance requirements. To the extent there is any medical opinion deficiency with respect to functional impairment of any joint or incomplete clinical findings, it is not prejudicial to the Veteran. See Shinseki, 556 U.S. at 409-10. Accordingly, the claims are ready to be considered on the merits. II. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In general, when 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). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Left knee disability The Veteran has a 10 percent left knee rating on the basis of limitation of flexion under DC 5260-5010. 38 C.F.R. § 4.71a, DCs 5260-5010. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. DC 5010 pertains to Arthritis, due to trauma and is rated by analogy under DC 5260 for limitation of leg flexion. DC 5260, limitation of flexion of a leg, provides a 10 percent rating is if flexion is limited to 45 degrees, and a 20 percent rating is warranted if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees warrants a 30 percent rating. Id. From March 27, 2018, the Veteran has a 10 percent left knee rating on the basis of limitation of extension under analogous rating DCs 5010-5261. 38 C.F.R. § 4.71a, DCs 5010-5261. Under DC 5261 for limitation of extension of a leg provides a noncompensable rating when extension is limited to 5 degrees, a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. The Board also notes that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004. Then, the Veteran also has a 10 percent rating for left knee instability associated with plica syndrome under DC 5257. Under DC 5257, recurrent subluxation or lateral instability a 10 percent rating is warranted for slight impairment of either knee, a 20 percent rating is warranted for moderate impairment, and a 30 percent rating is warranted for severe impairment. 38 C.F.R. § 4.71a, DC 5257. Turning to the evidence, the Veteran filed the increased rating claim at issue in March 2011. In September 2011, the Veteran underwent a VA knee examination. The examiner diagnosed plica syndrome, left knee status post excision. For symptoms, the examiner noted giving way and pain. The Veteran reported being able to stand between one and three hours and walk between one to three miles. He did not use any assistive devices. Clinical examination showed a normal gait. Left knee range of motion (ROM) was to 130 degrees. Extension was normal. Repetitive motion did not cause additional motion loss. X-rays showed minimal patellofemoral degenerative disease. The Veteran was not working. He recently moved with his wife and had been unable to find work. The examiner described the functional impact as occasional giving way of the left knee. February 2012 VA primary care records showed that the Veteran had a flare-up of left knee pain over the past two weeks. He described having left knee pain flare-ups every few months. The clinician noted degenerative joint disease at multiple joints and also a left knee joint swelling history. Clinical evaluation revealed moderate crepitus without significant swelling. The Veteran did not want further left knee treatment. He was advised to contact the clinic if his symptoms worsened. In his August 2012, notice of disagreement (NOD), the Veteran reported that the VA examiner did not fully describe the limitations of standing and walking due to left knee pain. He disputed telling the VA examiner that he was able to stand for one to three hours. He was unable to walk to his mailbox without experiencing knee and back pain. He had frequent giving way episodes when standing. He requested an increased rating due to pain and swelling. November 2013 VA primary care records noted mild swelling of the left knee with a good ROM. The clinician assessed the left knee as stable. He recommended a knee brace. In August 2014, the Veteran had a VA orthopedic surgery consultation. The clinician noted the longstanding history of left knee pain. However, the Veteran did not report any appreciable increased pain. He described left knee pain of 7-8/10 severity. The clinician recorded a full left knee ROM without effusion or local tenderness. He assessed the left knee X-rays as unremarkable except for mild degenerative change. He diagnosed traumatic arthritis in the knees, left greater than right. He recommended quadricep exercises and weight loss. He also advised continued activity and noted that the Veteran did not appear in a major degree of pain. June 2016 VA treatment records showed that the Veteran received an unloader knee braces for both knees. In March 2017, a private clinician submitted a letter in support of the claim. He reported that the Veteran continued to have significant bilateral knee pain and limited activity. In March 2017, the Veteran had a videoconference with the undersigned. For his left knee, he reported difficulty with standing for any length of time and using stairs. His left knee buckled three or four times per week. He wore knee braces for stability. He was concerned that the September 2011 VA examiner did not consider his in-service left knee surgery and considered the VA examination inadequate. He no longer worked as an insurance adjuster because of knee and back pain. He had falls from his left knee buckling. He had tried knee braces, but did not find them effective. He described having flare-ups of left knee pain from three to five times per week that lasted days. He iced his knees at least three days per week. It now took him much longer to complete domestic chores due to left knee pain. In March 2018, the Veteran was afforded a VA-contract left knee examination. The examiner diagnosed plica syndrome, left knee, status post excision via arthroscopy with scarring and left knee arthritis. Currently, the Veteran had pain and some instability, described as the left knee occasionally slipping out of place. He used analgesics, warm soaks, and a knee brace as needed for pain relief. He experienced pain daily. He described left knee flare-ups as swelling and increased pain. They occurred two to three times per week with severe pain lasting 10 to 12 hours. Functional impairment was inability to walk or stand for any length of time due to left knee pain. Left knee ROM flexion was to 85 degrees and extension was to 10 degrees. The examiner stated that there was some motion loss due to an unrelated condition and described the functional loss as unable to flex knee for daily activities (ADL’s). Pain was noted with flexion and extension, but not reported to result in functional loss. Objective evidence of pain was noted for the left patella region, described as mild. There was evidence of pain on weight-bearing and crepitus. Repetitive motion testing did not show further motion loss. The examiner declined to provide motion loss estimates from repetitive use over time and flare-ups. She cited her inability to observe the Veteran under such conditions. On joint stability tests, the examiner noted a history of slight recurrent subluxation and instability for the left knee. A history of recurrent effusion was described as occasional swelling in the morning. Joint stability testing was not performed since the Veteran had pain when attempting to follow stability test procedures. For meniscal conditions, the examiner reported no current symptoms, but acknowledged instability, pain and fatigue in the left knee. She noted the 2007 left meniscus repair surgery. For assistive devices, the examiner reported occasional use of a walking stick for lengthy walks. For occupational impact, the examiner noted at least five weeks of work time lost in the last twelve months. The left knee disability impaired walking, sitting, and standing for any length of time. The examiner confirmed objective evidence of pain with passive ROM testing and no objective evidence of pain in a non-weight bearing position. She noted the Veteran’s right knee had some damage as described above. (i) Limitation of left knee motion in flexion plane The Veteran has a 10 percent rating for left leg, limitation of flexion under DCs 5260-5010. 38 C.F.R. § 4.71a, DCs 5010-5260. The ROM studies are limited and indicate motion loss appreciably greater than the next-higher 20 percent rating criteria pursuant to DC 5260, which contemplates limitation of flexion to 30 degrees. Id. Given the Veteran’s objections to the September 2011 VA examination, the Board will not consider it. However, August 2014 VA surgical consultation and March 2018 VA-contract examination showed left knee flexion to 85 degrees, at worst. The Board has considered the Veteran’s reports of left knee functional impairment from flare-ups and repetitive use. English v. Wilkie, No. 17-2083 (Vet. App. Nov. 1, 2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups); 38 C.F.R. §§ 4.40, 4.45, 4.59. He is competent to describe such functional impairment. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) (lay evidence competent for readily observable symptoms). The Board finds his reports credible due to his consistency in reporting additional impairment throughout the record. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the Veteran in weighing evidence). Nonetheless, his left knee functional loss reports concern significant increases in pain and corresponding limitation in activity, as opposed to flexion motion loss. Thompson, 815 F.3d at 785 (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260. The left knee flexion to 85 degrees recorded at the March 2018 VA-contract examination is much greater than the 30 degrees contemplated by the next higher 20 percent rating criteria under DC 5260. Without more detailed reports suggesting additional left knee flexion motion loss during flare-ups or repetitive use, the weight of evidence is against finding that the left knee limitation of flexion more nearly approximate 30 degrees, even with consideration to the competent and credible reports of functional impairment. Id. (ii) Limitation of left knee motion in extension plane As to limitation of extension, the Veteran currently has a separate 10 percent rating from March 27, 2018 pursuant to DC 5261. The Board resolves reasonable doubt to find a separate 20 percent rating from March 27, 2018 is warranted as explained below. 38 C.F.R. §§ 3.400, 4.3, 4.7, 4.71a, DC 5261. (A) Prior to March 27, 2018 The ROM studies are limited and indicate motion loss appreciably greater than the next-higher 10 percent rating criteria pursuant to DC 5261, which contemplates limitation of extension to 10 degrees. Id. Given the Veteran’s objections to the September 2011 VA examination, the Board will not consider it. However, VA treatment records from November 2013 and August 2014 indicate that the Veteran had full or near full left knee extension to heavily weigh against a compensable rating during this period. Caluza, 7 Vet. App. at 506. The Board has considered the Veteran’s reports of left knee functional impairment from flare-ups and repetitive use. English, supra.; 38 C.F.R. §§ 4.40, 4.45, 4.59. As discussed above, his reports of functional impairment are competent and credible, but concern significant increases in pain and corresponding limitation in activity, as opposed to specific motion loss. Thompson, 815 F.3d at 785 (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261. The clinical reports from November 2013 and August 2014 indicate he had normal or near normal baseline left knee extension motion. Without more detailed reports suggesting additional left knee extension motion loss during flare-ups or repetitive use, the weight of evidence is against finding that the left knee limitation of flexion more nearly approximated 10 degrees, even with consideration to the competent and credible reports of functional impairment. Caluza, 7 Vet. App. at 506; Id. (B) From March 27, 2018 The March 2018 VA-contract examination showed left leg extension to 10 degrees, which facially does not meet the next higher, 20 percent rating under DC 5261. Id. Again, the Veteran’s competent and credible reports of functional impairment from flare-ups and repetitive use must be considered. English, supra. The Board observes that the 20 percent rating criteria under DC 5260 contemplate 15 degrees limitation of extension, which is only 5 degrees more than the 10 degrees contemplated by the currently assigned rating criteria. Thompson, 815 F.3d at 785 (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”); Id. Although the Veteran’s left knee functional loss reports concern significant increases in pain and corresponding limitation in activity as opposed to specific left leg extension motion loss, it is reasonable to infer that he experiences some degree of additional left leg extension motion loss during flare-ups and repetitive use. For leg extension motion loss, the ROM differences for each rating are 5 degrees as opposed to the 15 degrees for leg flexion. 38 C.F.R. § 4.71a, DCs 5260, 5261. Although estimated functional loss cannot be state with certainty, it is feasible to estimate that the left leg extension motion loss more nearly approximated 15 degrees during repetitive use over time or flare-up episodes. Caluza, 7 Vet. App. at 506; English, supra. Given the March 2018 extension ROM study and Veteran’s reports of functional impairment during flare-ups, repetitive use and the like, the Board resolves reasonable doubt to find that left leg extension estimated motion loss during functional impairments more nearly approximates 15 degrees. Id. Thus, from March 27, 2018, a 20 percent rating for left leg, limitation of extension is more nearly approximated with consideration to functional impairment. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5242; Mitchell, 25 Vet. App. at 44; Correia, 28 Vet. App. at 169-170; Sharp, 29 Vet. App. at 33. The Board finds that the service-connected left knee disability does not more nearly approximate the leg extension motion loss criteria for a rating greater than 20 percent. 38 C.F.R. § 4.71a, DC 5260. Again, the only ROM study showed left knee extension motion loss to 10 degrees. The Board has accounted for estimated motion loss due to functional impairment by assigning the next higher 20 percent rating. Id. Although the precise limitation of extension is not clear, there is no evidence suggesting that estimated motion loss to more nearly approximate the 20 percent rating criteria. Id.; Thompson, supra. Accordingly, the evidence weighs against a rating award in excess of 20 percent for left leg limitation of extension, even with consideration to functional impairment. Id. (iii) Left knee instability The Veteran has a 10 percent rating for left knee instability pursuant to DC 5257. 38 C.F.R. § 4.71a, DC 5257. Resolving reasonable doubt in the Veteran’s favor, the Board finds a 20 percent rating for moderate left knee instability is warranted from March 27, 2018. (A) Prior to 27, 2018 Prior to March 27, 2018, the lay reports of left knee instability include reports of frequent giving way episodes in the August 2012 NOD and frequent buckling episodes resulting in a fall at the March 2017 hearing. The Board notes lay reports regarding knee instability must specifically be considered and weighed in light of the entire record. English, supra. The Board finds the Veteran competent to describe left knee instability symptoms and his reports have been duly considered. Jandreau, 492 F.3d at 1376, n. 4. In this case, an November 2013 VA primary care record assessed the left knee as stable. This report weighs against a finding of moderate left knee instability. Then, the August 2014 VA clinician encouraged the Veteran to continue activity. It is reasonable to infer from this recommendation that left knee instability was not significant enough to contraindicate activity. Caluza, 7 Vet. App. at 506. Given these reports, the Board finds the weight of the evidence, with due consideration to the Veteran’s lay descriptions, does not show left knee instability more nearly approximating a moderate nature prior to March 27, 2018. English, supra.; 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.71a, DC 5257. (B) From March 27, 2018 At the March 27, 2018 VA-contract examination, the VA-contract examiner assessed slight instability, but was unable to perform joint stability testing due to pain. The examiner did not provide further explanation. However, it is reasonable to infer that stability testing could not be completed because of increased disability. By resolving reasonable doubt in the Veteran’s favor, the Board finds that moderate left knee instability is more nearly approximated from this examination report with consideration to the Veteran’s prior lay statements. Id. The Board finds the evidence does not more nearly approximate severe left knee instability under DC 5257. The Veteran reports of left knee instability include regular buckling and occasional subluxation. See March 2017 hearing transcript and March 2018 VA-contract examination. VA treatment records show that the Veteran received medical care on a regular basis during the claims period. They do not include complaints or treatment for knee instability. It is reasonable to find an absence of complaint for left knee instability in these recurring medical treatment records to weigh against a finding of severe instability. Caluza, 7 Vet. App. at 506. With due consideration to the Veteran’s reports, the weight of the evidence does show left knee instability more nearly approximating a severe nature. English, supra.; 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.71a, DC 5257. The left knee symptoms at issue have not either manifested as or been attributed to ankylosis, meniscus disorder, impairment of the tibia or fibula, or genu recurvatum. Therefore, separate/higher ratings do not merit further consideration under DCs 5256, 5258, 5262 or 5263. 38 C.F.R. §§ 4.14, 4.71a, DCs 5256, 5258, 5262, 5263. In conclusion, the Board resolves reasonable doubt in the Veteran’s favor to find that from March 27, 2018 both an increased 20 percent rating for limitation of left leg extension and an increased 20 percent rating for moderate left knee instability are warranted. Id.; 38 C.F.R. § 4.3, 4.7. As the preponderance of the evidence is against increased ratings, other than the ones granted above, the benefit of the doubt doctrine is not for application and such portions of the increased left knee disability claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative, has raised any other issues, nor have any other issues been reasonably raised by the record for this disability. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Lumbar spine disability The Veteran has a 10 percent rating prior to March 27, 2018 and a 20 percent rating thereafter for service-connected degenerative arthritis, thoracolumbar spine under DC 5242. 38 C.F.R. § 4.71a, DC 5242. DC 5242 provides ratings pursuant to the General Rating Formula. Under the General Rating Formula for lumbar spine disability, such disability is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Id. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, combined range of motion of the entire thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees. 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, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2). Any associated neurological abnormalities are evaluated separately under the appropriate diagnostic code. See Note 1, General Rating Formula for Disease and Injuries of the Spine, 38 C.F.R. § 4.71a. Turning to the evidence, the Veteran filed the increased rating claim at issue in March 2011. In September 2011, the Veteran underwent a VA spine examination. The examiner diagnosed degenerative arthritis, thoracolumbar spine. The Veteran reported having severe flare-ups every two to four months that lasted between two and four weeks. The flare-ups were described as increased pain. Currently, he described sharp to dull, mild constant pain. Clinical examination revealed a normal posture and gait. Abnormal spinal curvature was not found. Lumbar ROM was complete in all planes and free from pain. Repetitive motion did not cause further limitation. Reflexes were complete bilaterally. Sensory and motor strength findings were normal. Lumbar spine X-rays showed mild to moderate degenerative disc disease. The examiner diagnosed degenerative joint disease lumbar spine. For functional impact, she reported pain with bending. February 2012 VA primary care records showed that the Veteran complained about low back pain flare-up over the past two months. Straight leg raise (SLR) was positive bilaterally at 40 degrees. No motor deficit was found and deep tendon reflexes (DTR) were intact. The clinician assessed degenerative joint disease at multiple joints and noted further treatment for back pain was not requested. In his August 2012 NOD, the Veteran reported having constant back pain with flare-ups approximately every other month. It ranged from 6-8/10 normally and 8-12/10 during flare-ups. He reported taking muscle relaxers the night before the VA examination due to pain and restricted ROM. November 2013 VA primary care records showed that the Veteran complained about back spasms throughout his thoracolumbar spine. Physical examination showed mild paravertebral (PV) muscles spasms of the thoracolumbar spine. The clinician assessed back pain and recommended X-rays. In April 2015, the Veteran had a VA physical therapy (PT) consultation. He reported a longstanding history of low back pain that was gradually worsening. No specific factors were identified. Ice and medication provided temporary relief. The Veteran complained of occasional left lower extremity radiating pain. He currently worked as an ambassador at VA and walked eight or more miles a day. X-rays showed severe spondylosis, osteophytosis with degenerative joint disease. Physical examination showed an antalgic posture upon arising from a seated position. Gait was normal. Lumbar spine ROM flexion was decreased 75 percent with pain. Extension was decreased 25 percent. Side-bending was decreased 50 percent bilaterally. Motor strength was complete bilaterally. Sensation was intact to light touch. Tenderness to palpation was found. SLR was negative. The clinician assessed chronic low back pain and issued a PT program with the goal of decreasing pain. A May 2015 VA PT note included a report of overall improvement to 6-7/10 pain. The home exercise program (HEP) was continued. June 2016 VA pain clinic records showed that the Veteran sought treatment for lumbar spine pain with bilateral radiculopathy. He believed his back pain had been slowly increasing. He had constant neck and low back pain that increased through the day and woke him at night. His low back pain was the most bothersome. He currently worked as a VA ambassador. Clinical evaluation showed that the Veteran ambulated with an unassisted, steady gait. He had full strength in both lower extremities. Pain was noted in flexion and extension. L1-L2 paraspinal tenderness was found. The clinician reviewed an updated lumbar spine X-ray report and assessed lumbar degenerative disc disease and lumbar facet arthropathy. He recommended, among other things, a bilateral facet block, L1-L5 scheduled for July 2016. October 2016 VA pain clinic records listed a chief complaint of low back pain with bilateral radiculopathy. The Veteran reported that a July 2016 nerve block relieved his symptoms by 60 percent following the procedure. Clinical evaluation showed that the Veteran ambulated with an unassisted, steady gait. He had full strength in both lower extremities. Pain was noted in all planes of motion for the lumbar spine. February 2017 VA pain clinic records contained findings substantially similar to those reported in June 2016 and October 2016. In March 2017, the Veteran testified during a Board hearing. He reported having significant difficulty bending, picking up objects off the ground and tying his shoes. He currently worked as a VA ambassador. He assisted moving patients through the hospital. However, he had to miss work numerous times due to incapacitating back pain. He had been working at VA for the past three years and estimated missing a day and a half per month. His supervisor informally accommodated his back disability by giving him less strenuous assignments. He reported VA pain management was partially effective. He had flare-ups four or five times per week. He usually needed to rest in bed right following work. He reported being unable to bend or move laterally during flare-ups. In March 2018, the Veteran had a VA-contract back examination. The examiner diagnosed degenerative arthritis, thoracolumbar spine and bilateral lower extremity radiculopathy. The Veteran reported back pain starting in service that had become progressively worse. His current symptoms included pain, stiffness, lack of flexibility, difficulty sitting, and difficulty ambulating for long periods. He endorsed flare-ups precipitated by exertive activity. He described them as muscle spasms. He rested in bed for relief. The flare-ups lasted several hours. Lumbar spine ROM was forward flexion to 70 degrees. Extension was to 10 degrees. Right and left lateral flexion were to 20 degrees. Right and left lateral rotation were to 15 degrees. Functional loss was described as an inability to extend torso to perform routine daily activities due to back pain and stiffness. Pain was noted at rest and with all planes of lumbar motion. Mild pain was noted with palpation. Repetitive use testing did not result in additional motion loss. The examiner declined to estimate motion loss during repeated use over time and flare-ups. She cited an inability to observe the Veteran. Muscle spasm was noted and deemed to result in an abnormal gait or spinal contour. Muscle strength testing showed diminished strength bilaterally. Reflexes were hypoactive in the left lower extremity. Sensory testing was normal. SLR testing was normal bilaterally. The examiner noted mild radiculopathy symptoms and assessed bilateral radiculopathy involving L2/L3/L4 nerve roots. The Veteran occasionally used a walking stick for extensive walking. For functional impact, the Veteran had recently resigned from his job due to left knee and back pain. The Veteran contends a lumbar spine disability rating in excess of 10 percent prior to March 27, 2018 and 20 percent thereafter is warranted. Resolving reasonable doubt in his favor, the Board finds an increased, uniform 40 percent rating for service-connected degenerative arthritis, thoracolumbar spine is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The only ROM study with findings more nearly approximating the 40 percent rating criteria is the April 2015 PT report finding 75 percent lumbar forward flexion loss. 38 C.F.R. § 4.71a, DC 5242. This translates to approximately 23 degrees of forward flexion motion and meets the 40 percent rating criteria. Id., Note 2. Most of the ROM studies do not show the requisite motion loss to more nearly approximate the 40 percent rating criteria under the General Formula. 38 C.F.R. § 4.71a, DC 5242. Notably, the Veteran disputed the accuracy of the September 2011 VA examination report and this report will be disregarded. See August 2012 NOD (Veteran reports taking muscle relaxers to improve back movement before the examination). However, the Board must also consider functional impairment reports. English, supra; 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran has reported flare-ups of severe low back pain and specifically limited back movement as a part of these episodes. (See August 2012 NOD, March 2017 Board hearing, and March 2018 VA-contract examination). The Veteran is competent to report such limitations. Jandreau, 492 F.3d at 1377. The Board finds his reports credible as they are generally consistent throughout the record and plausible. Caluza, 7 Vet. App. at 506. The March 2018 VA-contract examiner declined to estimate motion loss from repetitive use over time or flare-ups due an inability to observe the Veteran. Sharp, 29 Vet. App. at 33. Nevertheless, it is reasonable to infer from his flare-up reports that he has significant lumbar spine motion loss due to back pain. Mitchell, 25 Vet. App. at 44; Thompson, 815 F.3d at 785 (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5242. This is corroborated by the April 2015 VA PT records. Accordingly, the Board considers the April 2015 VA PT ROM notes and the Veteran’s reports of frequent severe flare-ups sufficiently persuasive to show limitation of lumbar flexion more nearly approximating the 40 percent rating criteria with consideration to motion loss during flare-ups or repetitive use over time. Id. The Board has considered whether a rating greater than 40 percent is warranted under the General Rating Formula. 38 C.F.R. § 4.71a, DC 5242. As noted above, a higher 50 percent rating under the General Rating Formula contemplates ankylosis of the lumbar spine disability. There is no evidence suggesting ankylosis of the thoracolumbar spine. Moreover, in Johnston v. Brown, 10 Vet. App. 80, 85 (1997), the Court indicated that where the Veteran is in receipt of the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis, the cited regulations are not for application. See id. at 84-85 (although the Secretary suggested remand because of the Board’s failure to consider functional loss due to pain, remand was not appropriate because higher schedular rating required ankylosis). A rating greater than 40 percent under the General Rating Formula is not for further consideration. Id. The Board notes that the Veteran has separate ratings for right and left sciatic nerve neuropathy associated with lumbar radiculopathy and diabetes mellitus. (See March 2018 rating decision). To date, he has not disputed these separately assigned ratings. (See March 2018 NOD limiting disagreement to diabetes). Further discussion of this issue is not warranted at this juncture. The Board has also considered whether a rating greater than 40 percent is warranted based upon the IVDS Formula. Id. Although the Veteran has reported self-directed bed rest to relieve back pain, the frequency and duration of these treatments is unclear. There is no indication this therapy is directed by a physician. Based on these reports, further consideration of the alternative IVDS formula is not warranted. 38 C.F.R. § 4.71a, DC 5243 IVDS Rating Formula. For the foregoing reasons, an increased, uniform 40 percent rating is granted for degenerative arthritis, thoracolumbar spine. The preponderance of the evidence reflects the symptoms of the Veteran's lumbar spine disability do not more nearly approximate the criteria for a rating higher than 40 percent. Thus, the benefit of the doubt doctrine is not for application and a rating greater than 40 percent must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative, has raised any other issues, nor have any other issues been reasonably raised by the record for this disability. See Doucette, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Bilateral carpal tunnel syndrome (CTS) The Veteran has separate 10 percent ratings for CTS in each upper extremity pursuant to DCs 8599-8515. 38 C.F.R. § 4.124a, DCs 8599-8515. The DC 8599 refers to an unlisted disability, CTS, and the second DC 8515 refers to the listed paralysis of the median nerve. 38 C.F.R. § 4.27. DC 8515 provides ratings for both the "minor" and the "major" wrist. In this context "minor" and "major" refer to the dominant or nondominant side. Here, the Veteran's major hand (dominant) is the right upper extremity, and the minor hand is the left upper extremity. See March 2018 VA-contract examination report. DC 8515 addresses complete and incomplete paralysis of the median nerve. As relevant, under DC 8515, mild incomplete paralysis of the major or minor wrist warrants a 10 percent rating. Moderate incomplete paralysis warrants a 30 percent rating for the major wrist and 20 percent for the minor wrist. Severe incomplete paralysis warrants a 50 percent rating for the major wrist and 40 percent for the minor wrist. Complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances warrants a 70 percent disability rating for the major wrist and 60 percent disability rating of the minor wrist. See 38 C.F.R. § 4.124a, DC 8515. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. The words "mild," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. The term "incomplete paralysis," with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to the partial regeneration. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, 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. Neurological disorders are ordinarily to be rated in proportion to the impairment of motor, sensory, or mental function. In rating peripheral nerve injuries and their residuals, attention is given to the site and character of the injury, and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Normal ranges of motion of the wrist are dorsiflexion from 0 degrees to 70 degrees and palmar flexion from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I. Turning to the evidence, the Veteran filed the increased rating claim at issue in March 2011. In September 2011, the Veteran was afforded a VA CTS examination. The examiner confirmed the bilateral CTS diagnosis. It was described as stable. The Veteran reported wearing wrist braces at night for treatment. He described numbness and weakness in both hands as his symptoms. Clinical evaluations showed normal reflexes and full motor strength. Tinel’s sign was positive and Phalen’s sign was negative. The examiner noted functional impairment from hand soreness in the mornings. In the August 2012 NOD, the Veteran reported he had tingling and pain in his fingers when the VA examiner squeezed and tapped his wrists. He wore wrist braces at night and whenever he had increased pain. September 11, 2015 VA occupational therapy records included a CTS consultation upon complaints of numbness in both hands. The Veteran affirmed having bilateral hand weakness and numbness. He was independent in daily activities. He regularly used wrist splints, but they needed replacement. Clinical evaluation showed full movement and strength. Grip strength testing was performed. The clinician found impaired grip strength of both hands. However, the repetitive grip strength scores indicated that the Veteran did not provide full effort during the test. The Veteran was given replacement wrist braces and CTS exercise recommendations. January 2017 VA primary care records showed that the Veteran complained about increased bilateral numbness and weakened grip strength from CTS. Clinical evaluation did not include any pertinent findings. The clinician advised considering a CTS release procedure. During the March 2017 Board hearing, the Veteran reported that his grip had become very weak over the years. His primary care clinician recommended surgery. He also reported that his fingers would lock up. His wife noted it could take half an hour for the affected finger to straighten out during such episodes. These locking episodes happened two or three times per month, usually in the morning. The Veteran noted that surgery was initially recommended in 2007. He had regularly used wrist braces since service. He also reported that he did not believe the 2011 VA examination was sufficiently thorough for his bilateral CTS disability. His fingers were numb and tingled most of the time. August 2017 VA pain management records included a clinical evaluation showing full motor strength in both upper extremities, including hand grip. In March 2018, the Veteran had a VA-contract neurology examination. The examiner confirmed a bilateral CTS diagnosis. Currently, the Veteran had weakness in both wrists and some pain. He complained that he did not have maximum use of his hands. No current treatment was noted. The examiner listed the Veteran as right hand dominant. She did not report any sensory impairment for the upper extremities. Muscle strength testing was diminished. Elbow flexion and extension were 4/5 strength bilaterally. Right wrist flexion, extension, grip and pinch were 4/5 strength. Left wrist flexion, extension, grip and pinch were 3/5 strength. No muscle atrophy was found. Upper extremity reflexes were normal. Light touch sensory examination was normal. No trophic changes were found. Phalen’s sign and Tinel’s sign were negative. The examiner declined to identify an affected upper extremity nerve. The Veteran contends ratings in excess of 10 percent are warranted for right and left CTS. Upon review, the Board finds that moderate incomplete paralysis for bilateral CTS is more nearly approximated from September 11, 2015. 38 C.F.R. §§ 4.3, 4.6, 4.7, 4.124a, DC 8515. This is the first clinical report of bilateral decreased grip strength and it is followed by January 2017 reports of increased bilateral CTS disability. 38 C.F.R. § 3.400(o). (i) Prior to September 11, 2015 Prior to September 11, 2015, the evidence does not show that right and left CTS more nearly approximated the findings for the next higher rating, moderate incomplete paralysis of dominant wrist. 38 C.F.R. § 4.124a, DC 8515. The Veteran's reports of numbness and tingling are duly noted. The evidence does not include additional reports of loss of strength, diminished reflexes or sensory disturbances causing unusual impairment of the affected area or affecting a larger area in the nerve distribution for either upper extremity. The September 2011 VA examination included clinical findings of normal reflexes and full motor strength. Although the Veteran disputed the adequacy of this examination at the March 2017 hearing, these clinical findings are clearly reported and of probative value in ascertaining the severity of the bilateral CTS disability. Caluza, 7 Vet. App. at 506. They weigh against symptoms in either upper extremity more nearly approximating moderate impairment. Id. A rating in excess of 10 percent prior to September 11, 2015 for right and left CTS is denied. (ii) From September 11, 2015 The Board finds the September 11, 2015 VA occupational therapy records including the initial report of impaired grip strength to be the first factually ascertainable evidence of increased right and left CTS disability. 38 C.F.R. § 3.400(o). These reports are corroborated by January 2017 VA primary care records, testimony at the March 2017 Board hearing and clinical findings from the March 2018 VA-contract examination. From September 11, 2015, the Board finds moderate incomplete paralysis is more nearly approximated for the right and left median nerves. Increased ratings of 30 percent for right CTS and 20 percent for left CTS are warranted. However, the evidence does not show that either right or left CTS more nearly approximates severe incomplete paralysis of the median nerve. The September 2015 VA occupational therapy records confirm impaired grip strength with questionable results during repetitive grip testing. The March 2018 VA-contract examination showed at worst 3/5 strength, but did not include findings of muscle atrophy, absent reflexes or skin changes associated with severe nerve damage. The Veteran’s reports of locking fingers have been considered. However, he indicated these episodes occurred on a less than weekly basis and last half an hour. The Board finds the frequency, severity and duration of these symptoms to be reasonably encompassed by the newly assigned rating. 38 C.F.R. § 4.124a, DC 8515. For the foregoing reasons, an increased 30 percent rating for right CTS and a 20 percent rating for left CTS from September 11, 2015, but no higher, is warranted. As the preponderance of the evidence is against increased ratings other than the ones granted above, the benefit of the doubt doctrine is not for application and such portion of the claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Neither the Veteran, nor his representative, has raised any other issues, nor have any other issues been reasonably raised by the record for this disability. See Doucette, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). III. Additional considerations The Board notes that the Veteran filed a total disability based upon individual unemployability (TDIU) claim in October 2018 and it is considered part of the appeal for increased ratings. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); 38 C.F.R. § 4.16. His reports indicate that he was gainfully employed from March 2014 to April 20, 2018. Although the appeals period predates the start of this job, the fact that he was able to maintain employment for approximately four years weighs heavily against a finding of unemployability prior to March 2014. Thus, by the Veteran’s own report, he did not meet the basic eligibility criteria of unemployment until April 20, 2018. Entitlement to TDIU prior to April 20, 2018 is not for consideration. 38 C.F.R. § 4.16. From April 20, 2018, the instant decision results in a total rating award. The Court has held that a 100 percent schedular rating does not necessarily render the issue of entitlement to a TDIU moot, as the TDIU could in certain circumstances render the Veteran eligible for special monthly compensation (SMC) benefits pursuant to 38 U.S.C. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242 (2010); Bradley v. Peake, 22 Vet. App. 270 (2008). Notably, the Court has clarified that the combined rating table is for application when determining combining separate ratings of disability for TDIU eligibility. Moody v. Wilkie, No.16-1707 (Vet. App. November 8, 2018). (Continued on the next page)   In this case, the total rating award from the instant rating decision renders entitlement to a TDIU moot. The Veteran does not have a single disability rated 60 percent or greater with application of the combined ratings table for multiple disability ratings of the same affected part. Id. He does not otherwise assert, nor does the evidence in any way suggest extraschedular TDIU consideration pursuant to 38 C.F.R. § 4.16(b) is warranted for a specific disability. Then, the weight of the evidence strongly suggests that a combination of service-connected disabilities renders him unemployable. The Board finds that there is no reasonable possibility that a TDIU award would substantiate a SMC(s) award. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. D. Simpson, Counsel