Citation Nr: 1808081 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 13-31 446 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to a rating in excess of 30 percent for residuals of a right knee replacement. 2. Entitlement to a rating in excess of 10 percent for lumbar degenerative disc disease prior to April 22, 2014. 3. Entitlement to a rating in excess of 20 percent for lumbar degenerative disc disease since April 22, 2014. 4. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and the Veteran ATTORNEY FOR THE BOARD Mary E. Rude, Counsel INTRODUCTION The Veteran served on active duty from May 1972 to July 1977. The Veteran died in March 2017, and his surviving spouse has been substituted as the appellant. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. In March 2017, the Veteran and the appellant testified at a video conference hearing before the undersigned. In March 2017, the Veteran raised issues of entitlement to service connection for depression secondary to multiple service connected disorders, as well as entitlement to special monthly compensation based on a need for aid and attendance and being housebound. These issues, however, are not currently developed or certified for appellate review. Accordingly, they are referred to the RO for appropriate consideration. FINDINGS OF FACT 1. The Veteran's residuals of right knee replacement were not manifested by ankylosis in flexion between 10 and 20 degrees, extension limited to 30 degrees, nonunion of the tibia and fibula with loose motion requiring a brace, or by chronic residuals of severe painful motion or weakness. 2. Prior to April 22, 2014, the Veteran's lumbar degenerative disc disease was not manifested by forward flexion limited to 60 degrees, a combined range of motion limited to 120 degrees, or by muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 3. After April 22, 2014, the Veteran's lumbar degenerative disc disease was not manifested by forward flexion limited to 30 degrees or less, or by favorable ankylosis of the thoracolumbar spine. 4. The combined impact of the Veteran's service connected left knee replacement residuals, right knee replacement residuals, lumbar degenerative disc disease, residuals of a right elbow dislocation, erectile dysfunction, and bilateral knee scars prevented him from obtaining and retaining substantially gainful employment consistent with his educational background and work experience. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 30 percent for residuals of right knee replacement were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5055, 5257, 5260, 5261, 5262 (2017). 2. Prior to April 22, 2014, the criteria for a rating in excess of 10 percent for lumbar degenerative disc disease were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5235-5243 (2017). 3. Since April 22, 2014, the criteria for a rating in excess of 20 percent for lumbar degenerative disc disease were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5235-5243. 4. The criteria for an award of a total disability evaluation based on individual unemployability due to service-connected disorders were met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). While the VA examinations of record do not include testing of weight-bearing and both active and passive ranges of motion, there is no evidence indicating that such test results would reveal any more restricted range of motion which would allow for the assignment of any higher rating. Further, as the Veteran died during the course of the appeal there is no ability to perform further testing. Thus, the range of motion results are adequate to decide the claim at this time. See 38 C.F.R. § 4.59, Correia v. McDonald, 28 Vet. App. 158 (2016). Residuals of Right Knee Replacement The appellant contends that the Veteran's residuals of right knee replacement warranted a rating higher than 30 higher. In a July 2010 rating decision, the Veteran was granted a temporary total evaluation of 100 percent following his right total knee arthroplasty surgery and subsequent convalescence. He was thereafter assigned a 30 percent evaluation from June 1, 2011. In June 2011, the Veteran requested an increased rating for his knee disability, and it is this request for an increased rating that is currently on appeal. At a March 2017 Board hearing the Veteran described severe knee pain which prevented him from doing chores. He reported being unable to stand for more than a minute and that the knee did not fully support his weight. He reported requiring a wheelchair to get around. The evidence shows that the Veteran had undergone a below the right knee amputation, which the appellant said was due to diabetes and inservice chemical exposure. Entitlement to service connection for right below the knee amputation was denied in a May 2011 rating decision. That decision was not appealed and is final. 38 U.S.C. § 7105 (2012). The Board is therefore considering only the symptoms associated with the Veteran's residuals of a right knee replacement at this time, and not symptoms associated with his below the right knee amputation. In a June 2013 rating decision the Veteran was granted entitlement to a separate noncompensable rating for surgical knee scars. The Veteran did not appeal that decision, and therefore the evaluation of the right knee surgical scar is not on appeal. 38 U.S.C. § 7105 (2012)/ Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. In DeLuca, it was held that when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. Diagnostic Codes 5260 and 5261 pertain to limitation of knee motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. A normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. The rating governing a limitation of leg flexion allows for a 10 percent evaluation when it is limited to 45 degrees, a 20 percent evaluation when it is limited to 30 degrees, and a 30 percent evaluation when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The rating governing a limitation of leg extension provides for a 10 percent evaluation when extension is limited to 10 degrees, a 20 percent evaluation when extension is limited to 15 degrees, and a 30 percent evaluation when extension is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings for knee disabilities may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14 (2017). Under Diagnostic Code 5259, a 10 percent rating can be assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5258, a 20 percent evaluation can be assigned for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5257, recurrent subluxation or lateral instability can be rated as slight (10 percent), moderate (20 percent), or severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. Evaluations for knee impairment can also be assigned due to ankylosis or genu recurvatum. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5263 (2017). The Board notes, however, that because the Veteran was never found to have recurrent subluxation, instability, ankylosis, impairment of the tibia or fibula, or genu recurvatum, these rating criteria will not be further discussed. Diagnostic Code 5003 states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. Id. In this case, however, the Veteran was already been assigned more than a 10 percent rating for his right knee disability, and this rating criteria is not applicable. Under Diagnostic Code 5055, a knee replacement is assigned a 1 year rating of 100 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Following the end of the convalescence period, the Veteran is assigned a minimum rating of 30 percent. With intermediate degrees of residual weakness, pain, or limitation of motion, the symptoms are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. A rating of 60 percent is assigned when there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. Diagnostic Code 5262 evaluates impairment of the tibia and fibula, and assigns a 10 percent rating for slight knee or ankle disability, a 20 percent rating for moderate knee or ankle disability, a 30 percent rating for malunion with marked knee or ankle disability, and a 40 percent rating for nonunion with loose motion, requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The Board has reviewed all of the evidence of record and finds that no rating higher than 30 percent for residuals of a right knee replacement was warranted. At an August 2011 VA examination the Veteran reported knee weakness, stiffness, swelling, giving way, a lack of endurance, locking, fatigability, tenderness, and pain. He denied effusion, redness, deformity, drainage, subluxation, and dislocation. He reported having flare ups as often as once a day and lasting up to 24 hours, and reported difficulty with standing and walking, and trouble with balance. He said that flare ups were precipitated by physical activity and caused swelling, limitation of motion in the joint, and painful walking. The examiner noted that flare ups would affect lifting, walking, standing, or prolonged sitting. Physical examination revealed a nonpainful linear knee replacement surgical scar. There was no edema, inflammation, breakdown, or keloid formation. The scar did not limit function. The Veteran walked with a limp due to his right below the knee amputation. Physical examination found no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding. Range of motion testing revealed flexion to 70 degrees and extension to 0 degrees, with no change in the range of motion after repetitive motion. The examiner found that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. At an October 2012 VA examination the Veteran demonstrated right knee flexion to 140 degrees and extension to 0 degrees, with no objective evidence of painful motion. There was no change in range of motion after repetitive use testing. The Veteran reported left knee pain or tenderness, but not in the right knee. The Veteran reported flare ups that caused occasional buckling and serious weakness. Joint stability testing was normal, and there was no patellar subluxation or dislocation. The examiner noted that the Veteran had meniscal dislocation and meniscal tear that caused frequent episodes of joint pain and joint effusion. The Veteran attended a VA examination in October 2014, and reported having flare ups that impacted his ability to walk, run, or jump. Range of motion testing found flexion to 100 degrees and extension to 0 degrees, with no objective evidence of painful motion. After repetitive use testing, the range of motion was unchanged. There was no tenderness or pain to palpation. Joint stability testing and muscle strength testing were normal. The examiner found no meniscal condition. The examiner wrote that the Veteran's knee conditions affected his ability to walk, sit, and stand, and stated that during flare ups or repeated use over time there would be an additional limitation of functional ability that would affect walking ability, but the examiner was unable to provide the degree of additional range of motion loss without resort to mere speculation because the current examination showed only mild pain or no pain during range of motion testing and there was no significant loss of motion during repetitive use. The examiner opined that flare ups would limit prolonged walking or running. The Veteran was assigned a 30 percent rating for post-arthroscopy residuals under Diagnostic Code 5055, the minimum rating assigned after knee replacement. 38 C.F.R. § 4.71a, Diagnostic Code 5055. To be assigned a 60 percent rating under this diagnostic code, there must be chronic residuals consisting of severe painful motion or weakness in the affected extremity. While it is admittedly difficult to assess the weakness level in the Veteran's entire lower right extremity because of his nonservice connected below the knee amputation, the available evidence of record does not show that right leg pain or weakness was "severe" at any time after June 2011. The VA examiners did not find that the Veteran had painful right knee motion. At October 2012 and October 2014 VA examinations the Veteran denied tenderness and pain to palpation of the right knee. While VA treatment records show that he did have problems with walking and balance, this was regularly attributed to his back pain and right leg prosthesis, and not due to his right knee replacement. The Board therefore finds that a 60 percent rating under Diagnostic Code 5055 is not warranted. Id. Diagnostic Code 5055 also allows for rating by analogy to Diagnostic Codes 5256, 5261, or 5262 with intermediate degrees of residual weakness, pain, or limitation of motion. Id. These rating codes would not, however, allow for any ratings higher than the 30 percent already assigned. Range of motion testing throughout this period show that his right knee extension was always to 0 degrees, and flexion was, at its worst, to 70 degrees, which is not sufficiently restricted motion to allow for higher ratings. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Although a 10 percent rating could be assigned under 38 C.F.R. §§ 4.59 or 4.71, Diagnostic Code 5003 for painful motion or limitation of motion with arthritis, this would allow for only a 10 percent rating, and would be less than the 30 percent already assigned. The Veteran was never found to have ankylosis or a service connected impairment of the tibia or fibula, and therefore Diagnostic Codes 5256 and 5262 do not allow for any greater rating. While Diagnostic Code 5258 is not specifically listed as an alternate rating option in Diagnostic Code 5055, the October 2012 examiner found that the Veteran had meniscal dislocation and meniscal tear that caused frequent episodes of joint pain and joint effusion. A rating under Diagnostic Code 5258 for dislocated cartilage would only allow for a maximum rating of 20 percent, however. Such a rating, even if combined with a 10 percent rating for painful motion, would not result in any higher combined rating than the 30 percent already assigned to the Veteran under Diagnostic Code 5055. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. The Board acknowledges that the Veteran's complaints of knee pain, and considered 38 C.F.R. § 4.59 regarding painful motion. Under 38 C.F.R. § 4.59, with any form of arthritis, actually painful joints are entitled to at least the minimum compensable rating. In this case, however, the Veteran was already assigned at least the minimum compensable rating for his right knee residuals. The 30 percent evaluation took into account the Veteran's limitation of motion hampered by pain, repetitive motion, and flare ups, as these symptoms were evaluated on his examination. Furthermore, pain, by itself, does not constitute functional loss. Rather, there must be actual limitation of motion that is caused by pain. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Functional impairment during flare ups has also been considered, but as the October 2014 examiner explained, it was not possible at the time of examination to estimate any further additional loss of motion during examination since the examination showed only mild or no pain during testing and no significant loss of motion during repetitive use. The examiner estimated that flare ups would limit prolonged walking, which is a limitation that would be expected during a flare up, but would not necessarily indicate a loss of motion such that a higher rating could be assigned. The Board considered lay statements of the Veteran and the appellant regarding the functional impact of the right knee replacement residuals, including difficulty with prolonged walking or standing. They are competent to report observations with regard to the severity of the disability, including reports of pain and decreased mobility. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Their statements are consistent with the rating assigned. The occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed and measured in the Veteran's medical records. To the extent that they argued that the Veteran's symptomatology was more severe than shown on evaluation, their statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the more general lay assertions. Based on the foregoing, the Board finds that a rating higher than 30 percent for right knee replacement residuals was not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; as the preponderance of the evidence is against assignment of a higher rating, it is not applicable. See 38 U.S.C.A. § 5107(b). Lumbar Degenerative Disc Disease In June 2011, the Veteran claimed entitlement to an increased rating for lumbar degenerative disc disease, evaluated as 10 percent disabling. In April 2014, the Veteran submitted an additional claim for an increased rating indicating that his condition had again worsened. In a March 2015 rating decision, the Veteran was assigned an increased evaluation of 20 percent, effective April 22, 2014, for lumbar degenerative disc disease. The Veteran wrote in August 2011 that his lower back had been getting more painful during certain physical activities, and that it was often very stiff and painful. In March 2012, he wrote that he was unable to stand for 15 minutes without severe pain, and that he had discomfort when sitting and pain when sleeping. In September 2015, he wrote that he was unable to walk more than 100 feet that he required a walker and scooter to get around, that he was unable to stand for more than 5 minutes due to back pain, and that he could not lay flat due to severe back pain. He also wrote that his back problems caused frequent falls, and that he was mostly confined to a wheelchair. At a March 2017 Board hearing, the Veteran discussed how his back disability caused him severe pain. The applicable criteria for evaluating disability of the spine provide a single set of criteria for rating conditions of the spine, the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula). See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Disabilities of the spine are to be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating for an Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25 (2017). 38 C.F.R. § 4.71a, Note (6) (2017). The Veteran was not, at any time, found to have intervertebral disc syndrome or an incapacitating episode due to his lumbar spine degenerative disc disease. Therefore the rating specifically for rating intervertebral disc syndrome based on incapacitating episodes will not be further discussed. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1) (2016). There is no medical evidence of any further neurological symptoms associated with his lumbar spine disorder. Neurological manifestations of the Veteran's low back disorder will therefore not be further discussed. None of the VA examiners found any radiculopathy or other neurological abnormalities associated with lumbar degenerative disc disease. While the Veteran was noted to have neuropathy since at least 2016, this was diagnosed by his treating medical professionals as diabetic autonomic neuropathy, a nonservice connected disorder, and not related to his lumbar spine. Neurological manifestations of the Veteran's lumbar spine disorder will therefore not be further discussed. Under the General Rating Formula, a 10 percent rating is warranted for thoracolumbar spine flexion greater than 60 degrees but less than 85 degrees; a combined range of motion of 120 degrees but less than 235 degrees; muscle spasm, guarding, or localized tenderness; or vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. A 20 percent rating is warranted for thoracolumbar spine forward flexion greater than 30 degrees but not greater than 60 degrees; or, the 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. Id. A 40 percent evaluation is warranted for forward flexion of 30 degrees of less; or favorable ankylosis of the entire thoracolumbar spine. Id. The Board has considered all of the evidence of record, and finds that ratings of 10 percent prior to April 22, 2014 and 20 percent since April 22, 2014, were appropriate, and that no higher ratings were warranted. At an August 2011 VA examination the Veteran reported having problems walking, stiffness, fatigue, spasms, a limitation of bending, and decreased motion. He reported frequent pain, and that flare ups limited walking. He denied periods of incapacitation. Physical examination found no radiating pain, ankylosis, or spasm. There was evidence of tenderness. Range of motion testing found flexion to 90 degrees, and 30 degrees of extension, bilateral lateral flexion, and bilateral rotation. There was no change after repetitive motion, and joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. At an October 2012 VA examination the Veteran reported that flare ups limited his standing, sitting, running, and jumping. Range of motion testing found flexion to 90 degrees, extension to 0 degrees, and bilateral lateral flexion and bilateral rotation to 30 degrees. Pain started at 0 degrees in all planes of movement. There was no change after repetitive use testing. The Veteran had localized tenderness or pain to palpation, but no guarding or muscle spasm. There was no radiculopathy or other neurological abnormalities. The Veteran did not have an intervertebral disc syndrome. At the October 2014 VA examination, the Veteran reported that flare ups impacted his ability to lift, bend, sit, stand, and walk. Range of motion testing found flexion to 65 degrees, and extension to 5 degrees. Bilateral lateral flexion and lateral rotation were to 30 degrees in each plane. In all directions there was pain at 0 degrees, but there was no change in range of motion after repetitive use testing. The Veteran had localized tenderness or pain to palpation, but no spasm or guarding. There was no radiculopathy, sensory examination was normal, and there were no other neurological abnormalities related to the spine. The Veteran did not have an intervertebral disc syndrome. The examiner opined that the Veteran's disorder impacted his ability to lift, bend, sit, stand, walk, or run. The examiner also wrote that during flare ups or after repeated use over time, there would be an additional limitation of function resulting in a 5 degree loss of forward flexion. The Veteran's VA treatment records show complaints of chronic low back pain and treatment for lumbago, and he frequently was noted to use a walker, crutches, or wheelchair for mobility. In February 2013, the Veteran was treated for low back pain. He had forward flexion to about 90 degrees, and extension to 20 degrees. There was pain with extension and rotation. In June 2013, the Veteran was treated for low back pain that was aggravated by standing or walking. In October 2014, the Veteran's physiatrist noted that "functional mobility status (was) limited by severe back pain." He was able to take a few steps independently, but his balance was poor. At a February 2015 physical therapy consultation, it was noted that the Veteran could only walk for 2 to 3 minutes due to back pain. Forward flexion was within full limits, but there was guarding and pain with extension, lateral flexion, and extension with rotation. In December 2015, he again reported pain when sitting upright, standing, or walking. The Veteran stated that he woke from sleep every two hours due to back pain. The Board finds that entitlement to a rating higher than 10 percent prior to April 22, 2014 is not warranted. The Veteran's VA examinations and treatment records prior to April 22, 2014 did not show any findings of forward flexion of 60 degrees or less, or of a combined range of motion of 120 degrees or less. The October 2012 VA examiner specifically noted no guarding or muscle spasm. The earliest notation of guarding in the Veteran's treatment records was not until 2015. The Veteran therefore did not meet the criteria for a 20 percent rating prior to April 22, 2014. Id. The Board acknowledges that in October 2012 the Veteran had pain at 0 degrees in all directions, and VA treatment records show frequent complaints of severe back pain. This pain alone does not, however, indicate that a higher rating was warranted. As discussed, pain alone does not constitute functional loss. Rather, there must be actual limitation of motion that is caused by pain. See Mitchell, 25 Vet. App. at 38-43. The Veteran was already been assigned at least the minimum rating for the entire period on appeal. As he was found on multiple occasions to demonstrate flexion to 90 degrees during the period prior to April 22, 2014, his pain is not found to have caused so much impairment that he was unable to perform such ranges of motion. There is no medical evidence indicating that prior to April 22, 2014, pain, weakness, repetitive motion, or flare ups resulted in a further limitation of motion which effectively decreased the Veteran's forward flexion to 60 degrees or less or combined range of motion to 120 degrees or less, and would allow for a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The Board has considered whether the Veteran's range of motion would be decreased during flare ups, but there is no evidence regarding what the specific change in range of motion would be prior to April 22, 2014, and the Veteran reported at his VA examinations only that flare ups caused limitations in walking, standing, sitting, running, and jumping, not that he had actual decreased range of motion. Following the Veteran's new request on April 22, 2014 for an increased rating he attended an October 2014 VA examination. He was found to demonstrate forward flexion to 65 degrees, which would then be limited a further 5 degrees during a flare up. On that basis, the Veteran was assigned an increased rating of 20 percent. The evidence does not show that any rating higher than 20 percent can be assigned for the period after April 22, 2014. At no time did the Veteran show forward flexion to 30 degrees or less, even when painful motion and flare ups are taken into account, and he was never found to have any thoracolumbar ankylosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. The Board considered the Veteran's reports of pain, weakness, and incoordination in his back. These reports were taken into account when assigning a 20 percent rating, which was based on the estimated loss of motion during a flare up. The Veteran was assigned more than the minimum rating for his lumbar spine disorder, and therefore additional compensation under 38 C.F.R. § 4.59 or DeLuca, 8 Vet. App. 202 was not warranted. There is no medical evidence indicating that after April 22, 2014, pain, weakness, repetitive motion, or flare-ups resulted in a further limitation of motion which effectively decreased the Veteran's forward flexion to 60 degrees or less, or combined range of motion to 120 degrees or less, and would allow for a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The lay statements of the Veteran and the appellant regarding the functional impairment caused by his lumbar spine disorder have been considered. To the extent that they asserted that his rating should have been higher than 20 percent, their lay statements are outweighed by the clinical findings of the VA examiners. The Veteran also asserted that his lumbar spine disorder was a large part of why he was unable to continue working. These assertions are addressed further below. In sum, the preponderance of the medical and other evidence of record is against entitlement to a rating higher than 10 percent prior to April 22, 2014 or higher than 20 percent after April 22, 2014 for lumbar degenerative disc disease. As the preponderance of the evidence is against any higher ratings, the benefit of the doubt doctrine may not be further applied. See 38 U.S.C.A. § 5107(b). Total Disability Rating Based on Individual Unemployability In June 2012, the Veteran wrote to VA requesting to open a claim of entitlement to a total disability rating based on individual unemployability. The Veteran reported that he last worked in September 2008, and that he was unable to work because of his back, knee, and right leg disabilities. In December 2015, the Veteran wrote that he was almost totally housebound, had frequent falls, was unable to do any housework, and was almost unable to care for himself. At a March 2017 Board hearing the appellant described how the Veteran had difficulty using the bathroom and required help with all household tasks. She stated that he was unable to take a shower and had to be given a sponge bath. The Veteran stated that he had to stop working as a blackjack dealer because it was too painful to stand through his shift. The Veteran stated that he would not be able to do a sedentary job either, because it was too painful to sit in a chair for a long time. VA will grant a total disability evaluation based on individual unemployability due to service-connected disorders when the evidence shows that a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Veteran was assigned a temporary total evaluation from December 9, 2011 to January 31, 2013. Effective February 1, 2013, the Veteran was service connected for left knee replacement residuals (60 percent), right knee replacement residuals (30 percent), lumbar spine degenerative disc disease (10/20 percent), right elbow dislocation (0 percent), erectile dysfunction (0 percent), and bilateral knee scars (0 percent). He had a combined rating of 80 percent. Thus, he met the criteria to be eligible for a schedular total disability evaluation based on individual unemployability due to service-connected disorders under 38 C.F.R. § 4.16(a). The record also contains competent evidence indicating that the Veteran was unable to obtain or maintain gainful employment due to his service-connected disabilities. In this regard in the Veteran's 2010 application for Social Security Disability benefits, the appellant wrote that the Veteran had difficulty dressing and bathing himself, that he was not able to stand for long periods of time without falling, and that he needed help with household chores. The Veteran wrote that his disabilities affected his ability to do lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, stair climbing, using his hands, and also affected his memory and concentration. He wrote that he had one year of college, and that he had to stop working in September 2007 because of his disabilities The October 2012 VA examiner wrote that the Veteran's knee disabilities would prevent him from being able to run or perform strenuous activity, and his spine disability would impair his ability to bend or lift things, to do overhead work, or to perform any work for extended periods due to pain and decreased range of motion. At a December 2015 rehabilitation session the Veteran's treating rehabilitation physician found that the Veteran's back disorder would completely interfere with general activity, walking ability, and normal work, both inside and outside the home. A November 2016 letter from a chiropractor stated that the Veteran was disabled due to several conditions, including degenerative changes in his spine, which prevented him from participating in the majority of his routine daily activities and prevented any gainful employment. In sum, the medical evidence shows that the Veteran had extremely severe back pain which prevented walking or extended sitting, as well as severe knee disabilities that further compounded his mobility. Several medical professionals found that these disabilities prevented all types of employment, which would include sedentary employment. The Board therefore finds that there is adequate medical evidence indicating that the Veteran's service-connected disabilities, including, most significantly, his lumbar spine and bilateral knee disabilities, prevented him from being able to maintain any gainful employment, and entitlement to a total disability rating based on individual unemployability is granted. Wise v. Shinseki, 26 Vet. App. 517, 531 (2014). ("By requiring only an 'approximate balance of positive and negative evidence' . . ., the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding . . . benefits."). Lastly, the Board notes that the question of entitlement to referral for consideration of an extraschedular rating for either right knee replacement or lumbar spine degenerative disc disease is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities, and will not be discussed at this time. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). ORDER Entitlement to a rating in excess of 30 percent for residuals of right knee replacement is denied. Entitlement to a rating in excess of 10 percent for lumbar spine degenerative disc disease prior to April 22, 2014 is denied. Entitlement to a rating in excess of 20 percent for lumbar spine degenerative disc disease since April 22, 2014 is denied. Entitlement to a total disability rating based on individual unemployability is granted subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs