Citation Nr: 19104792 Decision Date: 01/22/19 Archive Date: 01/22/19 DOCKET NO. 05-07 659 DATE: January 22, 2019 ORDER New and material evidence having not been submitted, a claim of entitlement to service connection for an acquired psychiatric disorder is denied. Entitlement to an initial compensable rating of 10 percent for limitation of extension of the left hip is granted. Entitlement to an initial compensable rating for limitation of flexion of the left hip is denied. Entitlement to an initial rating in excess of 10 percent for impairment of the left hip is denied. Entitlement to an initial rating in excess of 30 percent for a right knee disability prior to July 7, 2003 is denied. Entitlement to an effective date earlier than December 7, 2007, for the grant of service connection for limitation of extension of the left hip is denied. Entitlement to an effective date earlier than December 7, 2007, for the grant of service connection for limitation of flexion of the left hip is denied. Entitlement to an effective date earlier than December 7, 2007, for the grant of service connection for impairment of the left hip is denied. Entitlement to service connection for a right shoulder disorder, to include as secondary to the service-connected right knee disability is denied. Entitlement to a total disability rating due to individual unemployability (TDIU) prior to December 5, 2011 is denied. FINDINGS OF FACT 1. In a final decision issued in August 2004, the Regional Office (RO) denied service connection for an acquired psychiatric disorder. 2. Evidence added to the record since the final August 2004 denial is either cumulative or redundant of evidence previously considered, does not relate to an unestablished fact necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the claim of service connection for a psychiatric disorder. 3. The competent, probative evidence of record fails to relate a right shoulder disorder to service or to a service-connected disability. 4. The Veteran’s abduction of the left hip is not limited to motion lost beyond 10 degrees. 5. The Veteran’s flexion of the left hip has been limited to, at most, 65 degrees. 6. Resolving all reasonable doubt in his favor, the Veteran’s left hip disability has been manifested by limitation of extension to 0 degrees. 7. For the period prior to July 7, 2003, the Veteran’s right knee disability has been found to lack full extension. Further, there are reports of pain, crepitus, infrapatellar tenderness, and notations of intermittent locking and swelling. 8. The Veteran’s claim of entitlement to service connection for impairment of the left hip was received by VA on December 7, 2007; there is no evidence in the claims file which can reasonably be considered as a claim prior to that date. 9. The Veteran’s claim of entitlement to service connection for limitation of extension of the left hip was received by VA on December 7, 2007; there is no evidence in the claims file which can reasonably be considered as a claim prior to that date. 10. The Veteran’s claim of entitlement to service connection for limitation of flexion of the left hip was received by VA on December 7, 2007; there is no evidence in the claims file which can reasonably be considered as a claim prior to that date. 11. For the period prior to December 7, 2007, the Veteran has a combined disability of 30 percent, which does not meet the schedular requirements for a TDIU. 12. For the period from December 7, 2007 to December 5, 2011, the Veteran has a combined disability rating of 60 percent, that includes the 30 percent rating for the right knee, 10 percent for the left hip, 10 percent for limitation of extension of the left hip, 10 percent for a left ankle disability, 0 percent for the left hip limitation of flexion, and 0 percent for a scar on the right knee, which does meet the schedular requirements for a TDIU when considering that these disabilities affect a single body system (orthopedic). 13. The preponderance of the evidence is against a finding that the Veteran’s service-connected disabilities preclude him from securing and following substantially gainful employment prior to December 5, 2011. CONCLUSIONS OF LAW 1. The August 2004 RO decision that denied the claim of entitlement to service connection for an acquired psychiatric disorder is final. 38 U.S.C.§ 7105(c) (West 2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. New and material evidence has not been received to reopen the claim for service connection for an acquired psychiatric disorder. 38 U.S.C. § 5108 (West 2012); 38 C.F.R. § 3.156(a) (2017). 3. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 4. The criteria for an initial rating in excess of 10 percent for impairment of the left hip have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5253. 5. The criteria for an initial compensable rating for left hip limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5252. 6. The criteria are met for an initial rating of 10 percent for left hip limitation of extension. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5251. 7. The criteria for an initial rating in excess of 30 percent for the right knee disability for the period prior to July 7, 2003, have not been met. 38 U.S.C. § 1155, 5103, 5107 (West 2012); 38 C.F.R. § .1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5261 (2017). 8. The criteria for an effective date earlier than December 7, 2007, for the grant of service connection for limitation of extension of the left hip have not been met. 38 U.S.C. § 5110 (West 2012); 38 C.F.R. § 3.400 (2017). 9. The criteria for an effective date earlier than December 7, 2007, for the grant of service connection for limitation of flexion of the left hip have not been met. 38 U.S.C. § 5110 (West 2012); 38 C.F.R. § 3.400 (2017). 10. The criteria for an effective date earlier than December 7, 2007, for the grant of service connection for limitation of motion of the left hip have not been met. 38 U.S.C. § 5110 (West 2012); 38 C.F.R. § 3.400 (2017). 11. For the period prior to December 5, 2011, the criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1979 to July 1982. In December 2007, the Veteran testified at a Board hearing before a former Veterans Law Judge (VLJ) regarding only his claim for a higher initial rating for the right knee. A transcript of this proceeding is associated with the claims file. The Veteran was provided the opportunity to attend another hearing before a new VLJ but he opted against a new hearing in January 2014. The appeal was most recently remanded by the Board in July 2017. The requested actions have been completed and the appeal returned to the Board for adjudication. New and Material Evidence 1. Acquired psychiatric disorder Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary’s duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Veteran’s claim for a psychiatric disorder, claimed as a nervous disorder, was initially denied by the RO in January 1986 on the basis the evidence failed to show in-service psychiatric treatment or evidence of psychosis within one year of separation from service. The RO did acknowledge the Veteran’s psychiatric treatment in 1985, which was diagnosed as an acute psychotic episode. The RO again denied the claim in a February 1999 rating decision, noting that new and material evidence had not been submitted. The Veteran filed a petition to reopen this claim for service connection in July 2003, claimed as schizophrenia. An August 2004 rating decision continued the previous denial of this claim on the basis that the evidence does not show a psychiatric disorder was incurred in or caused by the Veteran’s service. As the Veteran did not file either notice of disagreement within one year of the issuance of this rating decision or submit new and material evidence within one year, the August 2004 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as no evidence pertaining to the Veteran’s claim for service connection was received prior to the expiration of the appeal period stemming from the prior rating decisions, including the August 2004 rating decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). In denying the claim in the August 2004 rating decision, the RO considered the Veteran’s service treatment records, VA treatment records, and lay statements submitted by the Veteran that all failed to establish the Veteran suffers from a psychiatric disability that is attributable to his military service. In April 2009, the Veteran filed another petition to reopen this claim, now claimed as schizophrenia and bipolar disorder, and the July 2010 rating decision currently on appeal continued the denial of the claim for service connection for a psychiatric disorder. Evidence submitted since the last final denial includes VA treatment records, Social Security Administration (SSA) records, and additional statements from the Veteran submitted in support of his claim. While the Board notes the Veteran has sought treatment for psychiatric disorders, diagnosed as psychotic disorder and schizophrenia according to the available VA treatment records, there are no etiological opinions of record attributing these disorders to his military service. Further, the Veteran’s statements in support of his claim for service connection again set forth his assertion that his current psychiatric disorders are due to his military service. However, and most importantly, the Veteran has not submitted any evidence etiologically attributing any psychiatric disorder to his military service. Consequently, there is no evidence of record indicating the Veteran suffers from a psychiatric disorder that is due to his military service. As there are no new contentions or evidence to support the claim, the evidence added to the record is either cumulative, or unrelated to the claim. Therefore, new and material evidence has not been submitted, the claim is not reopened, and the appeal as to this issue is denied. Service Connection 2. Right shoulder disorder The Veteran is seeking entitlement to service connection for a right shoulder disorder that he alleges is either due directly to his military service or, alternatively, secondary to his service-connected right knee disability. Specifically, he argues that the right knee disability requires the use of a cane for ambulation, which has resulted in a right shoulder disorder. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish entitlement to service connection for a disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established for a chronic disease as enumerated for VA compensation purposes, to include hypertension and arthritis, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for an enumerated “chronic disease” listed under 38 C.F.R. § 3.309(a) can also be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1110, 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). That is, under 38 C.F.R. § 3.303(b), with an enumerated “chronic disease” such as arthritis is shown in service (or within the presumptive period under § 3.307), subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. See also Groves v. Peake, 524 F.3d 1306, 1309 (2008). This rule does not mean that any manifestation of joint pain in service will permit service connection of arthritis first shown as a clear cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity of symptomatology. 38 C.F.R. § 3.303(b). With regard to secondary service connection, a disability can be service-connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Moreover, secondary service connection may also be established by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b), effective October 10, 2006. See 71 Fed. Reg. 52,744-52,747 (September 7, 2006). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. In short, in order to establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) probative evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board concludes that, while the Veteran has a current diagnosis of arthritis of the right shoulder confirmed by x-ray findings (See February 2008 VA treatment record), the preponderance of the evidence is against finding that the Veteran’s right shoulder disorder is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability, or directly attributable to his military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a). As an initial matter, the Veteran’s service treatment records note the Veteran’s complaint of right shoulder pain in December 1981 after lifting a lawn mower. These records show a diagnosis of bursitis; however, there are no subsequent complaints of or treatment for his right shoulder during service. Further, there is no medical evidence that arthritis of the right shoulder manifested within one year of service. Thus, presumptive service connection for this disorder pursuant to 38 C.F.R. § 3.307 is not established. The Veteran was scheduled for in-person VA examinations in January 2009, September 2015, and June 2018. During the January 2009 VA examination, the VA examiner documented that the Veteran has used a cane since 2003 or 2004 with his right hand, but will sometimes use the cane with his left hand due to his right shoulder problems. The VA examiner concluded that x-rays showed evidence of degenerative arthritis of the right shoulder. The examiner ultimately concluded that degenerative arthritis can occur as a person gets older or when there is significant trauma, which, based on the examiner’s clinical experience, holding a cane is not likely cause for trauma. Therefore, the right shoulder disorder is less likely than not due to or the result of the right knee disability. During the September 2015 VA examination, the examiner diagnosed the Veteran with right shoulder arthritis and ankylosis, but concluded that these disorders did not begin in service. She stated that his right shoulder condition in service was a short-term bursitis that was unrelated to his current disorders and there is no evidence of another shoulder condition or permanent injury in service. She also concluded that the Veteran’s right shoulder disorders were not caused by or aggravated by the right knee disabilities because they do not exert biomechanical force on the right shoulder joint. She noted that the Veteran uses his cane with his left arm, rather than his right, and therefore the use of a cane is unrelated to his right shoulder condition. However, in the July 2017 Remand, the Board noted that the September 2015 opinion was inadequate with regards to the opinion for secondary service connection because the Veteran’s VA medical records indicate that the Veteran is right-handed and has ambulated to treatment visits with a cane in his right hand. Thus, the Board determined that this opinion was inadequate because the examiner inaccurately stated the Veteran never uses his right arm and did not address that the Veteran uses his left arm because of his right shoulder disability. In compliance with the July 2017 Remand directives, an in-person examination and addendum opinion were obtained in June 2018. The VA examiner indicated a review of the claims file was conducted and ultimately concluded that the right shoulder disorder is less likely than not due to or aggravated by the service-connected right knee disorder. By way of rationale, the examiner noted the in-service diagnosis of bursitis and the injury regarding lifting a lawnmower. Nevertheless, the examiner stated there is no study or reasonable medical knowledge to support the claim that the diagnosed right shoulder arthritis is caused by the arthritis in the other joint. Similarly, there is no study to confirm that infrequent cane use on the right side is causative of arthritis in the shoulder. Also of record are VA treatment records dated throughout the appeals period. However, while these records show the diagnosis of arthritis of the right shoulder, they do not contain any etiological opinions. The Board finds the VA examinations and opinions, collectively, are probative evidence as to whether the Veteran’s right shoulder disorder is etiologically related to his service-connected right knee disability. The examiners reviewed the evidence of record, interviewed the Veteran during the physical examinations, considered the relevant medical literature, and provided medical opinions supported by a well-reasoned rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Specifically, the September 2015 VA examiner conclude it was less likely than not that the right shoulder disorder is directly attributable to his military service, to include the in-service bursitis, and the June 2018 VA examiner concluded it was less likely than not the right shoulder disorder is due to or aggravated by the right knee disability. The Veteran is competent to provide information on when he was diagnosed with a right shoulder disorder and the Board finds his report to be competent, credible, and entitled to probative weight. His report has been internally consistent, and is consistent with other evidence of record, including the VA examinations and available treatment records. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, while the Veteran believes his right shoulder disorder is either directly due to his military service or, proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability, he is not competent to provide a nexus opinion in this case either on a direct or secondary basis. The issue is medically complex, as it requires knowledge of the musculoskeletal system in the body and the interpretation of complicated diagnostic medical testing, such as x-rays. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA opinions that fails to link the right shoulder disorder to the Veteran’s military service or a service-connected disability. Therefore, while the evidence does show the Veteran has a current diagnosis of degenerative joint disease of the right shoulder, the evidence fails to show that it may be presumptively associated with his military service, was incurred during service, or is proximately due to or the result of, or aggravated beyond the natural progression by a service-connected disability. As such, this claim is denied on all bases. In reaching the above conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (West 2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (West 2002); 38 C.F.R. § 4.1 (2017). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and, above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2017). Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding this appeal, the Board has considered whether separate ratings for different periods of time are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). A United States Court of Appeals for Veterans Claims (Court) decision addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. Finally, under 38 C.F.R. § 4.71a (2017), which sets forth the schedular rating criteria for the musculoskeletal system, Diagnostic Code 5010 directs VA to rate arthritis due to trauma under degenerative arthritis, or Diagnostic Code 5003. Diagnostic Code 5003 provides that degenerative arthritis is to be evaluated on the basis of limitation of motion as per the diagnostic codes for the specific joint or joints. Id. If, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is assigned for each major joint or group of minor joints affected by limitation of motion. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating can be assigned where there is x-ray evidence of 2 or more major joints or 2 or more minor joint groups and a 20 percent rating can be assigned if such involvement includes occasional incapacitating episodes. Id. Note (1) under Diagnostic Code 5003 provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Id. 3. Left hip disabilities The Veteran is seeking higher initial ratings for his left hip disability, rated at 10 percent pursuant to Diagnostic Code 5253, with separate noncompensable ratings for limitation of flexion and extension, pursuant to Diagnostic Codes 5252 and 5251, respectively. Diagnostic Code 5251 addresses limitation of extension of the thigh, and provides for a single 10 percent rating when extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Notably, in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Diagnostic Code 5252 addresses limitation of flexion of the thigh, and provides for a 10 percent rating when flexion is limited to 45 degrees. A 20 percent rating is assigned when flexion is limited to 30 degrees, and higher ratings are assigned for more severe limitations. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Diagnostic Code 5253 addresses other impairment of the thigh. A 10 percent rating is assigned when rotation is limited such that a veteran cannot “toe-out” more than 15 degrees, or when adduction is limited such that a veteran cannot cross his legs. A 20 percent rating is assigned when abduction motion is lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. Normal hip flexion is to 125 degrees; normal hip abduction is to 45 degrees. 38 C.F.R. § 4.71, Plate II. The Veteran was initially examined by VA in January 2009 in connection with his claim of service connection for a left hip disorder. At that time, the Veteran reported that his left hip had been bothering him for 2 to 3 years. He reported that the left hip is characterized by constant pain, but it is worse when the weather changes. The examiner noted the Veteran reported taking pain medications for the left hip, but there is no indication of treatment for this disorder. There is also no evidence of swelling, but the Veteran stated he feels weak and has decreased endurance due to the service-connected left knee disability. Upon physical examination, tenderness was noted over the muscles of the left hip. Range of motion testing revealed flexion to 85 degrees, with pain beginning at 10 degrees; extension to 0 degrees; abduction to 26 degrees; adduction to 10 degrees; external rotation to 50 degrees; and, internal rotation to 15 degrees. The examiner also noted moderate antalgia. Following repetitive testing, the examiner found range of motion to be flexion to 90 degrees; extension to 0 degrees; abduction to 26 degrees; adduction to 10 degrees; external rotation to 50 degrees; and, internal rotation to 15 degrees. X-rays of the left hip were normal. The examiner ultimately provided a diagnosis of arthralgia of the left hip with normal x-rays. No other clinical findings were noted. The Veteran was next examined by VA in September 2015 in connection with his claim for service connection. The VA examiner provided a diagnosis of chronic left hip strain. The Veteran denied flare-ups of the left hip, but reported functional impairment/loss as manifested by pain, stiffness, and loss of motion. Upon physical examination, tenderness to palpation was noted, but there was no evidence of crepitus. Range of motion testing revealed flexion to 65 degrees; extension to 10 degrees; abduction to 25 degrees; adduction to 10 degrees; external rotation to 15 degrees; and, internal rotation to 20 degrees. The examiner noted that adduction was limited so that the Veteran could not cross his legs. Pain was reported for all motions, including on weight-bearing, and caused functional loss. The examiner indicated the Veteran could not perform repetitive testing due to the baseline motion being too restricted. However, pain, weakness, fatigability, and incoordination were not found to significantly limit functional ability with use over time. There was no evidence of muscle atrophy or a reduction in muscle strength. Additionally, there was no evidence of ankylosis or malunion/ nonunion of femur, flail hip joint or leg length discrepancy. Upon x-ray testing, there was no evidence of arthritis in the left hip. Following the grant of service connection for his left hip disabilities, the Veteran was again examined by VA in June 2018 to determine the current nature and severity of his left hip disabilities. The VA examiner noted there was no objective evidence of a left hip disorder. Further, there was no indication in the claims file the Veteran has sought treatment for a left hip disorder or been prescribed medication. The Veteran denied experiencing flare-ups and any functional impairment/loss due to his hip disorder. Upon physical examination, there was no tenderness to palpation or crepitus. Range of motion testing revealed flexion to 125 degrees; extension to 30 degrees; abduction to 45 degrees; adduction to 25 degrees; external rotation to 60 degrees; and, internal rotation to 40 degrees. The examiner noted that adduction was not limited so that the Veteran could not cross his legs. The Veteran denied pain for all motions, including on weight-bearing. The Veteran was able to perform repetitive testing with no loss in range of motion or any factors contributing to functional impairment. There was no evidence of muscle atrophy or a reduction in muscle strength. Additionally, there was no evidence of ankylosis or malunion/nonunion of femur, flail hip joint or leg length discrepancy. Finally, the examiner remarked that the Veteran exhibited a distinct lack of effort yet he was able to ambulate without difficulty. The examiner ultimately concluded that the Veteran’s left hip disability had resolved. Also of record are VA treatment records dated throughout the pendency of this appeal. However, these records do not contain any treatment for a left hip disability or disabilities, to include pain management. As such, there is no objective evidence to consider as contained in these records. Turning first to the currently assigned noncompensable rating pursuant to Diagnostic Code 5251 for limitation of extension, a 10 percent rating is warranted when extension is limited to 5 degrees. Here, the January 2009 VA examiner found extension to 0 degrees, whereas the subsequent September 2015 and June 2018 examinations noted extension to 10 degrees and 30 degrees, respectively. Nevertheless, affording the Veteran the benefit of the doubt, the Board finds that an initial 10 percent rating is warranted based on limitation of extension due to the findings of the January 2009 examination. This is the highest rating allowed under the Diagnostic Code. As for Diagnostic Code 5252, the Veteran is currently in receipt of a noncompensable initial rating for limitation of flexion of the left hip. A 10 percent rating under this diagnostic code requires flexion to be limited to 45 degrees. Here, none of the VA examiners found flexion to be limited to 45 degrees. The Board notes the Veteran reported pain on motion beginning at 10 degrees during the January 2009 VA examination, but flexion was still found to be to 85 degrees. Throughout the appeals period, the Veteran’s flexion was found to be, at its worse, 65 degrees. Therefore, an initial compensable rating is not warranted based on limitation of flexion. Finally, the Veteran is currently in receipt of an initial 10 percent rating pursuant to Diagnostic Code 5253 for impairment of the left hip. In order to warrant the next higher 20 percent rating, the evidence must show abduction motion is lost beyond 10 degrees. Here, the evidence shows the Veteran’s abduction has been limited to, at its worst, 25 degrees. See September 2015 VA examination. Therefore, a 20 percent rating is not warranted for impairment of the left hip. In addition, the Board has considered whether repetitive motion and/or flare-ups resulted in additional functional loss due to symptoms such as pain, swelling, weakness, fatigue, or incoordination. The January 2009 VA examiner specifically noted there was pain on motion but repetitive testing showed flexion actually increased from 85 degrees to 90 degrees. There was no change in any other ranges of motion. The September 2015 VA examiner also noted pain on motion and specifically stated that repetitive testing could not be conducted due to such pain. However, the evidence fails to show limitation of flexion to even a compensable degree in any of the VA examinations, even in contemplation of functional loss caused by symptoms such as pain. Similarly, there was no change in the Veteran’s abduction, even when considering pain on motion as noted by the January 2009 and September 2015 VA examiners. As such, the Board finds that the Veteran is not entitled to initial compensable ratings under Diagnostic Code 5252 or 5253. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell, supra. Burton v. Shinseki, 25 Vet. App. 1 (2011). As for functional impairment in the context of limitation of extension, the Veteran is now in receipt of the highest rating allowed under Diagnostic Code 5251. Further, to the extent the VA examinations failed to comply with the holdings in Correia or Sharp such non-compliance is harmless error. In this respect, the Veteran specifically denied flare-ups throughout the appeal. Further, the September 2015 VA examination noted pain on weight-bearing but indicated there was no functional loss with use over time. Other potentially applicable diagnostic codes pertaining to the hip have been considered. See Schafrath, 1 Vet. App. at 595. However, there is no evidence of hip ankylosis, malunion of the femur, or flail hip joint. Therefore, Diagnostic Codes 5250, 5254, and 5255 are not for application. 38 C.F.R. § 4.71a. In reaching the above conclusions, the Board has not overlooked the Veteran’s statements with regard to the severity of his left hip disabilities. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing chronic pain in his left hip. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence through written statements throughout the course of his appeal with respect to the presence of pain and the severity of such during his VA examinations. He is competent to provide such statements, and the Board finds that the Veteran’s statements are credible. The Veteran’s reported symptomatology has been noted in the rating decisions above, and the Board has considered the Veteran’s reports with respect to pain in evaluating his assigned ratings. With respect to the Rating Schedule, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person. Therefore, the objective medical findings provided by the Veteran’s VA examination reports have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (“[t]he probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.”). The preponderance of the evidence is against the claims for higher initial ratings with respect to the limitation of flexion and impairment of the left hip. Thus, there is no doubt to be resolved and the claims are denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 4. Right knee disability By way of history, in the prior July 2017 Board decision, the Veteran was afforded an effective date of February 13, 1987, for the grant of service connection for his right knee disability. While the Board addressed the merits of the claim for a higher rating for the period since July 7, 2003, the claim of entitlement to an initial rating was remanded to the RO. On remand, the RO assigned an initial rating of 30 percent for the right knee disability pursuant to Diagnostic Code 5010-5261. For purposes of this decision, the Board notes that normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71a, Plate II. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98 (Aug. 1998). Moreover, the General Counsel also held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and under Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (Sept. 2004). The only relevant evidence of record prior to July 7, 2003, pertaining to this claim are the Veteran’s service treatment records. Specifically, the Veteran’s service treatment records show in-service treatment for a right knee disorder, diagnosed as chondromalacia of the right knee. A March 1980 examination reports the Veteran’s right knee lacks full extension but does not provide a specific finding regarding range of motion. Additionally, there is evidence of crepitus, infrapatellar tenderness, and pain. There are also notations of intermittent locking and swelling. Based on the evidence in the Veteran’s service treatment records, the Board finds no basis upon which a higher initial rating for the period prior to July 7, 2003 may be granted. There are no objective range of motion findings and no VA examinations were conducted. The only evidence in support of the Veteran’s claim is the indication in service that his right knee lacks full extension. Given that the evaluation period does not include the time of the Veteran’s time in service, and based on the aforementioned, a higher rating is not warranted. Additionally, the Board has considered whether the Veteran’s knee disability resulted in a level of functional loss greater than that already contemplated by the assigned rating for the period prior to July 7, 2003. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, the Veteran’s right knee has been found to lack full extension. Further, there are reports of pain, crepitus, infrapatellar tenderness, and notations of intermittent locking and swelling. However, the rating schedule is intended to allow for compensation for painful motion of a joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Thus, the evidence does not reflect functional loss that is not already contemplated by the assigned rating of 30 percent prior to July 7, 2003. A rating in excess of 30 percent is not warranted for the left knee on the basis of functional loss. In reaching the above conclusions, the Board has not overlooked the Veteran’s statements with regard to the severity of his right knee disability, to include his prior Board hearing testimony. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing chronic pain in his knee since service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence through written statements throughout the course of his appeal with respect to the presence of pain. He is competent to provide such statements, and the Board finds that the Veteran’s statements are credible. The Veteran’s reported symptomatology has been noted in the rating decisions above, and the Board has considered the Veteran’s reports with respect to pain in evaluating his assigned ratings. With respect to the Rating Schedule, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person. Therefore, the objective medical findings provided by the Veteran’s VA examination reports have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (“[t]he probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.”). The preponderance of the evidence is against the claim for an initial rating in excess of 30 percent for the right knee disability for the period prior to July 7, 2003. Thus, there is no doubt to be resolved and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Effective Date 5. Entitlement to effective dates earlier than December 7, 2007, for the grants of service connection for limitation of extension, limitation of flexion, and impairment of the left hip The Veteran is seeking entitlement to effective dates earlier than December 7, 2007, for the grants of service connection for his left hip disabilities. Specifically, on his August 2016 Notice of Disagreement, the Veteran argues that his left hip disabilities are secondary to this right knee disability, which has been assigned an effective date of February 13, 1987, and the evidence shows left hip symptomatology prior to the 2007 effective date currently assigned. Therefore, since the left hip disabilities are related to the service-connected right knee disability, the Veteran believes these disabilities should have to same effective dates. The provisions governing the assignment of the effective date of a claim for compensation or an increased rating are set forth in 38 U.S.C. § 5110(a) and (b)(2), and 38 C.F.R. § 3.400(o). The general rule regarding effective dates is that the effective date of an evaluation and award of compensation based on an original claim, a claim re-opened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, or the date of increase if the increase is shown within one year prior to filing the claim, whichever is the later. 38 C.F.R. § 3.400 (2017). The VA administrative claims process recognizes formal and informal claims. A formal claim is one that has been filed in the form prescribed by the Secretary. 38 C.F.R. § 3.151. Any communication or action, indicating an intent to apply for one or more benefits, under the laws administered by VA, from a claimant may be considered an informal claim. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. When a claim has been filed which meets the requirements of 38 C.F.R. § 3.151, an informal request for increase or reopening will be accepted as a claim. 38 C.F.R. 3.155. The provisions of 38 C.F.R. § 3.157 commence with notation of the general rule that the effective date of compensation benefits will be the date of receipt of the claim or the date when entitlement arose, whichever is the later. However, this regulation goes on to provide that receipt of clinical reports of examination or hospitalization may serve as informal claims “for increase or to reopen” where the claim is for an already service-connected condition. The date of receipt of such clinical evidence may serve to form the basis for an earlier effective date for the subsequent award of VA benefits if such benefits derive from (1) a claim for increased evaluation or (2) an application to reopen a claim for compensation denied because the service-connected disability was not of compensable degree. The Board notes that effective March 24, 2015, VA amended its regulations to require that all claims governed by VA’s adjudication regulations be filed on a standard form. The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant’s effective date of benefits must be received in one of three specified formats. The amendments also eliminate the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims to reopen under 38 C.F.R. § 3.157. See 79 Fed. Reg. 57,660 (Sept. 25, 2014) (now codified at 38 C.F.R. §§ 3.1(p), 3.151, 3.155). The amendments apply only to claims filed on or after March 24, 2015. Here, the Veteran’s claim was received by VA prior to that date, and, as such, the former regulations apply. “Application” is not defined in the statute. However, in the regulations, “claim” and “application” are considered equivalent and are defined broadly to include “a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit.” 38 C.F.R. § 3.1 (p); see also Rodriguez v. West, 189 F.3d 1351 (Fed. Cir. 1999). The Federal Circuit, in Rodriguez, supra, pointed out that for purposes of establishing the requirements and procedures for seeking veterans’ benefits, a claim, whether “formal” or “informal” must be “in writing” in order to be considered a “claim” or “application” for benefits, and that the provisions of 38 C.F.R. § 3.1 (p) defines “claim,” informal as well as formal, as a “communication in writing.” Further, the Federal Circuit stated that when 38 C.F.R. § 3.155 (a) refers to “an informal claim,” it necessarily incorporates the definition of that term in 38 C.F.R. § 3.1 (p) as a “communication in writing.” The Federal Circuit also pointed out the provisions of 38 C.F.R. § 3.155 (a) make clear that there is no set form that an informal written claim must take. All that is required is that the communication “indicat[e] an intent to apply for one or more benefits under the laws administered by the Department,” and “identify the benefits sought.” Here, the evidence of record shows that the Veteran filed his claim of entitlement to service connection for a left hip disorder on December 7, 2007. In granting the claim, for which the RO ultimately determined three separate ratings were warranted, effective dates of December 7, 2007 were assigned. While the Veteran argues, generally, that the medical evidence shows relevant symptomatology associated with his now service-connected left hip disabilities, neither he nor his attorney have pointed to an earlier pending claim, formal or informal, and a review of the record reveals no communication which could be construed as a claim prior to December 7, 2007. See 38 C.F.R. § 3.151, 3.155. As part of such review, the Board has considered the clinical evidence of record. Although clinical records may, in some instances, be considered informal claims under 38 C.F.R. § 3.157(b)(1)(2014), this provision is inapplicable, as the clinical evidence does not pertain to examination or treatment of a disability for which service connection had not been previously established. Pacheco v. Gibson, 27 Vet. App. 21 (2014). See also Massie v. Shinseki, 25 Vet. App. 123, 134 (2011), aff’d 724 F.3d 1325 (Fed. Cir. 2013) (section 3.157(b)(1) requires that a report of examination or hospitalization indicate that the Veteran’s service-connected disability worsened since the time it was last evaluated because, “[w]ithout such a requirement, every medical record generated by the Veterans Health Administration and received by VA that could possibly be construed as a report of examination would trigger the provisions of § 3.157(b)(1),” creating an unnecessary and unwarranted adjudicative burden on VA); MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed.Cir.2006) (stating that 38 C.F.R. § 3.157 (b)(1) “makes clear that a medical examination report will only be considered an informal claim for an increase in disability benefits if service connection has already been established for the disability.”) The applicable law provides that the effective date of an award of compensation based on a claim for service connection will be the date of receipt of the claim was received or date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Thus, for the reasons above, the date of the December 7, 2007, claim for service connection is an appropriate effective date of the award of service connection for the left hip disabilities. There is no legal basis upon which to assign earlier effective dates for the grants of service connection under the facts of this case. See Flash v. Brown, 8 Vet. App. 332, 340 (1995) (“When a claim to reopen is successful and the benefit sought is awarded upon re-adjudication, the effective date is the date of the claim to reopen”). In sum, for the reasons expressed above, the benefit of the doubt has been considered, but it is inapplicable where the Board finds that the preponderance of the evidence is against the claims of entitlement to earlier effective dates for the left hip disabilities predicated upon limitation of motion, limitation of extension, and limitation of flexion. TDIU 6. Entitlement to a TDIU prior to December 5, 2011 The Veteran is seeking entitlement to a TDIU prior to December 5, 2011, on the basis that he is unable to secure or follow substantiality gainful employment as a result of his service connected disabilities. As a jurisdictional matter, the Board notes that the Veteran’s TDIU has been granted from the date of receipt of his claim for this disability, as evidenced by the VA Form 21-8940, received on December 5, 2011. However, as his claim of entitlement to a TDIU is predicated, at least in part, on his service-connected right knee disability (see VA Form 21-8940 ), the issue arises within the same timeline as the claim for a higher initial rating for the right knee disability, so from February 13, 1987. See Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. The service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue will be addressed in both instances. 38 C.F.R. § 4.16(a), (b). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). For the period prior to December 7, 2007, the Veteran has a combined disability rating of 30 percent, which includes only the rating for the right knee disability. This rating does not meet the schedular requirement for a TDIU. For the period since December 7, 2007, to December 5, 2011, the Veteran has a minimum combined rating of 60 percent, that includes the 30 percent rating for the right knee, 10 percent for the left hip, the now 10 percent rating for the left hip limitation of extension, 10 percent for a left ankle disability, 0 percent for the left hip limitation of flexion, and 0 percent for a scar on the right knee, which does meet the schedular requirements for a TDIU when considering that these disabilities affect a single body system (orthopedic) and may be considered as one disability. Thus, since December 7, 2007, the Veteran is in receipt of a combined rating sufficient to meet the schedular requirements for TDIU. Nevertheless, a TDIU may still be available for the period prior to December 7, 2007 to if the Veteran is unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities. 38 C.F.R. § 4.16(b). As such, pursuant to 38 C.F.R. § 4.16(b), consideration must be given as to whether the Veteran is entitled to a TDIU on an extraschedular basis. In this regard, the Board notes that, for a Veteran to prevail on a claim for TDIU on an extraschedular basis, it is necessary that the record reflect some factor which places the case in a different category than other Veterans with an equal rating of disability. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The pertinent question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Id. This is so because a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Id. Significantly, however, the Board does not have jurisdiction to authorize an extraschedular rating in the first instance. Floyd v. Brown, 9 Vet. App. 88 (1996); Cf. 66 Fed. Reg. 49, 886 (Oct. 1, 2001) (final rule proposal to authorize the Board to assign an extraschedular rating). It may, however, determine that a particular case warrants referral to the Director of Compensation and Pension for extraschedular consideration pursuant to 38 C.F.R. § 4.16 (b). Individual unemployability must be determined without regard to any non-service-connected disabilities or a veteran’s advancing age. 38 C.F.R. § 3.341(a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. at 361. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran’s favor. 38 C.F.R. § 4.3. In Faust v. West, 13 Vet. App. 342 (2000), the Court defined “substantially gainful employment” as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran’s earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). In evaluating a veteran’s employability, consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran’s earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16 (a). Marginal employment, odd-job employment, and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. 38 C.F.R. § 4.17(a) (2017). The ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator), rev’d on other grounds sub nom, Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Although VA must give full consideration, per 38 C.F.R. 4.15, to “the effect of combinations of disability,” VA regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner’s opinion. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); 38 C.F.R. 4.16(a); see also Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011) (VA is not required to obtain an industrial survey from a vocational expert before making a TDIU determination but may choose to do so in an appropriate case). In this case, the evidence of record does not show that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities prior to December 5, 2011. Specifically, the Veteran has been afforded numerous VA examinations, the first dated in May 2004, that noted the Veteran does not work due to mental illness. The April 2007 VA examination for the right knee noted the Veteran is not employed and is receiving disability income for mental illness. The examiner also noted there are not physical restrictions on the Veteran from a physician, however, the Veteran stated he does not run, but also does not indicate how long he can stand or what other activities he cannot participate in due to the pain in his knee. Similarly, the May 2008 VA examination of the left ankle indicated there was no impairment with employability as a result of this disability. Thereafter, a January 2009 joints VA examination (pertaining to the right knee and left hip disabilities, specifically) noted the Veteran has not been employed for 20 years but has no activities of daily living deficits. The March 2010 VA examination for the right knee found moderate functional impairment as a result of the right knee, which included the use of a cane for instability, difficulty standing for longer than 5 to 10 minutes, and inability to crawl on the right knee. The December 2010 VA examination for the left ankle noted weakness, decreased strength, and pain in the left lower extremity but did not indicate that it impaired the Veteran’s ability to obtain or maintain employment. In fact, it was again noted the Veteran has been unemployed since 1985 due to mental illness. In sum, the examinations conducted prior to December 5, 2011 all noted the Veteran’s long-standing history of unemployment and some limitation as to his physical capabilities, but there is simply no indication that the Veteran is precluded from employment as a result of his service-connected disabilities. In fact, several VA examinations noted the Veteran is receiving disability income for mental health, a non-service connected disorder, which the record confirms. See Social Security Administration records. Therefore, while the Board readily acknowledges that the Veteran’s service-connected disabilities do limit some physical activities, in light of the Veteran’s overall disability picture, the evidence does not show that he is precluded from securing or following any substantially gainful occupation as a result of his service-connected disabilities. See Withers v. Wilkie, 30 Vet. App. 139 (2018). Based on the foregoing, the Board finds that the evidence fails to show that the Veteran is unable to secure and follow a substantially gainful occupation as a result of his service-connected disabilities. Rather, the evidence of record shows that, while the Veteran may be unemployed, it does not indicate that he is unemployable as a result of his service-connected disabilities. In essence, the evidence shows that, although the Veteran’s service-connected disabilities resulted in some impairment at work regarding physical demands, the evidence does not show that he is unable to secure or maintain any gainful employment as a result of these disabilities. Based on the foregoing, the Board concludes that this case does not present any unusual or exceptional circumstances that would justify a referral of the total rating claim to the Director of the VA Compensation and Pension Service for extra-schedular consideration pursuant to 38 C.F.R. § 4.16(b) for the period prior to December 7, 2007, or sufficient to award a TDIU pursuant to 38 C.F.R. § 4.16(a) thereafter. As discussed above, the Veteran’s service-connected disabilities have not been shown to cause any impairment that is not already contemplated by the currently assigned rating criteria, and the Board finds that the rating criteria reasonably describe his disability. Moreover, no medical professional has ever stated that the Veteran’s service-connected disabilities preclude him from securing or following a substantially gainful occupation, but has merely noted there to be limitations as to his physical capabilities. As such, in the absence of any evidence of unusual or exceptional circumstances beyond that which is contemplated by the assigned schedular disability evaluations, the preponderance of the evidence in this case is against the claim. The evidence in this case is not so evenly balanced so as to allow for application of the benefit of the doubt rule as required by law and VA regulations. See 38 U.S.C. §5107 (West 2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Therefore, the Veteran’s claim for entitlement to a TDIU is denied. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Berry, Counsel