Citation Nr: 20004663 Decision Date: 01/23/20 Archive Date: 01/21/20 DOCKET NO. 16-40 677A DATE: January 23, 2020 ORDER Entitlement to an increased disability rating in excess of 10 percent for the service-connected patellofemoral syndrome of the left knee is denied. Entitlement to an increased disability rating in excess of 10 percent for the service-connected patellofemoral syndrome of the right knee is denied. Entitlement to a separate compensable disability rating for limitation of extension of the left knee is denied. Entitlement to a separate compensable disability rating for limitation of extension of the right knee is denied. Entitlement to a compensable disability rating for scars of the bilateral knees is denied. Entitlement to service connection for a psychiatric disability, to include bipolar disorder, as secondary to service-connected patellofemoral syndrome with chondromalacia disability is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) on an extra-schedular basis is remanded. REFERRED The issue of entitlement to an increased rating for recurrent subluxation of the bilateral knee was denied in a June 2016 rating decision. The Veteran filed a timely notice of disagreement (NOD) in July 2016. The RO issued a statement of the case (SOC) in August 2016; however, did not include the issues of entitlement to an increased rating for recurrent subluxation of the bilateral knee on the SOC. In July 2019, the RO decreased the evaluation of bilateral knee recurrent subluxation from 20 percent to 10 percent. To date, an SOC has not been issued as to the claim for entitlement to an increased rating for recurrent subluxation of the bilateral knee. Thus, the issues are referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. The Veteran’s patellofemoral syndrome of the left knee is manifested by left knee pain and functional impairment; knee flexion is to 85 degrees and there is no limitation of extension; there is competent and credible evidence of left knee pain, but there is no significant or sustained additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, incoordination, or flare ups; there is no knee ankylosis, semilunar cartilage dislocation or removal, symptomatic tibia or fibula impairment, or genu recurvatum. 2. The Veteran’s patellofemoral syndrome of the right knee is manifested by right knee pain and functional impairment; knee flexion is to 90 degrees and there is no limitation of extension; there is competent and credible evidence of left knee pain, but there is no significant or sustained additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, incoordination, or flare ups; there is no knee ankylosis, semilunar cartilage dislocation or removal, symptomatic tibia or fibula impairment, or genu recurvatum. 3. The Veteran has three surgical scars in the left and right knee that are not painful or unstable. 4. The Veteran’s service-connected bilateral knee disability did not cause her bipolar disorder. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the service-connected patellofemoral syndrome of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5260. 2. The criteria for a rating in excess of 10 percent for the service-connected patellofemoral syndrome of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5260. 3. The criteria for a separate compensable rating for limitation of extension of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.71a, Diagnostic Codes (DC) 5261. 4. The criteria for a separate compensable rating for limitation of extension of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.71a, Diagnostic Codes (DC) 5261. 5. The criteria for a compensable rating for left and right knee surgical scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.118, DC 7805. 6. The criteria for service connection for bipolar disorder, to include as secondary to her service-connected bilateral knee disability, have not been met on a direct or secondary basis. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from September 1998 to February 1999 and from March 2003 to March 2005. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia which, inter alia, denied service connection for bipolar disorder, and denied increased ratings for the Veteran’s bilateral knee disability. The Veteran timely filed a notice of disagreement (NOD) and substantive appeal, via a VA Form 9, appeal to the Board of Veterans’ Appeals. Increased Rating 1. Entitlement to an increased disability rating in excess of 10 percent for patellofemoral syndrome of the bilateral knee and a compensable disability rating for limitation of extension of the bilateral knee The Veteran contends that an increased rating is warranted for her service-connected bilateral knee disability. Each knee is currently evaluated as 10 percent disabling under DC 5260 with a separate noncompensable rating under DC 5261. For VA compensation purposes, normal range of motion for the knee is flexion to 140 degrees and extension to zero degrees. 38 C.F.R. § 4.71, 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, DC 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 15 degrees is 20 percent; 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. Id., DC 5261. VA General Counsel has also held that separate ratings may be assigned under DC 5260 and DC 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-2004 (Sept. 17, 2004). DC 5257 pertains to other impairment of the knee involving recurrent subluxation or lateral instability and provides a 10 percent rating for slight impairment, a 20 percent rating for moderate impairment, and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a, DC 5257. As noted above, the Veteran has a separate rating for subluxation, bilaterally, which has been referred to the RO. The terms slight, moderate, and marked as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. VA General Counsel has held that separate ratings may be assigned for arthritis and instability under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97 (July 1, 1997). The criteria for evaluating degenerative arthritis are set forth at 38 C.F.R. § 4.71a, DC 5003. 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. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. In the absence of limitation of motion, a 10 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. The 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Id., Note 1. In addition, the 20 percent and 10 percent ratings based on x-ray findings will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024. Id., Note 2. A June 2016 VA examination report reflects that the Veteran reported flare-ups of the bilateral knee described as swelling and a tingling sensation from her knee down to her toes. She did not report any functional loss/impairment of the joint/extremity. Initial range of motion for the right knee revealed flexion to 80 degrees and extension from 80 to 0 degrees. Range of motion, itself, did not contribute to functional loss. Pain was noted on examination and caused functional loss. Range of motion exhibited pain on flexion and extension. There was evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was objective evidence of crepitus. As for the Veteran’s left knee, initial range of motion testing revealed flexion to 80 degrees and extension from 80 to 0 degrees. Range of motion, itself, did not contribute to functional loss. Pain was noted on examination that caused functional loss. Range of motion exhibited pain on flexion and extension. There was evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue described as generalized tenderness. There was objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion, bilaterally. The Veteran was not examined immediately after repetitive use over time. Pain significantly limits her functional ability with repeated use over a period of time. The examiner was unable to describe this in terms of range of motion. The examination was not conducted during a flare-up and pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups. The Veteran had interference with standing, instability of station of the knees. The Veteran did not have muscle atrophy and did not have ankylosis. There is a history of slight recurrent subluxation. There is no history of lateral instability. There is no history of recurrent effusion. There was no joint instability following testing. The Veteran did not have recurrent patellar dislocation, shin splits, stress fractures, chronic exertional compartment syndrome, or any other tibial/fibular impairment. The Veteran did not have a meniscus condition. No assistive devices were needed. A February 2019 VA examination report reflects that the Veteran reported flare-ups of the knee and/or lower leg. She did not report any functional loss/impairment of the joint or extremity. Initial range of motion testing of the right knee revealed flexion to 90 degrees and extension from 90 to 0 degrees. Range of motion itself did not contribute to a functional loss. Pain was noted on examination but did not result in/cause functional loss. Range of motion exhibited pain on flexion and extension. There was no evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the joint of associated soft tissue on the anterior described as moderate. Initial range of motion testing for the left knee revealed flexion to 85 degrees and extension from 85 to 0 degrees. Range of motion itself did not contribute to a functional loss. Pain was noted on examination but did not result in/cause functional loss. Range of motion exhibited pain on flexion and extension. There was no evidence of pain with weight-bearing. There was objective evidence of localized tenderness/pain on palpation on the anterior described as moderate. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion, bilaterally. The Veteran was not examined immediately after repetitive use over time. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over time. The Veteran had interference with standing of the right knee. The Veteran had disturbance of locomotion of the left knee. The Veteran does not have muscle atrophy. The Veteran does not have ankylosis. The Veteran did not have a history of recurrent subluxation, lateral instability, and recurrent effusion. There was no joint stability following testing performed. The Veteran did not have recurrent patellar dislocation, shin splits, stress fractures, chronic exertional compartment syndrome, or any other tibial/fibular impairment. The Veteran did not have a meniscus condition. VA treatment records reflect continued treatment of the Veteran’s bilateral knee disability. Upon review of the evidence of record, the Board finds that the Veteran’s symptoms more nearly approximate the 10 percent disability rating currently assigned for the right and left knee disabilities under DC 5260 based on the Veteran’s report of pain and limitation of motion. The Veteran’s bilateral knee disability produced a range of motion of no less than 80 degrees flexion with pain noted on movement during the VA examinations. Although pain was noted on examination, it did not result in/cause functional loss. The 10 percent rating contemplates the Veteran’s symptoms, as a 20 percent rating would require flexion limited to 30 degrees and the Veteran did not report flare-ups indicated to be so severe as to result in additional limitation of motion more nearly approximating this criterion. Although the Veteran reported flare-ups, she reported that it did not cause functional loss/impairment of the joint or extremity. Likewise, the Veteran’s bilateral knee disability produced a range of motion to 0 degrees extension with pain noted on movement during the VA examinations. The preponderance of the evidence shows that even considering pain and other functional factors, the Veteran’s knee symptoms have not been shown to be so disabling to actually or effectively result in limitation of knee extension more nearly approximating 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating for limitation of knee extension under DC 5261, respectively. There is also no evidence of ankylosis in the right and left knee as indicated by each knee examination of the Veteran. Moreover, there was no evidence of removed semilunar cartilage or impairment of the tibia and fibula warranting separate or higher ratings under DC 5259 or 5262. The Veteran does not have arthritis—a separate rating under DC 5003 is not warranted. See 38 C.F.R. § 4.71a, DC 5003. The Board has also considered whether a separate rating is warranted under DC 5258. See Lyles v. Shulkin, 29 Vet. App. 107 (2017) (there is no prohibition of separate evaluation under 38 C.F.R. § 4.71a, DC 5257 or 5261 and a meniscal DC, i.e., DC 5258 or 5259). Under 38 C.F.R. § 4.71a, DC 5258, a 20 percent disability rating is assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain and effusion into the joint. Semilunar cartilage is synonymous with the meniscus. There is no evidence of dislocated semilunar cartilage, the symptoms did not more nearly approximate joint pain, locking, and effusion in the joint. The VA examination reports specifically indicate that there was no effusion into the joint. A separate rating under DC 5258 is not warranted. With respect to the above evidence, the Board notes that the examination reports are adequate to decide the claim. The February 2019 VA examination report in particular addressed pain on active and passive motion, in weight bearing and nonweight-bearing, and with range of motion in both knees. Correia v. McDonald, 25 Vet. App. 158 (2016). For the foregoing reasons, the preponderance of the evidence is against the claim for an initial rating in excess of 10 percent for the Veteran’s right and left knee disabilities. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 2. Entitlement to a compensable disability rating for scars of the bilateral knee The Veteran contends that her service-connected scars warrant a compensable rating. The Veteran’s scars are currently rated noncompensable under DC 7805. Under DC 7805, scars, including linear scars, and other effects of scars, are to be evaluated under DC 7800-7802 and 7804. In addition, any disabling effects not considered in a rating provided under DC 7800-7804 is to be evaluated under an appropriate diagnostic code. As a preliminary matter, the Board notes that the Veteran’s scar are located on her bilateral knee. As such, DC 7800 (scars of the head, face, or neck) is not applicable. Under DC 7801, scars of other than the head, face, or neck that are deep or cause limited motion warrant a 10 percent rating when involving an area or areas exceeding 6 square inches (39 sq. cm.); warrant a 20 percent rating when involving an area or areas exceeding 12 square inches (77 sq. cm.); warrant a 30 percent rating when involving an area or areas exceeding 72 square inches (465 sq. cm.); and warrant a 40 percent rating when involving an area or areas exceeding 144 square inches (929 sq. cm.). Under DC 7802, scars other than head, face, or neck that are superficial and that do not cause limited motion, warrant a rating of 10 percent when involving an area of 144 square inches (929 sq. cm.) or greater. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802, Note (1), (2). Under DC 7804, one or two scars that are unstable or painful warrant a 10 percent rating; three or four scars that are unstable or painful warrant a 20 percent rating; and five or more scars that are unstable or painful warrant a 30 percent rating. A June 2016 VA examination report reflects that the Veteran’s scars are not on the Veteran’s head, face, or neck. She reported that the scars were not painful. They were not unstable with frequent loss of covering of skin over the scar. None of the scars were both painful and unstable. None of the scars were due to burns. The Veteran has superficial non-linear scars located on the right lower extremity. There are three scars that measure at 1.0 x 0.5 cm, 0.8 x 0.5 cm, 0.8 cm x 0.8 cm. The Veteran had superficial non-linear scars that measure at 0.8 x 08. cm, 1.0 x 0.5 cm, 0.5 x 0.5 cm. The approximate total area for the right lower extremity is 1.54 cm2. The approximate total area for the left lower extremity is 1.39 cm2. The scars do not result in limitation of function. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with any scar. Additionally, the Veteran reported that scars were non tender to palpation and appeared well healed. A May 2019 VA examination report reflects that the Veteran’s scars were not painful or unstable; did not have a total area equal to or greater than 39 square cm (6 square inches); or are located on the head, face, or neck. On the left knee the scars were measured as left anterior medial above patella 1.5 x 0.8 cm; anterior medial 9.5 cm from 1st 1 inch 8 cm x 0.5 cm; anterior lateral 0.5 x 0.5 cm; and 2.25 from 3rd 1.0 cm x 0.3 cm. On the right knee, the scars were measured as anterior medial 1.5 cm; 9 cm from 1st 1.0 cm x 0.8 cm; anterior lateral; and 2.5 cm from 3rd 1.3 cm x 0.5 cm. VA treatment records were reviewed in connection with this claim and there were no further complaints regarding the Veteran’s scars of the knee. Upon review of the evidence of record, the Board finds that a compensable rating for her service-connected scars ar not warranted. The VA examiners noted that the Veteran’s scars are not painful or unstable, and did not cover a total area equal to or greater than 39 square cm. There was also no evidence that the scars cause limitation of function or other complications. The examiner provided the Veteran with a thorough examination prior to reporting the finding, thus the examination report is afforded significant probative weight. The Veteran has not provided any additional evidence which would suggest that her scars are painful or unstable, exceed an area of 39 square cm, or cause limitation of motion. The symptomatology of the Veteran’s scars do not more nearly approximate symptomatology contemplated by a 10 percent rating, thus a compensable rating is not warranted. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a) (2019). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). 38 C.F.R. § 3.310 (b) provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. 3. Entitlement to service connection for a psychiatric disability, to include bipolar disorder secondary to service-connected bilateral knee disability The Veteran contends that her psychiatric disability is due to the pain from her bilateral knee disability. STRs do not reflect any symptoms, treatment, or diagnosis of a psychiatric disability. Post-service, a May 2016 Disability Benefits Questionnaire (DBQ) report reflects that the Veteran has a diagnosis of bipolar II disorder, in partial remission. The examiner noted that she claimed depression as part of her claim. He reported that major depressive episodes are a symptom of bipolar II disorder. She reported past major depressive episodes. He stated that as major depressive episodes are a symptom of bipolar disorder, they are not coded separately from bipolar disorder in the DSM. Thus, he found no separate diagnosis for depression. He opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition. As rationale, he reported that as indicated in the DSM-5, there is strong genetic heritability for the development of Bipolar Disorder. According to DSM-5, “there is an average 10-fold increased risk among adult relatives of individuals with Bipolar I and Bipolar II disorders.” DSM-5 also notes that “schizophrenia and bipolar disorder likely share a genetic origin, reflected in familial co-aggregation of schizophrenia and bipolar disorder.” To the examiner’s knowledge, there was no medical evidence in any research literature implicating knee injuries or other injuries in the development of bipolar disorder. Bipolar disorder is commonly treated with psychotropic medication due to the neurochemical processes implicated in the development and progression of the disorder. Thus, it is less likely than not that the Veteran’s bipolar disorder diagnosis is proximately due to or the result of the Veteran’s service-connected knee conditions. The Veteran submitted a May 2019 psychological report from Dr. J.P. who reported that based on records reviewed, it is evident that the Veteran met the criteria for Unspecified Bipolar Disorder, which was acquired during her time of service. Additionally, she reported that records indicate that her overall ability to function and maintain employment significantly declined. She reported that the 2016 VA examiner’s opinion was inaccurate. She cited medical treatise indicating that chronic pain is related to depression. She concluded that the evidence in the record indicated that it is at least as likely as not that her unspecified bipolar disorder and unspecified schizophrenia spectrum and other psychotic disorder are a direct result of her military service. She provided her opinion based on the Veteran’s statements of onset of symptoms and lack of evidence of any indication that the Veteran had a mental health disorder prior to joining the military. VA treatment records reflect continued treatment of bipolar disorder. Upon review of the evidence of record, the Board finds that service connection for bipolar disorder, to include on a secondary basis, must be denied. At the outset, that there is no evidence that the Veteran’s bipolar disorder had its onset in or is otherwise medically related to her military service. As indicated above, bipolar disorder was not shown in service or for years thereafter. While Dr. J.P. reported that the Veteran’s bipolar disorder was acquired in service, she provided no reasoning or rationale. Of note, the Veteran has not made any statements that her psychological symptoms began in service. Under these circumstances, the Board finds no prejudice to the Veteran in limiting its consideration of the claim on appeal to this theory of entitlement. Cf. Robinson v. Mansfield, 21 Vet. App. 545 (2008). The Veteran has a current diagnosis of bipolar disorder as confirmed by the medical evidence of record. As to whether the Veteran’s bipolar disorder was caused by her bilateral knee disability, the May 2016 VA examiner provided an adequate medical opinion based on a review of the available records and medical literature. As noted above, he concluded that the Veteran’s bipolar disorder was most likely genetic according to the DSM-5. Additionally, the VA examiner explained that depression is not a separate diagnosis and a part of bipolar disorder. In contrast, Dr. J.P. reported that chronic pain is related to depression; however, she never diagnosed the Veteran with depression and provided no link between the Veteran’s bilateral knee disability and the Veteran’s bipolar disorder. As the VA examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). REASONS FOR REMAND 1. Entitlement to a TDIU on an extra-schedular basis is remanded. Total disability ratings for compensation may be assigned pursuant to 38 C.F.R. § 4.16 (a) where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16 (a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system and/or disabilities resulting from common etiology or a single accident are considered as one disability. Id. Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. The Veteran does not meet the threshold percentage requirement for consideration of entitlement to a schedular TDIU. The Veteran’s combined disability rating is 40 percent from October 1, 2019. Even when the above threshold percentage requirements are not met, entitlement to a total rating, on an extra-schedular basis, may nonetheless be granted in exceptional cases, when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 3.321 (b), 4.16(b). The Veteran last worked in June 2012 as an administrative assistant. She had two years of college education. She reported that she was unable to sit or stand for periods of time. She reported that this made it difficult to maintain a job that required sitting and standing due to the pain and discomfort in her legs and back. She stated that every job required sitting or standing which she could not do. The 2016 VA examination report reflects that the examiner found that her bilateral knee disability impacts her to perform any occupational tasks due to her difficulty standing or walking for prolonged periods as well as limitation in climbing stairs and ladders. Likewise, the February 2019 VA examiner found the same—the Veteran’s knee disability impacted her ability for occupational tasks due to her difficulty climbing stairs, prolonged walking, and prolonged standing. The Board cannot consider entitlement to a TDIU on an extra-schedular basis in the first instance, instead it must refer the claim to the Director of the Compensation Service or appropriate designee for this special consideration initially. Bowling v. Principi, 15 Vet. App. 1 (2001); See also Barringer v. Peake, 22 Vet. App. 242 (2008). Accordingly, before the Board can make any determination in this case, the claim must be remanded for referral to the Director of Compensation Service for initial consideration of entitlement to an extra-schedular TDIU. (Continued on the next page)   The matters are REMANDED for the following action: 1. Refer the claim for TDIU to VA’s Director of Compensation Service for extraschedular consideration. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laroche, N. The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.