Citation Nr: 20021295 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 16-58 037 DATE: March 25, 2020 ORDER Entitlement for an initial evaluation in excess of 10 percent for a service-connected left knee disability is denied. Entitlement to an initial compensable rating for a service-connected left knee scar is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted on a schedular basis from March 15, 2013. REMANDED Entitlement to a TDIU prior to March 15, 2013, on an extraschedular basis, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence does not show limitation of flexion of the left knee to 60 degrees or extension limited to 10 degrees; or recurrent subluxation or lateral instability; or dislocation of the semilunar cartilage accompanied by frequent episodes of "locking," pain, and effusion into the joints. 2. The Veteran does not have a scar on the service-connected left knee. 3. The Veteran met the schedular requirements for a TDIU beginning March 15, 2013. 4. The Veteran is unable to secure or maintain substantially gainful employment as a result of his service-connected back, left knee, and radiculopathy disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent for the Veteran's left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261, 5257, 5258, 5259, 5260, 5261, 5262 (2017). 2. The criteria for a compensable evaluation for left knee scar have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.118, Diagnostic Code 7805. 3. The criteria for a TDIU have been met beginning March 15, 2013. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.1, 4.3, 4.15, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1974 to February 1977. These matters come to the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision of the Regional Office (RO) in St. Petersburg, Florida. In August 2017 and August 2019, the Veteran provided testimony in support of the claims. The transcripts for both hearings have been associated with the electronic claims file. During the August 2019 Board hearing, the Veteran indicated he did not wish to provide testimony at any additional hearings. In June 2017, the Board remanded the case to afford the Veteran his requested hearing, which was held in August 2017. The claims were again remanded in June 2018 for VA examinations which were conducted in August and October of 2019. After consideration of this evidence and these facts, the Board finds that there was substantial compliance with the Board directives as the underlying purpose of the remands were to obtain a hearing and adequate opinions regarding the severity of the Veteran's service-connected left knee disability and ability to maintain substantially gainful employment. As such, the Board finds the purposes of the development directed in the remand have been met and, as such, there was substantial compliance with the Board's instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Ratings 1. Increased Rating for Service-Connected Left Knee. Laws and Regulations The Veteran contends that the service-connected left knee disability is more severe than is currently reflected by their assigned disability rating. VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV (2017). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2017). Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261 - 62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2017). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2017). With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45 (2017). These provisions thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable diagnostic code(s) pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In Burton v. Shinseki, 25 Vet. App. 1 (2011), the United States Court of Appeals for Veterans Claims (Court) held that consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. The Court held that pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. Mitchell v. Shinseki, 24 Vet. App. 32, 33, 43 (2011). Although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Id. The Court explained in Mitchell that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997) 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. If the limitation of motion of the joint involved is noncompensable, a rating of 10 percent is applicable. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, but with X-ray evidence of involvement of two or more major joints or two or more minor joint groups and occasional incapacitating exacerbations, a 20 percent evaluation is assigned. With X-ray evidence of involvement of two or more major joints or two or more minor joint groups, a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability due to arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2017). Leg flexion limited to 60, 45, 30, and 15 degrees warrant noncompensable, 10 percent, 20 percent, and 30 percent evaluations, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Leg extension limited to 5 degrees, 10 degrees, and 15 degrees warrants a noncompensable evaluation, 10 percent, and 20 percent evaluations. 38 C.F.R. § 4.71a, Diagnostic Code 5261. VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59,990 (2004). The basis for the opinion is that the knee has separate planes of movement, each of which is potentially compensable. Id. Under the criteria for impairment of the knee other than ankylosis, 10, 20, and 30 percent evaluations are assigned for slight, moderate, and severe recurrent subluxation or instability, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2017). Arthritis manifested by limitation of motion and instability of the knee are two separate disabilities, and a veteran may be rated separately for these symptoms. See VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997) (when a claimant has arthritis and is rated under instability of the knee, those two disabilities may be rated separately under 38 C.F.R. § 4.71a, Diagnostic Codes 5003 or 5010 and Diagnostic Code 5257). Under Diagnostic Code 5258, a 20 percent rating is warranted for a dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent disability rating is warranted for a symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. While Diagnostic Code 5259 requires consideration of 38 C.F.R. §§ 4.40 and 4.45 because removal of the semilunar cartilage may result in complications producing loss of motion, the Court has explained there is no prohibition of separate evaluation under 38 C.F.R. § 4.71a , Code 5257 or 5260/5261 and a meniscal Code, i.e., Codes 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017); VAOPGPREC 9-98 (Aug. 14, 1998). Analysis In an October 2012 rating decision, the RO granted service connection for left knee degenerative joint disease and assigned a 10 percent disability rating under Diagnostic Code 5259. After review of the evidence, both lay and medical, the Board finds that the Veteran’s service connected left knee is more appropriately rated under Diagnostic Code 5003, for degenerative arthritis. In August 2012, the Veteran underwent a VA examination to determine the etiology and severity of the left knee. He reported left knee surgery in 2007 with aches and pains that caused difficulty walking, standing, and climbing. He reported no flare-ups. The VA examiner diagnosed the Veteran with degenerative joint disease of the left knee. On examination, range of motion testing revealed flexion of 130 degrees with painful motion at 130 degrees and no limitation of extension with no painful motion. Range of motion readings were unchanged after repetitive testing. The VA examiner noted less movement than normal, pain on movement, and interference with sitting, standing, and weight bearing in the left knee, as well as, pain to palpitation. There was no instability, evidence of patellar subluxation or dislocation. Specifically, stability testing in the left knee was normal (Lachman Test, Posterior drawer test, valgus/varus pressure application testing was performed). The Board notes the VA examiner indicated the Veteran had a meniscus condition that resulted in frequent joint locking and pain. As discussed above, the VA examiner incorrectly indicated that the Veteran underwent a meniscectomy in 2006. In August 2019, the Veteran underwent a VA examination to determine the etiology of his non-service connected right knee disability. However, range of motion of the left knee was taken and revealed flexion of 135 degrees and extension of 0 degrees that was unchanged after repetitive testing. There was no localized tenderness, crepitus, recurrent subluxation, instability, or recurrent effusion observed in the left knee and the Veteran reported no flare-ups. The Veteran denied any current symptoms in the left knee. The VA examiner changed the Veteran’s diagnosis from degenerative joint disease to degenerative arthritis because degenerative joint disease is subsumed within the umbrella of arthritis. In October 2019, the Veteran underwent an additional VA knee examination. The Veteran reported the left knee continued to worsen and was extremely weak with at least 25 to 30 falls due to its weakness. He reported walking with a cane at all times due to the left knee but reported no flare-ups. On examination, range of motion testing revealed left knee extension of 130 degrees and extension of 10 degrees, with no painful motion, crepitus, or evidence of pain on weight bearing. After repetitive testing the Veteran’s range of motion in the left knee showed flexion of 140 degrees and extension of 0 degrees. Joint stability testing revealed no recurrent subluxation, instability, and there was no effusion present. The VA examiner indicated weakness significantly limited functional ability with repeated use. The VA examiner noted a limping gait that required the use of assistive devices due to weakness in the left lower extremity. There was no ankylosis, subluxation, or instability in the left knee. The VA examiner added that although the Veteran reported significant weakness in the left knee it appeared to be subjective because the medical records did not support the complaint. The VA examiner supported this with findings that the Veteran’s left knee soft tissue was unremarkable with no fracture or acute abnormality noted. The VA examiner added that no degenerative joint disease was evident, there was no significant joint effusion, or calcified loose body. VA and private treatment records are consistent with the VA examinations of record. Range of motion testing during a March 2013 private examination revealed flexion of 100 degrees and extension of 0 degrees with no ligamentous laxity, joint effusion, or tenderness to palpitation. As an initial matter, the Board notes conflicting information regarding treatment of the service-connected left knee disability. Specifically, the August 2012 and October 2019 VA examiners both indicated that the Veteran had surgical repair of the knee. However, during the August 2017 Board hearing, the Veteran clarified that while he tore his left meniscus, surgery was performed to correct it and the left knee healed on its own. This is further supported by VA treatment records that show a torn left meniscus in 2001 with no mention of surgery. This error resulted in the Veteran’s knee being incorrectly rated under Diagnostic Code 5259 for removal of the semilunar cartilage. Turning to the evidence, the Board finds that Diagnostic Code 5003 more appropriately characterizes the Veteran’s service-connected left knee disability. The assignment of a particular Diagnostic Code is “completely dependent on the facts of a particular case.” Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Specifically, in this case, the Veteran is diagnosed with degenerative arthritis of the left knee. The record supports a finding that the Veteran’s left knee results in pain, occasional swelling, and difficulty with locomotion support and some limited motion. In light of this a 10 percent evaluation under 5003 is warranted. A higher rating under 5003 is not warranted as the left knee alone does not involve two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Next, as the record shows no evidence of ankylosis or tibia and fibula impairment, therefore, consideration of Diagnostic Code 5256 is not appropriate. Regarding Diagnostic Code 5257, while the Veteran is competent to report instability in the service-connected left knee, the Board ultimately places more weight on the consistent results of his VA examinations which revealed no objective evidence of instability in the left knee. Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Specifically, both the August 2012 and October 2019 VA examiners performed multiple joint stability tests and found no instability in the left knee. Consequently, a separate disability rating under Diagnostic Code 5257 is not warranted. Similarly, while the Veteran has reported "popping" or "locking" sensation in the left knee, there have been no objective findings of frequent, popping, locking, and effusion in the left knee. Diagnostic Code 5258 requires a clinical finding of dislocated semilunar cartilage "with frequent episodes of 'locking' pain, and effusion into the joint." 38 C.F.R. § 4.71a, Diagnostic Code 5258 (emphasis added). The Board notes and finds less probative the August 2012 VA examiner’s indication of frequent locking and pain in the joint because it was, in part, based on the factually incorrect finding that the Veteran underwent a meniscectomy on the left knee. To be sure, no evidence of dislocated semilunar cartilage was found upon physical examination or x-ray imaging. Effusion and pain without dislocated semilunar cartilage does not meet the criteria for a higher evaluation under Diagnostic Code 5258. As discussed above, the Veteran has not undergone removal of the cartilage, semilunar, therefore rating under Diagnostic Code 5259 is not warranted. Next, the Board finds a separate rating for limitation of extension is not warranted. The Board notes that the Veteran had a single reading of limitation of extension at 10 degrees in the left knee during the October 2019 VA examination, however, extension in the left knee returned to 0 degree after three repetitions. There is no other abnormal extension reading in the left knee throughout the appeal period. Because the medical evidence does not show a painful limitation of extension that approximates extension limited to 10 degrees that would warrant an increased evaluation at any point during the appeal period, a separate rating for limitation of extension is not warranted. Similarly, the medical evidence shows that at no time did the limitation of flexion in the left knee warrant a higher rating. Specifically, the lowest recorded limitation of flexion reading during the appeal period was 100 degrees, which would be noncompensable. Therefore, a separate or higher rating based on limitation of motion in the left knee is not warranted. The Board has also considered the Veteran’s statements that describe his pain and discomfort. The Board finds those statements to be competent and credible; however, the medical evidence does not reflect that the Veteran’s subjective reports of knee pain and weakness caused functional loss sufficient to warrant a disability rating in excess of 10 percent. See 38 C.F.R. § 4.40. As outlined above, examiners performed repetitive motion testing to assess the functional limitation of pain and found there was no additional limitation of motion after repetition. Although the Board is sympathetic to the Veteran’s credible account of pain and limitation of activities, his symptoms are already contemplated by the 10 percent ratings presently assigned. In short, the weight of evidence shows that the left knee disability has not been manifested by flexion limited to 60 degrees, extension limited to 15 degrees, slight recurrent subluxation or lateral instability, or dislocated semilunar cartilage. Therefore, increased ratings are not warranted, and the claim is denied. 2. Entitlement to a Compensable Rating for Surgical Scar of the Left Lower Extremity is Denied. Entitlement to a compensable rating for a left knee scar is properly before the Board. Because the Veteran has reported, and the medical evidence has confirmed, that he does not have a scar on the left knee, the Board finds that a compensable rating is not warranted. Diagnostic Code 7801 provides the criteria for rating disabilities due to scars that are not of the head, face, or neck, and that are deep and nonlinear. Under 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1), a "deep scar" is defined as one associated with underlying soft tissue damage. Under those criteria, a 10 percent disability rating is assigned for qualifying scars that encompass an area or areas of at least six square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent disability rating is appropriate for qualifying scars that cover an area or areas of at least 12 square inches (77 square centimeters) but less than 72 square inches (465 square centimeters). A 30 percent disability rating is appropriate where qualifying scars encompass an area or areas of at least 72 square inches (465 square centimeters) but less than 144 square inches (929 square centimeters). A maximum schedular 40 percent disability rating is warranted for qualifying scars that involve an area or areas of 144 square inches or 929 square centimeters) or more. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2018). Diagnostic Code 7802 provides for a maximum 10 percent rating for superficial and nonlinear scars over an area or areas of 144 square inches or greater. Note (1) states that a superficial scar is one not associated with underlying tissue loss. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2018). Diagnostic Code 7804 provides for ratings for superficial scars, which are either unstable or painful. Under this diagnostic code, a 10 percent rating is warranted for one or two scars that are unstable or painful, a 20 percent rating is warranted for three or four scars that are unstable or painful, and a 30 percent rating is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. Other scars are rated based on the limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805. 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. In the October 2012 rating decision, the RO granted service connection for surgical scar of the left lower extremity and assigned a zero percent disability rating under Diagnostic Code 7805. During the August 2012 VA examination, the examiner noted a scar but failed to indicate which extremity it was on. The scar was not found to be painful, unstable, or greater than 39 square cm (6 square inches). The August 2019 knee examination found no measurable or visible scar on the knee. In August 2019, the Veteran underwent a VA scar examination. No scars were found on the left lower extremity. VA and private treatment records throughout the appeal period are also silent for any left lower extremity scars. Finally, during the August 2017 Board hearing, the Veteran reported he does not have a scar on his left knee. Rather, he has a scar on his nonservice-connected right knee. As an initial matter, the Board finds that the Veteran is competent to report the observable absence of a scar, and the record contains no evidence undermining the credibility of the Veteran's statements. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Therefore, the Board finds the Veteran's reports that he does not have a scar on the left knee highly probative. Because the Veteran has reported, and the medical evidence has confirmed, that he does not have a scar on his left knee the Board finds no basis for an increased rating for a left knee scar and the claim must be denied. 3. Entitlement to a TDIU is Granted on a Schedular Basis from March 15, 2013. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a)(1) (2017). Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). A TDIU may be assigned when the disabled veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 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). 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 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. See 38 C.F.R. § 4.17(a) (2017). The Veteran contends that he is unable to secure or maintain employment due to his service-connected disabilities. The Veteran is currently service-connected for spondylolisthesis, evaluated at 40 percent, a left shoulder impingement, evaluated at 20 percent, left lower extremity radiculopathy, evaluated at 20 percent, left upper extremity radiculopathy, evaluated at 20 percent, right upper extremity radiculopathy, evaluated at 20 percent, right lower extremity radiculopathy, evaluated at 10 percent, degenerative joint disease, left knee, evaluated at 10 percent, cervical spine degenerative disc disease, evaluated at 10 percent, fracture, right wrist, evaluated at 0 percent, fracture, right hand, evaluated at 0 percent, fracture of nose, evaluated at 0 percent, and a residual scar, left knee, evaluated at 0 percent. The Veteran's combined rating is 90 percent and the Veteran has met the schedular requirements for a TDIU rating under 38 C.F.R. § 4.16(a) since March 15, 2015. The Veteran first indicated his service-connected disabilities prevented him from working in August 2010. He has further indicated he was last self-employed as an upholsterer in May 2005. The Veteran also indicated he completed high school and had no additional specialized training. In a March 2013 correspondence, the Veteran stated he had difficulty standing, sitting, bending, and walking. He further reported pain in the service-connected back and knees that limited his ability to walk to about 200 feet before he started limping. In March 2013, the Veteran underwent a private evaluation by Dr. J.S., that included an assessment of the functional impacts of the Veteran’s service-connected disabilities on his ability to maintain substantially gainful employment. After extensive review of the Veteran’s medical history and a physical examination, Dr. J.S. opined that within a high degree of medical certainty, that the Veteran had been unable to secure or follow substantially gainful employment due to his service-connected disabilities since April 2009. The Board first finds the lay and medical evidence supports the findings of Dr. J.S. Specifically, VA examinations, as well as, VA and private treatment records indicate the Veteran experiences pain and limitations of motion due to his service-connected disabilities. In October 2019, the Veteran underwent a series of VA examinations to determine the severity of both the service-connected back and left knee disabilities. On both examination reports, the VA examiner indicated that the Veteran’s service-connected disability impacted his ability to work. Specifically, the VA examiner indicated that the Veteran was prescribed a cane for the service-connected left knee and that the service-connected back could result in difficulty walking. On an individual unemployability statement, the VA examiner indicated the Veteran was limited by his service-connected disabilities such that he would likely only be able to perform occasional light work for a maximum of only 2/3 of a work day. Based on the above, the Board finds that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Specifically, reviewing the evidence above reflects that the Veteran owned an upholstery business for 6 years before retiring due to the service-connected disabilities. The Veteran has indicated no additional training or education. Next, the lay and medical evidence of record supports a finding that the Veteran's back disability, left knee disability, and upper and lower extremity radiculopathy, severely impact his ability to maintain substantially gainful employment. The Veteran has reported difficulties with walking, standing, and sitting because of the service-connected disabilities. Furthermore, both VA and private examiners have indicated that the Veteran's service-connected disabilities impact his ability to maintain substantially gainful employment. Considering the entire record in light of the above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence supports the assignment of a TDIU due to service-connected disabilities. 38 C.F.R. § 4.16(a). REASONS FOR REMAND Entitlement to a TDIU Prior to March 15, 2013, is Remanded. Above, the Board granted a TDIU beginning when the Veteran met the schedular requirements for its award. However, the Board notes, that the lay and medical evidence indicates that the Veteran’s service-connected disabilities potentially prevented him from maintaining substantially gainful employment prior to meeting the schedular requirements. In such situations, the Board may only refer the case to the Director of Compensation Service (Director) for consideration of an extraschedular TDIU. 38 C.F.R. § 4.16(b); see also Cantrell v. Shulkin, 28 Vet. App. 382, 387 (2017). Upon review of the record, the Board finds such referral is warranted. The matters are REMANDED for the following action: Refer the application for a TDIU to the Director of Compensation Service for a determination as to whether the Veteran is entitled to a TDIU prior to March 15, 2013, on an extraschedular basis in accordance with the provisions of 38 C.F.R. § 4.16(b). A full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be provided. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Teague, Associate Counsel 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.