Citation Nr: 20021631 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 02-10 190 DATE: March 26, 2020 ORDER Entitlement to an initial rating in excess of 10 percent for internal derangement with mild degenerative changes, left knee, is denied. Entitlement to an initial rating in excess of 10 percent for internal derangement with mild degenerative changes, right knee, is denied. Entitlement to a separate rating of 10 percent for limited extension due to internal derangement with mild degenerative changes, left knee, for the period from September 30, 2016, to September 16, 2019, is granted. Entitlement to a separate rating of 10 percent for limited extension due to internal derangement with mild degenerative changes, right knee, for the period from September 30, 2016, to September 16, 2019, is granted. Entitlement to a separate rating of 10 percent for instability of the left knee, from January 4, 2005, is granted. Entitlement to a separate rating of 10 percent for instability of the right knee, from January 4, 2005, is granted. REMANDED The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the rating period, the Veteran’s internal derangement with mild degenerative changes, left knee, was manifested by painful motion and flexion limited at its most severe to 45 degrees. 2. Throughout the rating period, the Veteran’s internal derangement with mild degenerative changes, right knee, was manifested by painful motion and flexion limited at its most severe to 45 degrees. 3. During the period from September 30, 2016, to September 16, 2019, the Veteran’s internal derangement with mild degenerative changes, left knee, was manifested by extension limited to 10 degrees. 4. During the period from September 30, 2016, to September 16, 2019, the Veteran’s internal derangement with mild degenerative changes, right knee, was manifested by extension limited to 10 degrees. 5. From January 4, 2005, the Veteran’s service-connected left knee internal derangement with mild degenerative changes, has been manifested in slight recurrent instability. 6. From January 4, 2005, the Veteran’s service-connected right knee internal derangement with mild degenerative changes, has been manifested in slight recurrent instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for internal derangement with mild degenerative changes, left knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5260. 2. The criteria for entitlement to an initial rating in excess of 10 percent for internal derangement with mild degenerative changes, right knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5260. 3. The criteria for entitlement to a separate rating of 10 percent for limited extension due to internal derangement with mild degenerative changes, left knee, are met for the period from September 30, 2016, to September 16, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5261. 4. The criteria to entitlement to a separate rating of 10 percent for limited extension due to internal derangement with mild degenerative changes, right knee, are met for the period from September 30, 2016, to September 16, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5261. 5. The criteria for entitlement to a separate rating of 10 percent for instability of the left knee, from January 4, 2005, have been met. U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 6. The criteria for entitlement to a separate rating of 10 percent for instability of the right knee, from January 4, 2005, have been met. U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1984 to August 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal of an August 2001 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2006, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. This case was previously remanded by the Board in October 2010, September 2017, and March 2019. A review of the claims file shows that there has been substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The case has been returned to the Board for review. In March 2019, the Board remanded the claim of entitlement to service connection for hypertensive vascular disease for additional development. A November 2019 rating decision granted entitlement to service connection for hypertensive vascular disease. As this represents a total grant of the benefit sought on appeal with respect to this issue, it is no longer before the Board. See Grantham v. Brown, 114 F. 3d 1156, 1159 (Fed. Cir. 1997). In September 2017, the Board denied entitlement to an initial rating in excess of 10 percent for internal derangement of the right knee, with degenerative changes, and denied entitlement to an initial rating in excess of 10 percent for internal derangement of the left knee, with degenerative changes. The Veteran appealed the Board’s decision to the Court, and in an August 2018 Order, the Court granted a July 2018 JMR, vacated the September 2017 Board decision and remanded the issue to the Board for readjudication. In addition, the December 2017 Board decision also determined the issue of entitlement to a TDIU was no longer before the Board since the issue was considered and denied by the RO in an April 2017 rating decision. The Veteran appealed the Board’s decision to the Court, and the Court granted a June 2018 JMR and determined that the Board must adjudicate the issue of entitlement to a TDIU. Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). In rating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant 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. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). 1. Entitlement to a Higher Initial Rating or Separate Ratings for Internal Derangement with Mild Degenerative Changes, Left Knee 2. Entitlement to a Higher Initial Rating or Separate Ratings for Internal Derangement with Mild Degenerative Changes, Right Knee The Veteran seeks a higher initial rating for his service-connected internal derangement with mild degenerative changes, left knee, and a higher initial rating for his service-connected internal derangement with mild degenerative changes, right knee. The Veteran’s service-connected bilateral knee disabilities are rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5260-5003. The applicable rating period is from May 19, 2000, the effective date for the award of service connection for bilateral knee disability, through the present. See 38 C.F.R. § 3.400. Under Diagnostic Code 5003, rating shall be on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If noncompensable limitation of motion is demonstrated, a 10 percent rating is assigned for each major joint or group of minor joints affected. In the absence of any limitation of motion, a 10 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45. Under 38 C.F.R. § 4.71a , Diagnostic Code 5260, a 0 percent rating is warranted for flexion of the knee limited to 60 degrees; a 10 percent rating is warranted for flexion of the knee limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; and a 30 percent rating is warranted for flexion limited to 15 degrees. Under 38 C.F.R. § 4.71a , Diagnostic Code 5261, a 0 percent rating is warranted for extension of the knee limited to 5 degrees; a 10 percent rating is warranted for extension of the knee limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71a, Plate II. Separate ratings may be awarded under Diagnostic Codes 5257, 5260, and 5261. See VAOPGCPREC 9-2004. In addition, even if a veteran did not have limitation of motion of the knee meeting the criteria for a compensable rating under Diagnostic Code 5260 or 5261, a separate rating could be assigned if there was evidence of full range of motion “inhibited by pain.” Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Turning to the relevant evidence of record, the medical treatment records dated during the relevant period show that the Veteran has reported bilateral knee pain. However, they do not contain any range-of-motion measurements for the bilateral knees. They also do not show that the Veteran had ankylosis of the knee at any point during that period. As such, the medical treatment evidence of record does not show that the Veteran was entitled to an initial rating in excess of 10 percent for his service-connected bilateral knee disability at any time during the relevant period. The Veteran was provided a VA examination in May 2001. The Veteran reported that he has impairment in his ability to squat, kneel, stair climb and run. The VA examiner reported that the Veteran’s gait was normal, and he did not use an assistive device. Upon examination, the Veteran had bilateral knee flexion to 45 degrees and bilateral knee extension to 5 degrees. The Veteran demonstrated pain on motion with no instability. In a January 2005 statement in support of claim, the Veteran reported that he was prescribed a brace on both knees to decrease buckling and a cane due to instability. The Veteran was provided a VA examination in January 2005. The Veteran reported bilateral knee pain. The Veteran reported flare-ups with weather changes and with repetitive use. Upon examination, the Veteran demonstrated right knee extension to 0 degrees and right knee flexion to 130 degrees with pain throughout the range of motion. He was able to perform repetitive use testing without additional loss of range of motion. The Veteran’s right knee was stable. The Veteran demonstrated left knee extension to 0 degrees and left knee flexion to 120 degrees with pain on motion. He was able to perform repetitive use testing without additional loss of range of motion. The Veteran’s left and right knees were stable. The Veteran was provided a VA examination in November 2010. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported bilateral knee pain with flare-ups with standing, sitting or walking more than 200 feet. He further reported that three times a month, his bilateral knees will give way. Upon examination, the Veteran’s gait was normal. He demonstrated right knee flexion to 120 degrees and extension to 0 degrees with pain. He demonstrated left knee flexion to 120 degrees and extension to 0 degrees with pain. The Veteran was able to perform repetitive use testing without additional loss of range of motion. The Veteran was provided a VA examination in September 2016. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported constant bilateral knee pain that worsens with activity. He further reported that his knee gives out with extended walking. The Veteran stated that he could perform sedentary work if he is allowed to get-up, stretch and adjust frequently. The Veteran did not report flare-ups. Upon examination, the Veteran demonstrated right knee flexion to 130 degrees and right knee extension to 10 degrees. He demonstrated left knee flexion to 125 degrees and left knee extension to 10 degrees. The Veteran was able to perform bilateral repetitive use testing without additional loss of range of motion. The Veteran did not have ankylosis of the bilateral knees. Upon joint stability testing, the Veteran did not demonstrate instability of the knees. The Veteran was provided a VA examination in September 2019. The VA examiner reviewed the record, interviewed the Veteran and conducted an in-person examination. The Veteran reported that his bilateral knees give out. He further reported that he is unable to turn or stand up quickly, run, jump or squat. Upon examination, the Veteran demonstrated right knee flexion to 90 degrees and extension to 0 degrees with pain on examination that causes functional loss. The Veteran demonstrated left knee flexion to 100 degrees and extension to 0 degrees with pain on examination that causes functional loss. The Veteran was able to perform repetitive use testing. His right knee flexion after repetitive use was 80 degrees and his left knee flexion was 90 degrees. The VA examiner estimated that the Veteran’s right knee flexion would be 60 degrees after repeated use over time and his left knee flexion would be 60 degrees after repetitive use. The VA examiner further estimated that the Veteran’s right knee flexion would be 80 degrees during flare-ups and his left knee flexion would be 60 degrees during flare-ups. The VA examiner noted additional contributing factors related to the Veteran’s bilateral knee disability, including swelling, instability of station, disturbance of locomotion and interference with standing. The Veteran did not demonstrate ankylosis of the bilateral knees. Upon joint stability testing the Veteran did not demonstrate instability. The VA examiner noted that the Veteran uses a wheelchair constantly. The Veteran’s service-connected left knee disability and right knee disability have been rated as 10 percent disabling under Diagnostic Code 5260 for the entire period on appeal. These ratings were awarded based on arthritis with painful, limited motion that was not compensable under the relevant diagnostic codes. Additional or higher ratings could be warranted if the Veteran’s service-connected left knee disability and right knee disability manifested in flexion limited to 30 degrees or less and/or extension limited to 10 degrees or more. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. With regard to the Veteran’s degenerative joint disease of the left knee and right knee, the Board concludes that the record supports a finding that, throughout the relevant rating period, the disability manifested in painful motion and noncompensably limited flexion of the left knee and right knee. In addition, aside from the period from September 30, 2016, to September 16, 2019, the condition manifested in noncompensably limited extension of the left knee and right knee. Specifically, during those periods, the Veteran’s left knee and right knee degenerative joint disease was manifested by flexion limited to no less than 45 degrees and flexion limited to no greater than 5 degrees, including on repetition, during flare-up, on weight-bearing, and on passive motion. As such, the Veteran was entitled to only the previously awarded single 10 percent rating under Diagnostic Codes 5260 and 5261 based on flexion limited to 45 degrees. See Lichtenfels, 1 Vet. App. 484; VAOPGCPREC 9-2004. However, the record shows that on September 30, 2016, the Veteran had left knee extension and right knee extension limited to 10 degrees, which warrants a 10 percent rating under Diagnostic Code 5261. An award of a separate 10 percent rating under Diagnostic Code 5261 in addition to the previously awarded 10 percent rating based on painful, limited motion does not constitute impermissible pyramiding because the previously awarded 10 percent rating compensates the Veteran for his painful but noncompensably limited flexion while the separate ratings under Diagnostic Code 5261 compensates the Veteran for his compensably limited left knee extension and right knee extension. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). However, at the VA examination on September 17, 2019, the Veteran had extension to 0 degrees in both the left knee and right knee, which warrants a noncompensable rating under Diagnostic Code 5261. Subsequent records do not show that the Veteran had left knee or right knee extension limited to 10 degrees or greater such that a separate compensable rating was warranted after September 17, 2019. Therefore, the Board concludes that, only for the period from September 30, 2016, to September 16, 2019, a separate rating of 10 percent was warranted for limited extension due to internal derangement with mild degenerative changes, left knee, and internal derangement with mild degenerative changes, right knee. The Board has also considered whether the Veteran is entitled to higher or separate ratings under Diagnostic Code 5257 for recurrent subluxation or lateral instability. Since January 4, 2005, the Veteran has consistently reported that his left knee and right knee give out, and that he has been provided knee braces to assist with his bilateral knee instability. However, the stability tests conducted at all the VA examinations were negative for instability. The Veteran is competent to report his knee periodically gives way and causes falls. As such, in resolving doubt in the Veteran’s favor, the Board finds that the Veteran’s subjective complaints in conjunction with the VA examiner’s competent medical opinion, support a finding of slight instability under Diagnostic Code 5257 for the Veteran’s left knee and right knee. Slight instability of the left knee and right knee entitles the Veteran to a 10 percent rating, each, under Diagnostic Code 5257. Since all objective tests are negative for instability, the Board finds that the evidence of record does not support a higher rating. In determining the appropriate ratings for the Veteran’s service-connected left knee and right knee disabilities throughout the relevant rating period, the Board has considered whether the Veteran was entitled to higher or additional ratings under the other criteria for rating disabilities of the knee and leg. In this case, 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not for consideration because the record does not reflect that the Veteran had ankylosis of the bilateral knee, dislocated semilunar cartilage, impairment of the tibia and fibula associated with the service-connected bilateral knee disability, or genu recurvatum of the left knee at any time during the rating period. The Board has also considered whether the record shows that the Veteran was entitled to higher ratings based on additional functional loss or impairment under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See DeLuca, 8 Vet. App. 202, Burton v. Shinseki, 25 Vet. App. 1 (2011). At the September 2019 VA examination, the Veteran demonstrated reduced range of motion after repetitive use. Specifically, the VA examiner noted that the Veteran’s left knee and right knee flexion would be 60 degrees and his left knee and right knee extension would be 0 degrees after repetitive use over time. As discussed above, even with such limitation, the Veteran’s service-connected left knee and right knee disability did not manifest to a severity more closely approximating that contemplated by the higher rating criteria. Therefore, higher ratings were not warranted even in view of the findings on examination in September 2019. See 38 C.F.R. §§ 4.40, 4.45, and 4.59, and DeLuca, 8 Vet. App. 202. The Board notes that in the December 2019 Appellant’s Post-Remand Brief, the Veteran’s representative stated that the Veteran uses a wheelchair due to his bilateral knee disability, and as such, his condition would be equally well served with amputation and prosthesis. Regulations pertaining to for loss of use of a hand or foot state that loss of use is held to exist when no effective function remains other than that which would be equally well served by an amputation with use of a suitable prosthetic appliance. The determination should be made on the basis of the actual remaining function, such as the ability to balance and propel the body. See 38 C.F.R. §§ 3.350 (a)(2), 4.63. The Court has found that a “loss of use” exists when there is “deprivation of the ability to avail oneself” of that extremity, and functional impairment caused by pain, weakness, or incoordination should be taken into account when making that determination. See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). The preponderance of the probative medical evidence demonstrates that the Veteran does not have loss of use of one or both lower extremities due to service-connected bilateral knee disability. The record reflects that at the September 2019 VA examination the Veteran reported decreased mobility and disturbance of locomotion. The Veteran further reported that he cannot walk more than a few feet at a time and is unable to stand for greater than five minutes due to instability of station and that he feels unsteady on his feet. He also reported that he constantly uses a wheelchair. The Veteran’s medical treatment records and the VA examinations reflect that, although he has pain, weakness, and limited motion in the bilateral lower extremities due to his service-connected disabilities of the knees, such symptoms have not been shown to prevent the Veteran from walking with the use of a single cane or standing for five minutes. No VA examiner or other competent medical source has opined that the Veteran has limited functional impairment of the right or left lower extremity due to the service-connected disabilities such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Although the Veteran may have pain, weakness, and limited motion in the bilateral lower extremities due to his service-connected disabilities, which make walking a challenge, the evidence does not show that the Veteran has at any time had loss of use of a lower extremity such that he is unable to avail himself of use of one or both lower extremities for balance, propulsion, and other typical functions. The Board assigns weight to the medical evidence and notes that it is the Board’s responsibility, not the evaluating medical professionals, to determine whether “loss of use” exists. Tucker v. West, 11 Vet. App. 369 (1998). The preponderance of the evidence is against finding that the Veteran’s service-connected disabilities of the bilateral knees have resulted in functional impairment comparable to loss of use of one or both lower extremities. The Board has considered the lay statements of the Veteran regarding his problems with walking and standing. The Board does not doubt those assertions, as the Veteran is competent to report that he has difficulty walking and standing. See Jandreau, 492 F.3d at 1376-77. Those statements, however, are insufficient to establish loss of use of one or both lower extremities, and they do not outweigh the medical evidence that demonstrates that the claimant does not meet any of the required criteria under 38 C.F.R. §§ 3.808. The Board therefore finds that the criteria for entitlement to a separate rating of 10 percent was warranted for limited extension due to internal derangement with mild degenerative changes, left knee, and internal derangement with mild degenerative changes, right knee, for the period from September 30, 2016, to September 16, 2019. Additionally, the Board finds that the criteria for entitlement to a separate rating of 10 percent was warranted for instability due to internal derangement with mild degenerative changes, left knee, and internal derangement with mild degenerative changes, right knee, from January 4, 2005. However, to the extent the Veteran seeks initial ratings for the service-connected left and right knee disabilities higher than or in addition to those assigned previously and assigned herein, the preponderance of the evidence is against the appeal, the benefit-of-the-doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Extraschedular Considerations The issue of entitlement to an extraschedular rating for the Veteran’s service-connected left knee and right knee disabilities was raised by the Veteran’s representative in the December 2019 Appellant’s Post-Remand Brief. In that correspondence, the representative stated “[t]he Veteran requests the maximum benefit allowed by law and regulation, including, but not limited to, an extraschedular rating based on the exceptional and unusual symptoms and severity of his service-connected disability.” Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, and the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran’s disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. In regard to the first element, comparison of the Veteran’s symptoms and functional impairment associated with the service-connected bilateral knee disabilities do not show that the rating criteria are inadequate to describe his disability picture. The record shows that the Veteran has complaints and findings of painful, limited motion of the knees and instability of the knees. Diagnostic Codes 5003, 5257, 5260, and 5261 reasonably described and compensate for such symptoms, as discussed above. Additionally, for all musculoskeletal disabilities, the Schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the Schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. In this case, they contemplate the Veteran’s functional impairments caused by the service-connected bilateral knee disabilities. Because the Schedule was purposely designed to compensate for such functional effects of the Veteran’s disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the Schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. REASONS FOR REMAND 1. Entitlement to a TDIU The Veteran seeks entitlement to a TDIU. During the entire rating period on appeal, the Veteran has not met the schedular requirements for a TDIU. 38 C.F.R. § 4.16 (a). However, a TDIU can be awarded on an extraschedular basis under 38 C.F.R. § 4.16 (b), if it is determined that the veteran is unemployable by reason of service-connected disability, but fails to meet the percentage standards set forth in 38 C.F.R. § 4.16 (a). However, if it is determined that the veteran is unemployable by reason of service-connected disability, but fails to meet the percentage standards set forth in 38 C.F.R. § 4.16 (a), the Board cannot consider such entitlement in the first instance. Instead, the claim must be remanded so that it can be referred to VA’s Director, Compensation Service for initial consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). In this case, the Veteran indicated in a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, received December 2010, that he last worked full time in march 2006. At the September 2016 VA examination, the Veteran reported that he would be able to work sedentary employment if he is allowed to get-up, stretch and adjust frequently. Additionally, the September 2016 VA examiner reported that the Veteran would not be able to do a job that required any standing over five to ten minutes, required long walking, or required climbing/descending stairs. The VA examiner further reported that the Veteran would be able to do sedentary work if he was allowed to gut up and stretch periodically as needed. Furthermore, due to the Veteran’s service-connected right elbow disability, the VA examiner reported that the Veteran would not be able to do a job that required repetitive movements with the right elbow and could not lift above 25 pounds. The Board notes that the Veteran is right handed. Based upon the above evidence, the Board concludes that the facts of this case meet the criteria for submission of the Veteran’s claim to the Director, Compensation Service, for extraschedular consideration of entitlement to a TDIU. The matter is REMANDED for the following action: 1. Refer the claim to the Director, Compensation Service, for consideration of whether a TDIU is warranted on an extraschedular basis. Include a full statement as to the Veteran’s service-connected disability(ies), employment history, educational and vocational attainment, and all other factors having a bearing on the issue. See 38 C.F.R. § 4.16 (b). 2. After completion of the above, review the expanded record, including the evidence entered since the most recent adjudication of the issue on appeal, and determine whether a TDIU may be granted on an extraschedular basis. If the benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. U. R. POWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. G. LeMoine 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.