Citation Nr: 20048784 Decision Date: 07/21/20 Archive Date: 07/21/20 DOCKET NO. 18-07 819 DATE: July 21, 2020 ORDER Service connection for a left wrist disability is denied. A rating in excess of 10 percent for left knee instability is denied. A rating in excess of 10 percent for right knee instability is denied. Prior to February 7, 2020, a rating in excess of 10 percent for left knee degenerative joint disease (DJD) with limitation of flexion is denied. Prior to February 7, 2020, a rating in excess of 10 percent for right knee DJD with limitation of flexion is denied. A 30 percent rating for left knee DJD with limitation of flexion for the period beginning February 7, 2020 is granted. A 30 percent rating for right knee DJD with limitation of flexion for the period beginning February 7, 2020 is granted. A rating in excess of 40 percent for left knee limitation of extension, residual of left knee DJD is denied. A rating in excess of 40 percent for right knee limitation of extension, residual of right knee DJD is denied. Effective September 29, 2014, a total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran’s left wrist disability did not onset due to injury sustained during a period of service. 2. The left knee instability most nearly approximated slight impairment of the knee. 3. The right knee instability most nearly approximated slight impairment of the knee. 4. Prior to February 7, 2020, the Veteran had flexion of the left knee at most limited to 90 degrees due to pain and weakness with repeated use over time or during flare-up. 5. Prior to February 7, 2020, the Veteran had flexion of the right knee at most limited to 85 degrees after repetitive motion testing and due to pain, weakness, fatigue and lack of endurance during flare-up. 6. Beginning February 7, 2020, the Veteran had flexion of the left knee limited to 15 degrees due to pain during flare-up 7. Beginning February 7, 2020, the Veteran had flexion of the right knee limited to 20 degrees due to pain during flare-up. 8. The Veteran had extension of the left knee at most limited to 30 degrees. 9. The Veteran had extension of the right knee at most limited to 30 degrees. 10. Effective September 29, 2014, the Veteran meets the schedular criteria for assignment of a TDIU rating and his service-connected disabilities are shown to preclude the Veteran from securing and following substantially gainful employment consistent with his work and education background. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left wrist disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for a rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5257. 3. The criteria for a rating in excess of 10 percent for right knee instability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5257. 4. Prior to February 7, 2020, a rating in excess of 10 percent for left knee DJD with limitation of flexion have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5260. 5. Prior to February 7, 2020, a rating in excess of 10 percent for right knee DJD with limitation of flexion have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5260. 6. Beginning February 7, 2020, the criteria for assignment of a 30 percent rating for left knee DJD with limitation of flexion have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5260. 7. Beginning February 7, 2020, the criteria for assignment of a 30 percent rating for right knee DJD with limitation of flexion have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5260. 8. The criteria for a rating in excess of 40 percent for left knee limitation of extension, residual of left knee DJD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5261. 9. The criteria for a rating in excess of 40 percent for right knee limitation of extension, residual of right knee DJD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code 5010, 5261. 10. The criteria for the assignment of a TDIU rating effective September 29, 2014 have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to February 1980. These matters initially came before the Board of Veterans’ Appeals (Board) on appeal from December 2014 and October 2018 rating decisions issued by the RO. The Board remanded the appeal in April 2019 for additional development. Specifically, the Board instructed the Agency of Original Jurisdiction (AOJ) to schedule the Veteran for VA examination to ascertain the etiology of the left wrist disability and level of severity of his service-connected left and right and knee disabilities. The Veteran received VA examinations in July 2019 and February 2020 addressing the severity of his left and right knee disabilities and etiology of his claimed left wrist disability. The development has been completed and the case has been returned to the Board for appellate consideration. In an August 2019 rating decision, the RO granted separate 40 percent ratings for left and right knee limitation of extension, residual of left and right knee DJD effective July 9, 2019. As the appeal originated from the Veteran’s claim for increased ratings for his service-connected left and right knee disabilities, the claims for increased ratings for left and right knee limitation of extension, residual of left and right knee DJD are also before the Board on appeal. The appeal originally included the issues of entitlement to increased ratings for left and right shoulder disabilities and entitlement to service connection for a lumbar spine disability. In October 2019, the Veteran timely elected to participate in the modernized review system with regard to those issues, requesting higher level review from the AOJ. Accordingly, those issues have been withdrawn and discontinued from the legacy appeals process and are not before the Board on appeal at this time. The claim for a TDIU rating prior to August 9, 2017 has been added to the appeal pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection 1. Entitlement to service connection for a left wrist disability Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § § 3.303. In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. § §§ 3.307, 3.309. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted, arthritis is a chronic disease. 38 U.S.C. § 1101. Therefore, section 3.303(b) is potentially applicable. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The Veteran asserts that he sustained an injury during a rough landing of a parachute jump which led to the onset of his claimed left wrist disability. The service treatment records show no complaints, findings or treatment of a left wrist disability. A December 2014 VA treatment record documents the Veteran’s complaint of a six to eight-month history of worsening left wrist pain. His left wrist was tender to palpation and the pain radiated to the thumb and up the arm. The December 2014 left wrist x-ray findings showed faint corticated calcification was present adjacent to the ulnar styloid, likely related to remote fracture. The impression was mild chronic degenerative changes suggestive of remote prior traumatic injury. The February 2020 report of VA wrist conditions examination documents diagnoses of left wrist osteoarthritis; bilateral DeQuervain’s syndrome; and, left remote avulsion fracture of the ulnar styloid. The Veteran reported that he served in an Airborne unit and that he had two parachute landings that were “hard.” He reported that on one occasion, he struck wood with his arm extended but he was unsure if he sustained any injury to his left wrist. The examiner noted that x-ray findings of the left wrist showed DJD development over the first carpal metacarpal (CMC) joint and a possible old fracture at the ulnar stylis. The examiner reported that the left wrist osteoarthritis and remote fracture of the left wrist ulnar styloid were documented in 2014 but explained the DeQuervain’s tenosynovitis was a new diagnosis since 2014. The examiner stated that the findings of osteoarthritis of the thumb CMC joint and DeQuervain’s tenosynovitis could cause the symptoms described by the Veteran (i.e., pain with the use and palpation of his thumb and radiation up the radial aspect of the wrist). The examiner noted that the Veteran complained of tenderness over the entire wrist, but his primary area of complaint was at the thumb and surrounding structures which supported the diagnosis of osteoarthritis of the CMC thumb joint; however, his DeQuervains’ was the diagnosis responsible for his symptoms. The examiner explained that the area of the styloid fracture was on the opposite side of the wrist of his reported symptoms. The examiner noted that the Veteran’s service treatment records contained no complaints of a left wrist condition and that he reported that he had two bad parachute landings during service but was unsure if he injured his left wrist. The examiner observed that the Veteran reported a six to eight-month history of left wrist pain in 2014 with an insidious onset. There was no report of prior injury. The examiner reiterated that the area of the remote fracture was on the opposite side of the wrist where the Veteran reported his current symptoms (i.e., the ulnar side was the area of possible remote fracture and the radial side was the area of the Veteran’s symptoms of pain). The examiner opined that it was not at least as likely as not that the Veteran’s left wrist osteoarthritis at the CMC thumb joint and DeQuervain’s tenosynovitis were connected to his service. The examiner explained that the remote ulnar styloid fracture was not the area of pain reported by the Veteran on examination and concluded the remote fracture healed and did not have any residuals that could be considered chronic or disabling. The examiner also noted that there was no evidence that the Veteran sustained any fracture in service based on the absence of service treatment records documenting any such injury and the Veteran’s inability to recall sustaining any such injury in service. Though the Veteran has a current left wrist disability, the preponderance of the evidence is against a finding of a linkage between the onset of the left wrist disability and a period of service. Rather, the evidence shows that to the extent that the Veteran sustained a remote ulnar styloid fracture, the remote fracture healed without residual disability and his current left wrist disability symptoms were unrelated to that fracture. Regardless, there was no evidence that the Veteran sustained any fracture in service (see February 2020 VA examination report). By his own admission, the Veteran was unsure if he had sustained any left wrist injury in a parachute landing accident during service. In December 2014, he reported the history of left wrist pain with an insidious onset. Thus, the evidence of record shows that the current left wrist disability had no etiological relationship to in-service injury, having onset many years after service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (observing that the passage of so many years between discharge from active service and the objective documentation of a claimed disability is a factor that tends to weigh against a claim for service connection). This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between the left wrist disability and a period of the Veteran’s service. Additionally, there is no evidence of left wrist arthritis in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1339. No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (arthritis) entity were not noted. Further, there is no demonstration of continuity of symptomatology or evidence of arthritis within one year of separation from service. Thus, service connection for the left wrist disability cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The Veteran is not competent to link his left wrist disability to service. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran’s death). The Veteran is competent to describe events of his period of service. However, he is a lay person and is not competent to establish that his current left wrist disability onset as a result of any in-service event or injury. The Veteran is not competent to offer an opinion as to etiology of any current left wrist disability. The question regarding the etiology of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, his allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim of entitlement to service connection for a left wrist disability must be denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Rating Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). “Staged” ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. The ratings for the Veteran’s left and right knee disabilities have been assigned pursuant to diagnostic codes (DC) 5257, 5260 and 5261. Under DC 5260, a 10 percent rating is assigned for limitation of flexion to 45 degrees. A 20 percent rating contemplates limitation of flexion to 30 degrees. A rating of 30 percent requires limitation of flexion to 15 degrees. 38 C.F.R. § § 4.71a, DC 5260. The VA General Counsel has held that separate ratings under 38 C.F.R. § § 4.71a, DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Under DC 5261, a rating of 10 percent requires limitation of extension to 10 degrees. A rating of 20 percent requires limitation of extension to 15 degrees. A rating of 30 percent requires limitation of extension to 20 degrees. A rating of 40 percent requires limitation of extension to 30 degrees, and a rating of 50 percent requires limitation of extension to 45 degrees. 38 C.F.R. § § 4.71a, DC 5261. Separate evaluations may also be assigned for subluxation or lateral instability. See 38 C.F.R. § § 4.71a, DC 5257. A 10 percent rating is assigned for slight subluxation or lateral instability. A 20 percent rating is assigned for moderate subluxation or lateral instability. A 30 percent rating is warranted for severe subluxation or lateral instability. Words such as ‘severe,’ ‘moderate,’ and ‘mild’ are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104 (2012); 38 C.F.R. § §§ 4.2, 4.6. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The November 2014 report of VA knee and lower leg conditions examination documents the Veteran’s complaint of giving way of the knees, worse on the right knee and pain after prolonged sitting or walking. He had no complaints of swelling of the knees. Objectively, range of motion findings of the right knee were as follows: flexion limited to 95 degrees, with no objective evidence of painful motion and full extension with no objective evidence of painful motion. Flexion of the left knee was limited to 100 degrees, with no objective evidence of painful motion and he had full extension of the knee. Repetitive-use testing of the right knee did not result in additional limitation in range of motion of the knee; on the left, repetitive-use testing resulted in additional limitation in range of motion of the knee (i.e., flexion of the left knee was limited to 95 degrees). Pain and weakness significantly limited functional ability during flare-ups or with repeated use over time resulting in flexion of the knees limited to 90 degrees, bilaterally. He had no tenderness or pain to palpation for joint line or soft tissues of the knees. Muscle strength testing was normal. Anterior instability, posterior instability and medial-lateral instability tests were normal and there was no evidence or history of recurrent patellar subluxation/ dislocation. The Veteran had a right knee meniscal tear, i.e., a semilunar cartilage condition and had undergone meniscectomy in October 2007. Residuals of his right knee meniscectomy included aching on use of the right knee. The physician indicated that the Veteran’s right and left knee disabilities impacted his ability to work in that it limited the Veteran to walking 100 yards at a time; walking approximately 1 hour during an 8 hour day; sitting 10 – 15 minutes at a time and standing 3 – 4 minutes at a time; and, sitting 1 hour and standing 20 minutes during an 8 hour day. The October 2017 report of VA knee and lower leg conditions examination reflects the Veteran’s complaint of constant right and left knee pain, worse in the left knee. He denied swelling. He walked with a cane occasionally. His right and left knee pain was aggravated by walking 100 yards; prolonged standing (excess of 4 minutes); and, prolonged sitting (excess 20 minutes). He reported that his knees were about 50 percent worse compared to examination two years earlier because of the frequency and intensity of the knee pains and stated that his knees pop and crack. Objectively, range of motion findings of the right knee were as follows: flexion limited to 120 degrees and he had full extension of the right knee with sharp pain in all planes of motion. Additionally, there was pain with weight bearing; objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue (laterally); and, objective evidence of crepitus. Flexion of the left knee was limited to 120 degrees and he had full extension of the left knee with sharp pain in all planes of motion. Additionally, there was pain with weight bearing; objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue (medially); and, objective evidence of crepitus. The Veteran was able to perform repetitive-use testing without additional limitation in range of motion or functional loss of the right and left knees. Repeated use over time and flare-ups did not cause significantly limited functional ability in the right or left knees. Muscle strength testing was slightly diminished (4/5 active movement against some resistance) and there was no evidence of muscle atrophy. There was no evidence of right or left knee ankylosis. He exhibited medial and lateral instability in the right and left knees (1+ (0-5 millimeters)). Residual symptoms of right knee meniscectomy were not documented. The examiner indicated that the Veteran’s right and left knee disabilities impacted his ability to work in that the Veteran would be prevented from engaging in manual work such as lifting, squatting, kneeling or walking for prolonged periods. The examiner stated that the Veteran would be able to engage in sedentary work. The July 2019 report of VA knee and lower leg conditions examination reflects the Veteran’s complaint of bilateral knee pain, popping, grinding, stiffness, decrease in range of motion and a sensation of “giving out.” He treated his knee pain with medication. He reported that he experienced flare-ups of bilateral knee pain, described as an increase in stiffness and pain. He had trouble in long distance ambulation, standing for prolonged periods of time and navigating stairs (climbing up and down stairs). Objectively, range of motion findings of the right knee were as follows: flexion limited to 90 degrees and extension of the right knee limited to 30 degrees with moderate pain around the patella. An increase in pain caused decreased locomotion. Additionally, there was pain with weight bearing and objective evidence of crepitus. Flexion of the left knee was limited to 100 degrees and extension of the left knee was limited to 30 degrees with moderate pain around the patella. An increase in pain caused decreased locomotion. Additionally, there was pain with weight bearing and objective evidence of crepitus. Repetitive-use testing resulted in flexion of the right knee limited to 85 degrees and flexion of the left knee limited to 95 degrees; there was no additional limitation in extension in either knee on repetitive-use testing. Pain, fatigue, weakness and lack of endurance significantly limited functional ability with repeated use over time but did not result in additional limitation of motion. Pain, fatigue, weakness and lack of endurance significantly limited functional ability during flare-up and resulted in flexion of the right knee limited to 85 degrees and flexion of the left knee limited to 95 degrees; there was no additional limitation in extension in either knee during flare-up. The examiner indicated that right and left knee pain caused weakened movement resulting in less movement. Additionally, pain caused instability of station and interference with standing. Further, knee swelling caused pain. Muscle strength testing was slightly diminished (4/5 active movement against some resistance) and there was no evidence of muscle atrophy. There was no evidence of right or left knee ankylosis. Anterior instability, posterior instability, medial instability and lateral instability tests were normal and there was no evidence or history of recurrent patellar subluxation/ dislocation. Residual symptoms of right knee meniscectomy were not documented. The examiner indicated that the Veteran’s right and left knee disabilities impacted his ability to work in that the Veteran would have difficulty in pushing or pulling; climbing stairs or ladders; long distance ambulation; and rising from a seated position. The examiner commented that there was no evidence of pain when the knee joints were used in non-weight bearing. Additionally, the passive range of motion findings in the right and left knees were the same as the active range of motion findings in the right and left knees. The February 2020 report of VA knee and lower leg conditions examination reflects the Veteran’s complaint of daily knee pain. He reported that on occasion, his knee would lock, and he had to force flexion, more often in the right knee than the left knee. He stated that he felts unstable at times and his knees would give way approximately 2 – 3 times per month. He treated his knee pain with medication, rest and elevation. He reported that he experienced flare-ups of bilateral knee pain. He stated that he took more time to do household chores; had difficulty preparing meals due to limitations in prolonged standing; had to alter how he dressed; had to lean against the wall of the shower; had to take a break after 1 hour of driving; could not stand longer than 3 – 5 minutes, walk longer than 5 – 10 minutes or sit longe than 10 minutes before he needed to change position; and, could not squat or climb. In addition, he had difficulty with descending stairs. Objectively, range of motion findings of the right knee were as follows: flexion limited to 90 degrees and extension of the right knee limited to 10 degrees with pain in all planes of motion. Additionally, there was pain with weight bearing; the anterior and posterior aspect of the right knee was tender to palpation; and, there was objective evidence of crepitus. Flexion of the left knee was limited to 75 degrees and extension of the left knee was limited to 10 degrees with pain in all planes of motion. Additionally, there was pain with weight bearing; the anterior and posterior aspect of the left knee was tender to palpation; and, there was objective evidence of crepitus. The Veteran was able to perform repetitive-use testing without additional limitation in motion. Pain significantly limited functional ability with repeated use over time and resulted in flexion of the right knee limited to 45 degrees and flexion of the left knee limited to 40 degrees; there was no additional limitation of extension in either knee. Pain significantly limited functional ability during flare-up and resulted in flexion of the right knee limited to 20 degrees and flexion of the left knee limited to 15 degrees; there was no additional limitation of extension in either knee. Muscle strength testing was normal and there was no evidence of muscle atrophy. There was no evidence of right or left knee ankylosis. He exhibited anterior instability in the right and left knees (1+ (0-5 millimeters)). Residual symptoms of right knee meniscectomy included frequent episodes of joint “locking” and frequent episodes of joint pain. The examiner indicated that the Veteran’s right and left knee disabilities impacted his ability to work and reported that the Veteran used to work as a shop manager for a trucking company, a trailer mechanic and a truck mechanic. He also worked as a service writer and had multiple jobs as a shop manager and foreman. The Veteran was retired and had not worked since February 2008. The examiner indicated that the Veteran would not be able to work a job that required him to engage in prolonged standing or walking or repeatedly squat or climb. The examiner commented that there was evidence of pain on passive range of motion testing and when the knee joint was used in non-weight bearing. 2. Entitlement to ratings in excess of 10 percent for left knee and right knee instability The October 2017 report of VA knee and lower leg conditions examination documents that the Veteran exhibited medial and lateral instability in the right and left knees, 1+ (0-5 millimeters). The February 2020 report of VA knee and lower leg conditions examination documents that he exhibited anterior instability in the right and left knees, 1+ (0-5 millimeters). At most, this documented degree of right and left knee instability represents slight instability of the knees and is adequately contemplated by the assigned 10 percent ratings. Thus, ratings in excess of 10 percent for left knee and right knee instability are not warranted. 3. Entitlement to ratings in excess of 10 percent for left knee and right knee DJD with limitation of flexion The Veteran demonstrated flexion of the right knee limited to 95 degrees (November 2014), 120 degrees (October 2017) and 90 degrees (July 2019); flexion of the left knee was limited to 100 degrees (November 2014), 120 degrees (October 2017) and 100 degrees (July 2019). The November 2014 report of VA examination documents that pain and weakness significantly limited functional ability during flare-ups or with repeated use over time resulting in additional limitation of motion demonstrated by flexion of the knees limited to 90 degrees, bilaterally. The July 2019 report of VA examination documents that repetitive-use testing resulted in additional limitation of motion demonstrated by flexion of the right knee limited to 85 degrees and flexion of the left knee limited to 95 degrees. Additionally, pain, fatigue, weakness and lack of endurance significantly limited functional ability during flare-up and resulted in additional limitation of motion also demonstrated by flexion of the right knee limited to 85 degrees and flexion of the left knee limited to 95 degrees. Even considering the additional limitation in motion documented in the November 2014 and July 2019 VA examination reports, there is no evidence of flexion of the right or left knees limited to 30 degrees. Thus, prior to February 7, 2020, ratings in excess of 10 percent for left knee and right knee DJD with limitation of flexion are not warranted. Ankylosis, frequent episodes of locking pain and effusion into the joint or tibia or fibular impairment is not demonstrated; therefore, prior to February 7, 2020, ratings in excess of 10 percent under Diagnostic Codes 5256, 5258 and 5262 are not warranted either. However, the February 2020 report of VA knee and lower leg conditions examination documents that the Veteran had flexion of the right knee limited to 90 degrees flexion of the left knee limited to 75 degrees. Pain significantly limited functional ability during flare-up and resulted in additional limitation of motion demonstrated by flexion of the right knee limited to 20 degrees and flexion of the left knee limited to 15 degrees. When viewed in a light most favorable to the Veteran, the evidence supports the assignment of 30 percent ratings for left knee and right knee DJD with limitation of flexion for the period beginning February 7, 2020 (the date a worsening of his disabilities was documented on examination). The Board notes that these 30 percent ratings are the maximum rating assignable for limitation of flexion. Ankylosis or tibia or fibular impairment is not demonstrated; therefore, ratings in excess of 30 percent under Diagnostic Codes 5256 and 5262 are not warranted. 4. Entitlement to ratings in excess of 40 percent for left knee and right knee limitation of extension, residual of left knee and right knee DJD At worst, the Veteran displayed extension of the right and left knees limited to 30 degrees (see July 2019 report of VA knee and lower leg conditions examination). Thus, the 40 percent ratings for the left knee and right knee limitation of extension, residual of left knee and right knee DJD adequately contemplate the severity of his disabilities. Ratings in excess of 40 percent for left knee and right knee limitation of extension, residual of left knee and right knee DJD are not warranted. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 5. Entitlement to a TDIU for the period prior to August 9, 2017 Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or, as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. Prior to August 9, 2017, service-connection was in effect for right shoulder DJD and glenohumeral joint dislocation (20 percent disabling), left shoulder DJD and glenohumeral joint dislocation (20 percent disabling), right knee instability (10 percent disabling), left knee instability (10 percent disabling), right knee DJD (10 percent disabling), left knee DJD (10 percent disabling) and right knee surgical scar associated with right knee DJD (0 percent disabling); the combined rating for all of these service-connected disabilities was 60 percent. The central inquiry is “whether a veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran’s education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant 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. The ultimate question, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. The August 2012 report of VA knee and lower leg conditions examination documents that the Veteran’s right and left knee disabilities impacted his ability to work. The Veteran had been unemployed since 2008 and previously worked as a shop manager. Similarly, the August 2012 report of VA shoulder and arm conditions examination reflects that the Veteran’s right and left shoulder disabilities impacted his ability to work reiterating that the Veteran had been unemployed since 2008 and previously worked as a shop manager. The November 2014 report of VA knee and lower leg conditions examination reflects that the Veteran’s right and left knee disabilities impacted his ability to work. The Veteran was limited to walking 100 yards at a time; walking approximately 1 hour during an 8-hour day; sitting 10 – 15 minutes at a time and standing 3 – 4 minutes at a time; and, sitting 1 hour and standing 20 minutes during an 8-hour day. The November 2014 report of VA shoulder and arm conditions examination documents that the Veteran’s right and left shoulder disabilities impacted his ability to perform any type of occupational task. The physician explained that the Veteran was unable to reach or lift above shoulder level due to his shoulder pain. The Social Security Administration (SSA) disability file records reflect that the Veteran was awarded SSA disability benefits due to his bilateral knee and bilateral shoulder disabilities. The Veteran’s application for a TDIU rating indicated that he last worked full-time in 2008 as a diesel mechanic. He reported that his service-connected right and left knee and right and left shoulder disabilities prevented him from securing or following any substantial gainful occupation. He had completed 2 years of college and reported that he completed an online course in business communication but struggled to sit through the studies. He stated the pain of his service-connected orthopedic knee and shoulder disabilities made it difficult to concentrate. He reported that he was unable to perform the work of a diesel mechanic, so he was let go from his employment in February 2008. He reported that the company had a series of layoffs and since he was having trouble performing his work duties because of his knee and shoulder disabilities, he was a casualty of the layoffs. He stated that he had trouble performing the physical aspects of his job and also had difficulty with concentration which affected his ability to perform computer jobs or sedentary work. He reported that he became unable to perform either the physical or sedentary components of the job due to his service-connected shoulder and knee disabilities. He reported that he tried to return to work in November 2008, but he was unable to keep up with the work. He attempted to go back to school but experienced concentration difficulties due to his service-connected knee and shoulder disabilities which included the pain medication prescribed for treatment of the knee and shoulder disabilities. The Veteran stated that but for his service-connected right and left knee and shoulder disabilities, he would have been able to continue working. He asserted that he was unable to secure or follow any substantially gainful employment. (Continued on the next page)   Given the Veteran’s contentions regarding the affects his service-connected right and left knee and right and left shoulder disabilities had on his ability to engage in sedentary employment and the obvious affects his service-connected disabilities had on his ability to engage in physical/manual labor, in light of the fact his present claims for increased ratings for his right and left knee and right and left shoulder disabilities were received on September 29, 2014, the Board concludes that assignment of a TDIU rating effective the date his claims for increased ratings were received is warranted. Thus, an effective date of September 29, 2014, for the grant of a TDIU rating is warranted. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Jackson 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.