Citation Nr: 21001100 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 13-18 866 DATE: January 7, 2021 ORDER Entitlement to an increased rating of 10 percent for tendonitis, Osgood-Schlatter's disease, excision of the left tibial tubercle with degenerative joint disease (left knee disability) is denied. Entitlement to a separate rating of 20 percent for a left knee disability with involvement of the meniscal cartilage is granted. Entitlement to an increased rating in excess of 10 percent for popliteal nerve entrapment of the left lower extremity is denied. Entitlement to service connection for a left hip disability is denied. Entitlement to a TDIU on an extra-schedular basis is granted. FINDINGS OF FACT 1. The Veteran’s left knee disability manifests, at worst, as flexion limited to 40 degrees. 2. The Veteran’s left knee disability also manifests in involvement of the meniscal cartilage with frequent episodes of pain and effusion. 3. The Veteran’s popliteal nerve entrapment of the left lower extremity manifests in mild incomplete paralysis. 4. The Veteran’s left hip arthritis is not secondary to service-connected left knee disability and is not otherwise related to an in-service injury or disease. 5. The evidence of record establishes that the Veteran’s service-connected disabilities render him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a non-initial increased rating of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 2. The criteria for a separate rating of 20 percent for a left knee disability with involvement of the meniscal cartilage have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5258. 3. The criteria for an initial increased rating in excess of 10 percent for popliteal nerve entrapment of the left lower extremity have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8521. 4. The criteria for service connection for left hip arthritis due to service or the Veteran’s service-connected left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for a TDIU on an extra-schedular basis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1974 to November 1976, and for 9 days in May 1992. These matters are on appeal to the Board of Veterans’ Appeals (Board) from September 2011, September 2013, October 2014, and November 2016 rating decisions. The claims were remanded in a January 2019 Board decision; the Board finds the remand directives have been substantially complied with. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to an increased rating for a left knee disability The Veteran currently has a 10 percent rating for his left knee disability based on limitation of flexion to 45 degrees and painful motion. The Veteran has been service-connected for a left knee disability since discharge from service. He filed a new claim for an increased rating on June 17, 2011. While the Veteran’s entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Thus, the Board will consider the evidence one year prior to the date of claim – June 17, 2010. Diagnostic Code 5003 directs that the disability should be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. If limitation of motion is noncompensable, a 10 percent rating should be assigned if objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Ratings can also be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege that he has tibia or fibula impairment, genu recurvatum, or ankylosis of the knee. As such, those diagnostic codes are not for application. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.”). In a July 2011 VA examination, the report reflected the Veteran’s severe pain in his left knee, inhibiting his ability to walk or stand for over 30 minutes and his difficulty in squatting or kneeling. His pain increased throughout the day until he rest his feet at the end of the day. This occured daily related to position and activity, but he had “no other flare-ups affecting speed, coordination or function.” The Veteran felt a snapping and popping sensation, but no catching, locking, giving way, or swelling. The report reflected that the Veteran walks slowly but without a gait abnormality. The impression was degenerative medial meniscal tear and chondromalacia patellae. In July 2013, the Veteran submitted a statement expressing dissatisfaction with the July 2011 examination. The Veteran stated that contrary to the examination report, he does have deformity and tenderness. He stated that the examination consisted more of a verbal history than a physical examination. He also reiterated that the extreme knee pain inhibits him from lifting, bending, stooping, or squatting. Walking is painful and difficult. He has difficulty fulfilling most daily tasks at home and on his property. The Veteran was afforded another examination in September 2013. He experienced flare-ups during cold weather, and stated it was becoming more difficult to bend his knee. His flexion was noted to end at 100 degrees with no objective evidence of painful motion. He experienced no additional limitation following repetitive use testing. His disability caused a functional impairment of less movement than normal and pain on movement. Tenderness was indicated. The Veteran had no instability upon testing, and the examiner indicated there was no evidence or history of recurrent patellar subluxation/dislocation. He reported using a knee brace regularly. While a 1975 left knee surgery was noted, the examiner indicated no prior meniscal conditions or surgical procedures for a meniscal condition. There were no noteworthy findings of additional limitations due to pain, weakness, fatigability or incoordination. Several VA treatment records in 2013 reflect sensations of instability in the knee at all times, with pain consistently rated at an 8 or 9 out of 10. The Veteran complained he experienced swelling and an inability to straighten his knee. A June 2011 record reflects pain in knee, a sense of “giving out,” and mild swelling. In an April 2014 orthopedic consultation note, it was noted that the Veteran experienced chronic pain with a history of a medial meniscectomy in 1975. Tenderness and abnormal gait were noted with no swelling. An X-ray showed mild lateral patellar subluxation; “doubt torn meniscus” was written as well as “[g]rade 2 signal is present in the medial meniscus suggesting early degenerative change.” Previous X-rays in 2011 and 2013 reflected an unremarkable patella. In an October 2014 VA examination, the Veteran reported the knot on his knee was becoming larger and his symptoms had increased over the past year. He experienced significant pain and numbness to entire lower leg, resolving in approximately 20 minutes. He reported flare-ups with kneeling, walking for 5-10 minutes, standing with his knee bent, going up and down stairs, and walking on uneven ground or bouncing on a tractor. His initial range of motion was flexion ending at 110 degrees with painful motion beginning at 70 degrees. There was no limitation of extension or evidence of painful motion in extension. Upon repetitive use testing, the Veteran’s left knee flexion ended at 95 degrees, resulting in a functional loss due to less movement than normal, pain on movement, and deformity. His stability was normal upon testing, and the examiner indicated there was no evidence or history of recurrent patellar subluxation/dislocation. He also indicated there was no X-ray evidence of patellar subluxation; it is unclear whether the April 2014 X-rays were reviewed. The examiner indicated the Veteran did have a previous meniscectomy with residuals of early degenerative joint disease. Soft swelling was noted. He uses a brace regularly. In his most recent October 2019 VA examination, he reported flare-ups upon overuse of the knee or leg; his left swells with increased pain lasting overnight. He endorsed functional loss as he is unable to walk on uneven ground, climb a ladder, or ride a tractor. The Veteran’s flexion ended at 65 degrees with objective evidence of pain on flexion, rest/non-movement, and weight-bearing. Tenderness was noted. Following three repetitions, the Veteran’s flexion ended at 55 degrees. Following repetitive use over time and during a flare-up, the examiner determined a functional loss due to pain likely resulted in flexion ending at 40 degrees. Additional contributing factors of disability include disturbance of locomotion and interference with sitting and standing. The Veteran had reduced muscle strength (active movement against some resistance). No ankylosis was indicated. The examiner indicated no history of recurrent subluxation or lateral instability. There was no instability upon testing, though significant pain was reported. The examiner indicated the Veteran had never had a meniscus condition. The October 2019 examiner was also requested to opine, to the extent she was able, on the range of motion the Veteran experienced during flare-ups in the previous VA examinations as such ranges had not been provided. As to the July 2011 examination, the examiner opined the Veteran was not experiencing flare-ups at that time. While the Veteran reported pain increasing throughout the day as he bore weight on the leg, she reasoned this would not be a flare-up but normal pain with use. As to the September 2013 examination, the examiner opined that flare-ups when bending the knee on a cold day would likely decrease his range of motion by about 20 degrees (later clarified to be in flexion). As his range of motion in flexion at that time ended at 100 degrees, this would equate to flexion ending at 80 degrees in a flare-up. As to his October 2014 examination, the examiner estimated the range of motion noted on repetitive movements would be the same as one would see during a flare-up during that time. Thus, the range of motion during a flare-up would have ended at 95 degrees. There is a significant amount of inconsistency among the examinations, particularly with the Veteran’s ranges of motion in flexion. Even affording the Veteran the benefit of the doubt, particularly in consideration of the severe pain he experiences, his most reduced range of motion ends at 40 degrees in flexion, warranting a 10 percent rating under Diagnostic Code 5260. The Board has also considered other potentially applicable diagnostic codes. The evidence is unclear whether the Veteran’s meniscus has been removed. Some records do reflect a prior meniscectomy; however, 2011 and 2013 X-rays show meniscal changes. The service treatment records (STRs) do not reflect removal of the meniscus. Some examinations do not indicate any meniscal condition, yet there is objective evidence of degenerative meniscal changes in the record. The Board finds that, in affording the Veteran the benefit of the doubt, the preponderance of the evidence reflects a meniscal condition with frequent episodes of pain and effusion in the joint, warranting a separate 20 percent rating under Diagnostic Code 5258. The Board has also acknowledged the Veteran’s contention that he should be rated under Diagnostic Code 5257 for recurrent subluxation or lateral instability. The record does reflect subjective complaints of instability in 2011 and 2013. A 2014 X-ray shows evidence of patellar subluxation. However, the preponderance of evidence does not show recurrent subluxation, as each examination has indicated there is no history of such. There is no objective evidence of instability upon testing in examinations. While subjective complaints have been duly considered, the lack of objective evidence coupled with the fact that such subjective complaints have not been consistent over the appeal period, weighs against a separate rating under Diagnostic Code 5257. In sum, based on the overall evidence of record, the Veteran is entitled to a 10 percent rating under Diagnostic Code 5260 and a 20 percent rating under Diagnostic Code 5258. Entitlement to an increased rating in excess of 10 percent for popliteal nerve entrapment of the left lower extremity The Veteran was granted service connection for his left lower extremity nerve entrapment in a November 2016 rating decision rated at 10 percent disabling. The effective date was later determined to be June 17, 2011, the date of claim. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). As the Veteran is pursuing his initial 10 percent rating, the Board will consider the evidence as of June 17, 2011. Disability ratings for diseases of the peripheral nerves are based on relative loss of function of the involved extremity with attention to the site and character of the injury, the relative impairment of motor function, trophic changes, or sensory disturbances. See 38 C.F.R. § 4.120. Under Diagnostic Code 8521 for the external popliteal nerve, a 10 percent rating is warranted for mild incomplete paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. A 30 percent rating is warranted for severe incomplete paralysis. A 40 percent rating is warranted for complete paralysis, which is manifested by foot drop and slight droop of the first phalanges of all toes, inability to dorsiflex the foot, loss of extension (dorsal flexion) of the proximal phalanges of the toes; loss of abduction of foot, weakened adduction; and anesthesia covering the entire dorsum of foot and toes. Descriptive words such as “slight,” “moderate” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104 (a); 38 C.F.R. §§ 4.2, 4.6. The term “incomplete paralysis” indicates a degree of lost or impaired function less than the type picture for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. However, VA’s Adjudication Manual does provide guidance in evaluating the severity of nerve paralysis. According to the Manual, “mild” incomplete paralysis is demonstrated by subjective symptoms or diminished sensation. M-21, III.iv.4.G.4.b. “Moderate” incomplete paralysis is manifested by the absence of sensation confirmed by objective findings. Id. “Severe” incomplete paralysis is manifested when more than sensory findings are demonstrated, such as atrophy, weakness, and diminished reflexes. Id. In a May 2013 treatment record, the Veteran complained of new numbness the prior two months from his left knee that radiates down onto his foot. In April 2014, radicular symptoms were noted. In September 2014, the Veteran complained of lower leg numbness after kneeling for a few minutes. Some numbness and tingling with firm palpation to popliteal area was noted. The assessment was popliteal nerve entrapment. In an October 2014 VA examination, a diagnosis of left popliteal nerve entrapment was indicated. The report reflected that the Veteran experienced significant pain and numbness to the entire lower leg, describing it “like there is no leg there at all,” resolving in approximately 20 minutes. In November 2015, the Veteran complained of numbness at times. In December 2017, the Veteran stated his whole leg goes numb sometimes, worsening during flexion. In the Veteran’s November 2016 VA examination for his nerve entrapment, the Veteran endorsed numbness in the lower leg after bending for more than a minute. The numbness subsides upon straightening. He reported no other symptoms. The examiner indicated the Veteran suffered from mild incomplete paralysis of the left lower extremity. There were no trophic changes noted; however, the examiner did describe an abnormal gait as the Veteran favors and avoids hyperflexion due to issues with range of motion. Decreased sensation in the lower leg/ankle and foot/toes was indicated. The preponderance of the evidence indicates the Veteran’s nerve entrapment symptoms are mild. In considering VA’s Adjudication Manual as a guide, the Veteran’s incomplete paralysis is demonstrated by diminished, but not absent, sensation. More severe findings such as atrophy, weakness, and diminished reflexes are not indicated. Considering the evidence as a whole, the Veteran reports numbness when he bends his knee that subsides after a few minutes upon straightening. The VA examination report objectively found the Veteran’s incomplete paralysis to be mild. The Board affords this opinion significant probative weight as it is based on a review of the relevant evidence and provides a clear rationale for her conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion must support its conclusion with an analysis that the Board can consider and weight against contrary opinions”). In sum, the Board finds the overall evidence of record reflects mild incomplete paralysis due to the Veteran’s nerve entrapment. The Veteran’s claim for an increased rating is denied. 2. Entitlement to service connection for a left hip disability The Veteran contends his diagnosed osteoarthritis of the left hip is caused or aggravated by his service-connected left knee disability. In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); Ward v. Wilkie, 17-1204 (holding that a “permanent worsening” of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation).  In an October 2014 VA examination, the examiner declined to conduct a hip examination as it was “not pertinent to his recurrent knee condition.” She stated the Veteran had radicular pain in his left hip that he does not contend is due to his left knee pain. She opined it was less likely than not that the Veteran has any hip condition that is due to his knee condition. The Veteran objected to this opinion, and lack of examination, in subsequent correspondence. In June 2016, a VA examination was conducted for the Veteran’s hip disability. A diagnosis of osteoarthritis of the left hip was listed. The Veteran stated he had developed left hip pain approximately 2 years prior. He had not received treatment for his hip. There was no hip condition or diagnosis documented in his STRs. The examiner opined that the Veteran’s left hip arthritis was less likely than not proximately due to or a residual of his left knee disability. The examiner explained it was more likely related to his age and heredity. It would be less likely related to his left knee as there is a lack of biomechanical or physiologic link between the two conditions. In an October 2019 VA examination, it was noted that the Veteran first mentioned pain in his left hip in April 2014 and was first diagnosed with arthritis in the left hip in the June 2016 VA examination. The examiner concluded the Veteran has had hip arthritis since April 2014. She opined the Veteran’s hip arthritis is consistent with the Veteran’s age, and it is less likely than not directly related to service as there are no STRs that address left hip complaints in service. Regarding relation to the left knee condition, the examiner stated that the abnormal gait, due to the knee condition, is likely the cause of the wear and tear of the left hip joint that has caused the arthritis of the left hip. Antalgic gait or limping can cause irregular pressure to the hip joint and cause early degenerative changes. To reconcile the conflicting opinions that the hip arthritis was consistent with the Veteran’s age but also likely caused by his antalgic gait, in a May 2020 addendum the examiner was asked to specifically clarify whether the Veteran’s left hip arthritis was due to or secondary to the left knee disability or aggravated by it. She opined that the left hip arthritis was less likely than not due to the left knee disability because the X-rays show essentially equal arthritis formation to the bilateral hips. She explained that while it is true a limp or abnormal gait can cause arthritis to a hip joint, it will cause damage to one joint much more than the contralateral joint. Thus, it is less likely that the Veteran’s left hip degenerative changes, which are equal to his right hip degenerative changes, are due to his left knee. She also opined the left hip arthritis is not permanently aggravated compared to the right hip, as the X-rays show equal degenerative changes to the bilateral hips. The preponderance of the evidence is against the Veteran’s claim. The most probative evidence of record, the May 2020 addendum opinion, found a negative nexus between the two disabilities, as did the June 2016 opinion. As there is no other favorable evidence of record regarding nexus to consider, the preponderance of the evidence is against the Veteran’s claim and his claim must be denied. 3. Entitlement to a TDIU The Veteran contends he is unemployable in his field as a heavy equipment mechanic due to his left knee and lower extremity disabilities. VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. There are two regulatory subsections that allow for a TDIU. The first, called a “schedular TDIU,” is found at 38 C.F.R. § 4.16 (a) and requires that certain disability rating percentages be in place. Either the Board or the AOJ can grant a schedular TDIU in the first instance. The second, called an “extra-schedular TDIU,” is found at 38 C.F.R. § 4.16 (b). It does not have the percentage requirement but cannot be granted by the Board or the AOJ in the first instance, it must be submitted to VA’s Director, Compensation Service in the first instance. 38 C.F.R. § 4.16 (b). The schedular TDIU subsection provides that a total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. The extra-schedular subsection explains that it is the established policy of the Department of Veterans Affairs that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation Service, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in paragraph (a) of this section. The rating board will include 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. 38 C.F.R. § 4.16 (b). In light of the decisions above, the Veteran’s service-connected disabilities are as follows: left knee disability (10 percent); left meniscal cartilage involvement (20 percent); popliteal nerve entrapment of the left lower extremity (10 percent); right ring finger fracture (0 percent); left knee scar (0 percent); and degenerative arthritis of the lumbar spine (0 percent). His combined disability evaluation is 40 percent. Consequently, the Board finds that the Veteran does not meet the schedular criteria for TDIU. See 38 C.F.R. § 4.16 (a). The Board is prohibited from assigning a TDIU on the basis of 38 C.F.R. § 4.16 (b) in the first instance without ensuring that the claim was referred to VA’s Director of Compensation Service for consideration of an extra-schedular rating under 38 C.F.R. § 4.16 (b). See Bowling v. Principi, 15 Vet. App. 1 (2001). In this case, the Director rendered an opinion regarding entitlement to extra-schedular TDIU under 38 C.F.R. § 4.16 (b) pursuant to the January 2019 Board remand. Thus, the Board now has jurisdiction to grant TDIU under § 4.16 (b). See Wages v. McDonald, 27 Vet. App. 233 (2015). In an August 2020 Administrative Review to the Director, Compensation Service, VA concluded the available evidence supports the Veteran’s contention that his service-connected disabilities would prevent employment that required any weight bearing. While the Veteran’s service-connected disabilities would not prevent sedentary employment, based on his work history as a laborer and mechanic, and the fact that his disabilities prevent physical labor, due consideration should be given to an extra-schedular TDIU from June 17, 2011. In a November 2020 VA Memorandum, the Director, Compensation Service concluded that the overall evidence did not support the contention that the Veteran’s knee disabilities supported an exceptional situation that prevents gainful employment. The Veteran has been unemployed since 2009. His MOS in his first period of service was a field artillery crewman and, in his second period of service, a heavy wheel vehicle mechanic. He worked as a mechanic and laborer post-service. His educational background includes one year of college and air conditioning/refrigeration and diesel equipment technician training. According to his VA Form 21-8940 submitted in August 2013, his knee began to affect his ability to continue working in 2003, due to his inability to squat or kneel. In a VA Form 21-8940 submitted in June 2019, the Veteran stated he has difficulty keeping up with yard maintenance and home repairs due to pain and numbness in the knee. He is unable to squat or kneel and is unable to find employment for this reason. In a statement received in July 2013, the Veteran stated the pain in his knee over the past decade has prevented him from seeking employment. Due to the extreme pain, he cannot do manual labor such as bending, lifting, stooping, or squatting. Even walking is difficult, rendering him unable to complete daily tasks. According to the Veteran, the pain is so unbearable and overwhelming that he is forced to stay off his feet. A July 2011 VA examination reflected the Veteran worked as a heavy equipment mechanic doing repairs out in the field at job sites until 2009 but has not been employed since. The report reflected increased knee pain when on his feet, particularly using stairs, kneeling, or squats. The pain does not subside until he rests. In a September 2013 VA examination, the examiner opined that the Veteran’s knee disability causes a functional impact, and that kneeling, being out in the cold, and repetitive climbing tasks would be inhibitive and unsafe. In an October 2014 VA examination, the examiner opined that the Veteran’s knee disability causes a functional impact. The Veteran’s career was as a heavy equipment mechanic which required kneeling and crawling under vehicles frequently. The Veteran reported he could no longer due this due to pain, and the numbness in his left leg made it difficult to walk. In a November 2016 VA examination, the examiner opined that the Veteran’s knee disability causes a functional impact. While the Veteran is able to perform light sedentary activity, moderate activity is limited by bending, squatting, and kneeling due to limited range of motion in knee. In a December 2016 VA examination for his popliteal nerve entrapment, the examiner opined that the Veteran’s disability allowed him to perform all sedentary work as he is able to sit or drive up to two hours before requiring a break. However, he is unable to engage in physical labor requiring kneeling or repetitive bending of the knee. He can walk approximately two blocks, and up two flights of stairs, without rest. In a November 2019 VA examination, the examiner opined that the Veteran would have difficulty with any employment that required weight-bearing frequently. He would not be able to sit with his left leg bent at a sharp angle for periods of time. He would need to stretch his leg out if he were to perform sedentary employment. In a November 2015 primary care provider note at Roseburg VAMC, the Veteran endorsed pain, pressure, and numbness in the left leg forcing him to curtail activity and rendering him unable to care for his property or stand for periods of time. In a July 2013 treatment note, it was recommended to the Veteran to decrease weight-bearing activities, avoid prolonged standing, and immobilize the knee. Treatment records reflect severe, constant pain and swelling, causing an abnormal gait and limited range of motion. The record is replete with evidence that the Veteran is unable to find employment in his field due to his left knee disabilities. While some evidence suggests he could engage in light sedentary employment, the Veteran’s education, training, and work experience is solely in physical labor – predominately as a heavy equipment mechanic. This position requires him to engage in substantial physical labor, to include walking to job sites on uneven ground, kneeling, bending, or positioning himself under heavy equipment. The Veteran’s abnormal gait, numbness while bending his knee, and constant pain and swelling prevents him from completing these tasks and, ultimately, prevents him from obtaining and maintaining gainful employment that is consistent with his educational and occupational experience. A TDIU is granted on an extra-schedular basis. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Carroll, 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.