Citation Nr: 21002825 Decision Date: 01/15/21 Archive Date: 01/15/21 DOCKET NO. 12-10 062 DATE: January 15, 2021 ORDER Entitlement to a 20 percent rating for mechanical low back pain, with osteophytic formation (back disability), but no higher, from January 23, 2009 to June 16, 2016, is granted. Entitlement to a rating in excess of 20 percent for back disability from June 16, 2016, is denied. Entitlement to a rating in excess of 10 percent for a healed fracture of the left tibia and fibula is denied. Entitlement to a total disability rating based on individual unemployability (TDIU), to include on an extraschedular basis pursuant to 38 C.F.R. § 4.16(b), is denied. FINDINGS OF FACT 1. From January 23, 2009 to June 16, 2016, the Veteran’s service-connected back disability manifested with flexion of less than 60 degrees. 2. For the entire appeal period since January 23, 2009, even when considering his complaints of pain, pain on motion, functional impairment, and flare ups, the Veteran’s service-connected back disability was manifested by no less than 30 degrees of forward flexion and combined range of motion of greater than 120 degrees, no ankylosis or evidence of invertebral disc syndrome (IVDS) resulting in incapacitation during any 12-month period, and there is no evidence of a separate neurological manifestation of back disability other than the already service-connected radiculopathy of the left lower extremity and the assigned effective date or rating for this disability is not on appeal. 3. The Veteran’s service-connected healed fracture of the left tibia and fibula has been manifested by no more than malunion of the tibia with a slight knee impairment. 4. The Veteran does not meet the schedular criteria for a TDIU. 5. The Veteran’s service-connected disabilities do not render him unable to obtain or retain substantially gainful employment. CONCLUSIONS OF LAW 1. For the period from January 23, 2009 to June 16, 2016, the criteria for a 20 percent rating, but no higher, for a back disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5237. 2. For the period from June 16, 2016, the criteria for a rating in excess of 20 percent for a back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5237. 3. The criteria for a rating in excess of 10 percent for residuals of a fractured left tibia and fibula have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5262. 4. The criteria for entitlement to a TDIU, to include on an extraschedular basis pursuant to 38 C.F.R. § 4.16(b), have not been met. 38 U.S.C. § 1155, 5107(b); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1979 to November 1984. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In a January 2018 decision, the Board denied entitlement to increased ratings for mechanical low back pain with osteophytic formation and granted an increased 10 percent rating for a healed fracture of the left tibia and fibula. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court), which issued an order in March 2019 granting a Joint Motion for Remand (JMR) filed by the Veteran and VA’s Office of General Counsel. The Court’s order vacated and remanded the Board’s January 2018 decision. The Court did not disturb the Board decision that awarded an increased rating of 10 percent for a healed fracture of the left tibia and fibula. In September 2019, the Board remanded the appeal consistent with the JMR. The Agency of Original Jurisdiction completed the requested evidentiary development, and the appeal is now returned to the Board for further appellate review. Increased rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes, at the outset, that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.4; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Notably, pain, alone, does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. Joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. At the outset, the Board notes the legal guidance concerning functional impairment assessments in rating orthopedic disabilities. Sharp, supra; Correia supra. When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the Board finds that the December 2019 VA examinations regarding the back and left leg tibia and fibula are more than adequate, as they are predicated on a full understanding of the Veteran’s medical history and provides a sufficient evidentiary basis for the claims to be adjudicated, as detailed below. With specific regard to the Veteran’s musculoskeletal examinations, to the extent that the December 2019 examinations did not specifically provide measurements of flexion on passive range of motion (PROM) or on weightbearing or non-weightbearing, the Board is able to assess the level of limitation from such episodes through the Veteran’s own statements of how his disabilities impact him on a day-to-day basis, as well as the estimated range of motion (ROM) during flare-ups and after repetitive use, as provided by the examiner. Furthermore, the 2017 VA opinion specifically explained that such range of motion testing could not be conducted without injury to the Veteran. Therefore, the Board does not find that a new examination would be necessary to specifically provide additional range of motion testing pursuant to Correia. I. Back Disability The Veteran has been assigned a 10 percent evaluation for back disability under Diagnostic Code 5237 prior to June 16, 2016, and 20 percent thereafter. However, all spine disabilities are rated pursuant to the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a. The General Rating Formula provides for assignment of a 20 percent rating is warranted where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires forward flexion of the thoracolumbar spine of 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion is zero to 30 degrees, and left and right lateral rotation is zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id. at Note (2). See also 38 C.F.R. § 4.71a, Plate V. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note (5). The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance for rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Alternatively, disability involving disc disease may be rated under the Formula for Rating IVDS Based on Incapacitating Episodes, pursuant to which ratings from 10 to 60 percent are assigned based on the total duration of incapacitating episodes during a 12-month period. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. The Veteran requested an increased rating for his service-connected back disability on January 23, 2009. An October 2008 VA treatment record noted the Veteran reported still having leg and back pain, and he reported it was getting worse over the last couple of weeks. He reported inflammation medications made him sick and pain medication did not help. He reported he had never had physical therapy and had never seen an orthopedic doctor. On VA examination in March 2009, the examiner observed that the Veteran’s forward flexion was to 80 degrees, extension to 30 degrees, left lateral flexion to 30 degrees, right lateral flexion to 30 degrees, left lateral rotation to 45 degrees, and right lateral rotation to 45 degrees. Three repetitions of range of motion testing resulted in some increase in pain. The examiner also noted some fatigue, weakness, lack of endurance, and incoordination. Per DeLuca, the examiner noted no discomfort of difficulty with range of motion testing. There was no edema, effusion, tenderness, palpable deformity, weakness, fatigue, or instability except as were noted. The examiner stated additional limitations due to flare ups could not be determined without resorting to mere speculation. No neurological defects were noted. The examiner diagnosed the Veteran with lumbar spine degenerative disc and degenerative joint disease without radiculopathy. In a March 2009 Form VA-2142 Authorization for Release of Information, the Veteran stated that he could not walk much and could not get out of bed because of back pain. He reported that when the pain is bad, he obtains VA treatment, but the treating physician indicated there was not much he could do for his back, knee, and hip pain. A January 2010 VA treatment record noted the Veteran had his right leg amputated above the knee, due to vascular insufficiency and gangrene, two years ago. He had a femoropopliteal bypass graft on the left leg about 6 years ago. He reported his left knee has been painful intermittently for the past 15 years and became constant three years ago. The Veteran noted mainly lateral knee pain, which was aggravated by standing and walking. He reported he was frequently awakened at night, by a deep aching pain, in the thigh and calf, with pain and paresthesias down the right leg to the ankle. The physician concluded that it suggests radicular pain and that he does not think that it is vascular pain. An X-ray noted mild to moderate narrowing of the lateral compartment with it being 5.6mm of cartilage in the lateral compartment and 5.6mm of cartilage in the medial compartment. He noted an MRI scan from December 2008 revealed advanced osteoarthritis of the knee, but it also showed a large tear of the posterior horn and body of the lateral meniscus. The final impression was vascular insufficiency of both legs, above the knee amputation of the right leg, secondary to vascular insufficiency, femoral popliteal bypass graft, secondary to vascular insufficiency, osteoarthritis of the left knee, and large lateral meniscal tear of the left knee. A March 2010 VA treatment record noted ischemic pain in the left leg was resolved by the new femoral graft. The physician noted if the radicular pain in the left leg persists, it needs to be addressed by one to three lumbar steroid epidural blocks. A March 2010 VA treatment record noted the Veteran was evaluated for gait and low back pain. He reported chronic back pain and that he had never received treatment. Physical examination revealed gait was antalgic with stiff right prosthetic knee, with right leg prosthesis and single point cane. The physician indicated physical therapy would be ordered for low back pain, especially in relation to abnormal gait with right leg prosthesis. An April 2010 VA treatment record noted an X-ray noted degenerative disc disease (DDD) and degenerative facet disease. A neurological examination noted no deficits in reflexes, motor, or sensory processes. There was tenderness to palpation of the lumbar paravertebral. Compression and distraction revealed no changes with seated distraction. Left straight leg raises was to “25*” with lumbar pain. The assessment indicated the Veteran experienced limited and painful ROM, pain level of 5/10, decreased tolerance to standing, sitting, and walking long distances, as signs and symptoms consistent with his degenerative joint disease (DJD). April 2010, May 2010, and June 2010 VA treatment records noted the Veteran reported low back pain. His level of pain was described as 4 out of 10. Flexion was limited by 50 percent with lumbar pain. Extension was limited by 75 percent with pain noted. Right side bending was limited by 50 percent and left side bending was limited by 70 percent, right rotation was limited by 25 percent, each with pain. Left rotation was limited by 25 percent with pain greater on the left side. The combined range of motion was 121.5 degrees. A June 2011 VA treatment record noted back and right leg pain with pain of 7 out 10. An April 2014 VA treatment record noted the Veteran has one leg, and a bad knee and back, and that he cannot work. In an April 2016 VA treatment record, the Veteran reported chronic pain and left knee pain, and he requested different pain medication and reduction to one pill a day due to the cost of medications. The Veteran underwent a VA examination in June 2016 for his back condition. The examiner observed that the Veteran’s forward flexion was to 50 degrees, extension to 10 degrees, left lateral flexion to 10 degrees, right lateral flexion to 10 degrees, left lateral rotation to 15 degrees, and right lateral rotation to 15 degrees. The examiner noted the ranges of motion were affected by both personal effort and his nonservice-connected right above the knee amputation with prosthesis, which causes poor balance when standing and ambulating, and contributes to back pain. The examiner noted there was a painful range of motion with all of the measured movements. The examiner indicated the Veteran was able to perform repetitive movements and had no functional loss after three repetitions, nor any pain, weakness, fatigability, or incoordination which significantly limit functional ability with repeated use over time. During the June 2016 examination, the Veteran stated he had flare-ups with any movement. The examiner stated she was unable to determine without mere speculation the pain, weakness, fatiguability, or incoordination resulting from flare-ups. The examiner noted no ankylosis, other neurological abnormalities, or invertebral disc syndrome (IVDS). The examiner concluded the service-connected disability remained unchanged since the previous VA examination in March 2009. An April 2017 VA treatment record noted complains of chronic low back pain but now with sharp shooting electrical type pain, shooting down the right leg with sitting too long on his left buttocks or standing still for any prolonged period of time. The Veteran reported severe back pain and burning in his mid-back down the left side of his body. There was lumbar sacral pain on palpation on the left side but no spine tenderness on exam. Positive straight leg raise was noted on the left. The assessment was chronic lumbar pain with left leg sciatica pain in the L4/L5 dermatome pattern. In May 2017, a VA examiner provided an opinion after a review of the available records. In regard to Correia, the examiner noted the passive range of motion (PROM) testing could not be performed without risk of injury or perceived injury and that testing would be suboptimal and partially reduced by personal effort and the Veteran’s right leg prosthesis causing poor balance when standing or ambulating. Further, the examiner stated that there is no weight bearing medico-legal standard available for the spine at this time. Additionally, the examiner clarified that the June 2016 VA examination report does not clearly constitute a flare-up, but that of a baseline functional limitation. The examiner opined that there is no supporting objective medical record documenting diagnosis, management, or treatment for flare-ups of back pain. Further, the examiner stated that it was not possible to ascertain the degree of functional limitation attributable to each condition without resorting to mere speculation, because the Veteran has other unrelated non-service-connected conditions causing difficulty walking and climbing steps. Pursuant to the JMR and Board remand, in December 2019, the Veteran underwent an additional VA examination to address the Veteran’s reported flare-ups pursuant to Sharp. The Veteran reported that his current symptoms included back pain, leg pain, and numbness. He reported that his back disability is treated with physical therapy, pain medication, heat pads, and stretching. The examiner indicated that the condition causes difficulty with prolonged standing, heavy lifting, limits driving, and causes him to sit on one side and stand awkwardly. The Veteran reported flare-ups of his back disability are precipitated by chores around the house or random movements and are moderate to severe, lasting three to seven days. He reported flare-ups are alleviated by medication, heat pad, and lying down. The Veteran reported functional loss or impairment due to limitations with stooping, lifting, and prolonged standing and sitting. Upon examination, forward flexion was to 80 degrees, extension to 30 degrees, bilateral lateral flexion to 30 degrees, and bilateral lateral rotation to 30 degrees. Pain was noted on forward flexion and extension. The examiner indicated that pain noted on exam does not result in or cause functional loss. The examiner indicated the Veteran was able to perform repetitive movements and had no functional loss after three repetitions. He indicated pain significantly limited functional ability with repeated use over time, resulting in a decrease in flexion to 70 degrees. Regarding flare-ups, the examiner indicated pain significantly limits the Veteran’s functional ability with flare-ups, also resulting in a decrease in flexion to 70 degrees. The examiner noted the Veteran had left leg radiculopathy of a mild severity, and no other neurological findings related to the back disability is noted. The examiner indicated the Veteran did not have IVDS, muscle guarding, or muscle spasms. In regard to Correia, the examiner indicated there was no pain on PROM testing, no evidence of pain on non-weight bearing testing of the back. The examiner opined that the Veteran’s back disability impacted his ability to work because it limited low back pain with stooping, lifting, prolonged standing and sitting which is also complicated by right leg and left leg/knee diagnoses. He further concluded that the low back condition does not otherwise interfere with activities of daily living except as noted above. Although it cannot be stated with certainty as to precisely when the Veteran’s back limitation of flexion increased, based on the above and resolving reasonable doubt in the Veteran’s favor, the Board finds that a 20 percent rating for the entire period on appeal is warranted. Although the range of motion testing conducted in March 2009 VA examination reflects the Veteran’s back flexion was to 80 degrees, the examiner did not address the Veteran’s report that he experienced lumbar pain with pain from 9 to 10 out of 10, several times a month, lasting days at a time, as well as the Veteran’s March 2009 statement that he cannot get out of bed at times due to his back pain. As noted, the examiner could not determine whether flare-ups caused additional limitation due to the Veteran’s flare ups without resorting to mere speculation. Additionally, the record reveals the Veteran’s pain is severe enough to require the use of pain medication to provide relief. Moreover, the Board cannot consider the ameliorative effects of medication unless medication is referenced in the applicable diagnostic code. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) (“the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria”). Thus, in resolving reasonable doubt in the Veteran’s favor, the Board finds that Veteran’s report of flare-ups resulting in severe pain and difficulty getting out of bed were as likely as not so disabling to actually or effectively result in limitation of back flexion to at least less than 60 degrees during this entire period, consistent with the March 2010 to June 2010 VA treatment records indicating the Veteran’s flexion was limited by 50 percent, which correlates to 45 degrees (normal flexion is 90 degrees), when the Veteran sought treatment, to include physical therapy, for his back pain. However, the Board finds that a rating in excess of 20 percent is not warranted for the entire appeal period. The evidence of record is absent of any findings or notations that forward flexion is to 30 degrees or less, or any unfavorable ankylosis of the entire thoracolumbar spine, as required for the next higher rating. The Veteran’s forward flexion of the thoracolumbar spine has been limited to at worst 45 degrees, and the combined range of motion was 121.5 degrees, even with painful motion and flare ups considered. Additionally, the June 2016 and December 2019 VA examiners found the Veteran did not have ankylosis of the lumbar spine. The Board acknowledges the lay reports of the Veteran’s symptoms, to include pain, decreased motion, and problems walking. The Board has also taken into consideration the provisions under Deluca. The Board notes that the Veteran has functional impairment on repeated use due to pain, loss of motion, fatigue and weakness. However, the Board finds that the Veteran’s symptoms and functional limitations do not more closely approximate the criteria for the next higher rating. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202; Mitchell, 25 Vet. App. at 38. The reported range of motion results contemplate the Veteran’s pain during testing, and there is no objective indication that, during flare-ups, the Veteran’s pain is or has been so disabling as to meet the criteria to warrant any higher rating. Notably, the criteria of the General Rating Formula are to be applied with or without symptoms such as pain. The lay assertions made in support of his claim for higher ratings are not entitled to more weight than the objective findings rendered by trained medical professionals in this case, and which are needed to evaluate the Veteran’s back disability under relevant rating criteria. See 38 C.F.R. § 3.159(a)(1). The Board has also considered whether the Veteran is entitled to a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Veteran did not report any incapacitating episodes as a result of his back pain during his VA examinations. In addition, the VA examiners did not observe any signs of intervertebral disc syndrome. Therefore, a higher rating for IVDS is not warranted by the record. VA regulations also provide that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Given that the RO granted a separate rating for radiculopathy affecting the left lower extremity, effective from December 9, 2019, the date of a VA examination, in a September 2020 rating decision and he has not disagreed with the assigned effective date or rating for this disability, under these circumstances, the Board will not address the propriety of the rating of the left lower extremity assigned. Notably, the Board notes that despite the RO’s grant of left leg radiculopathy secondary to service-connected mechanical low back pain, the December 2019 VA examination appears to reflect that left leg radiculopathy is attributable to lumbar DDD, which is not service-connected and the May 2017 examiner provided a negative nexus opinion as to the etiology of the lumbar DDD and spondylosis. Thus, there is also no medical evidence that the Veteran has experienced any additional, separate neurological manifestation of mechanical low back disability, to include radiculopathy for the left lower extremity prior to the December 9, 2019, effective date. Absent a showing of any other neurological manifestations, no additional rating for associated neurological impairment is warranted. The Board also notes that no earlier effective date than January 23, 2009 can be assigned for the increase to a 20 percent rating. Except when otherwise provided, the effective date of a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400 (2016). Claims for increased benefits may be awarded at the earliest date in which it is factually ascertainable that an increase in disability had occurred, if the claim is received within one year of the date such an increase occurred. Otherwise, the increase is effective the date of receipt of claim. 38 C.F.R. § 3.400(o)(2). While the Veteran reported in October 2008 that his back pain was getting worse, there was no indication that he had a decreased range of motion or any other symptomatology that would have met the criteria for a higher 20 percent rating at that time. There is no evidence in the record indicating that it was factually ascertainable that an increased in the disability had occurred any earlier than the 2010 treatment records. The Board therefore finds that no earlier effective date can be assigned for the increased rating of 20 percent for the Veteran’s back disability. In sum, the Board finds that, after affording the Veteran the benefit of the doubt, a 20 percent, but no higher, rating from January 23, 2009 to June 16, 2016, is warranted. However, as discussed above, the preponderance of the evidence is against assignment of a rating greater than 20 percent for the entire appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, v. Derwinski 1 Vet. App. 49, 53-56 (1990). II. Healed Fractures of the Tibia and Fibula Under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability. A 20 percent disability rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The words “slight,” “mild,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA 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. A July 2008 VA treatment record reflects the Veteran reported pain in his knees, ankle, and low back. He reported that after his tibia-fibula injury while in service, he has had some knee pain since. The Veteran indicated he was prescribed Lortab by orthopedics for his amputation and wants more for his joint pain. His pain was about 9.5 out of 10. He indicated he could not work since he had the amputation. He reported knee and ankle pain are exacerbated by walking. A November 2008 VA treatment record noted left knee osteoarthritis and left knee brace was issued. His gait was greater than 200 feet with a single point cane. The left lower extremity had normal range of motion, strength, and sensation was intact. The assessment was left knee arthritis. An MRI and a soft sleeve type knee brace were ordered. On VA examination in March 2009, the examiner noted evidence of a healed fracture on the lower third of the left tibia with a palpable deformity. There was no swelling, redness, or other evidence of any infection. The examiner observed that the Veteran was able to bear weight without difficulty. Per DeLuca, the examiner noted no discomfort or difficulty with range of motion testing. The Veteran reported he experienced some aching pain at the site, but there was no evidence of drainage or instability. The Veteran complained of flare-ups producing aching pain in the bone two or three times a year, which were precipitated by prolonged walking or standing and alleviated with rest. A January 2010 VA treatment record noted the Veteran reported left knee has been painful intermittently for the past 15 years and the pain became constant three years ago and has been constant since then. He reported lateral knee pain is aggravated by standing and walking. Examination of the left knee revealed no effusion. Range of motion was limited to 50 percent of normal by pain. There was no ligamentous instability. McMurray’s maneuver could not be completed due to pain. He was very tender over the lateral joint line. X-rays of the left knee showed mild to moderate narrowing of the lateral compartment, with 5.6mm of cartilage in the lateral compartment and 5.6mm of cartilage in the medial compartment. The physician noted he had some osteoarthritis of his left knee, and a large meniscal tear. A March 2010 VA treatment noted the Veteran had a femoropopliteal bypass graft on the left leg about 6 years ago. He reported his left knee has been painful intermittently for the past 15 years and became constant three years ago. The Veteran reported mainly lateral knee pain, which is aggravated by standing and walking, and he was frequently awakened at night by pain in the thigh and calf, with pain and paresthesias down the right leg to the ankle. The physician indicated his symptoms suggests radicular pain, and not vascular pain. A March 2010 VA treatment record noted an MRI scan of the left knee showed a torn anterior horn of the lateral meniscus. The physician noted a partial lateral meniscectomy on the left knee was necessary to facilitate his walking. A September 2010 VA treatment record noted strength of 5 out of 5 in the upper and lower bilateral extremities. Left foot examination was normal, and sensation in foot decreased, sensation anterior ankle chronic. A June 2011 VA treatment record noted left knee pain 2 out of 2 scope with cartilage removal, attributed to arthritis as well. A February 2013 VA treatment record noted osteoarthrosis involving the knee and that his left knee still gives out on him. The physician noted the Veteran had a tear of lateral cartilage or meniscus in the left knee and had surgery approximately a year ago. A March 2013 VA treatment record noted that standing X-rays of the left knee revealed mild narrowing of the lateral joint line, with very large peripheral osteophytes of the lateral, femoral and tibial condyles. He did not have any significant narrowing in the medial compartment. An MRI scan of the left knee showed the remnants of a partially resected lateral meniscus. There was moderately severe chondromalacia of the articular surfaces of the lateral joint space, mild chondromalacia of the articular cartilage of the medial joint space. An April 2013 VA treatment record noted pain in left and right knee, and he had functional strength in knee, and range of motion was noted as functional. In a June 2013 VA treatment record, the received injections to his left knee. He had some aching pain in his left calf which the physician noted may be lumbar radiculitis or due to vascular insufficiency. A February 2016 VA treatment record noted free range of motion in all extremities, and no edema was appreciated. On VA examination in June 2016, the examiner found the Veteran’s healed fracture of the left tibia and fibula resulted in a mild functional limitation and showed evidence of chronic osteomyelitis by X-ray of the distal shaft of the left leg. The examiner noted no flare-ups of the knee or lower leg, and there was no functional loss or functional impairment of the extremity, including but not limited to repeated use over time. The examiner noted knee pain with flexion, tenderness on medial and lateral joint line, tenderness on palpation site of the tibia/fibula fracture and noted a slight deformity. The examiner noted the Veteran wears a left knee brace for pain. In May 2017, a VA physician provided an opinion after a review of the available medical records. The examiner opined the limitation of the left knee and muscle strength reduction noted by the June 2016 examiner is primarily caused by the unrelated nonservice-connected left knee degenerative joint disease and meniscectomy. The examiner provided further rationale that the 1984 left tibia/fibula X-ray showed a distal fibula fracture, which does not affect the left knee joint, which is anatomically proximally located. Further, the examiner opined the range of motion testing performed in both March 2009 and June 2016 showed the functional impact of the Veteran’s left leg is due to a combination of service connected and nonservice-connected conditions including the healed fracture of the tibia and fibula, nonservice-connected left knee degenerative joint disease and meniscectomy, and the nonservice-connected above the right knee amputation with prosthesis. The examiner further noted that Correia testing could not be performed without risk of injury or perceived injury. The examiner indicated that his left tibia and fibula healed fracture caused mild functional limitation and he can perform light physical activity or sedentary desk work. Additionally, the examiner stated that the Veteran’s nonservice-connected conditions, including the above the right knee amputation with prosthesis, left knee degenerative joint disease and meniscectomy, and vascular insufficiency of the bilateral lower extremities, would further compromise the Correia testing results. A December 2019 VA treatment record noted chronic pain, secondary trauma in the army as well peripheral vascular disease. The impression was advanced degenerative arthritis of the lateral aspect of knee and patella horizontal tear of lateral meniscus with meniscal cyst formed anteriorly. Pursuant to the JMR and Board remand, in December 2019, the Veteran underwent an additional VA examination to obtain address the Veteran’s reported flare-ups pursuant to Sharp. The Veteran reported his current symptoms included pain with occasional numbness and swelling, and knee pain. He reported that he uses a knee brace, medication, shock therapy, and injections into the knee every six months. He reported the impact of the condition is limited walking, standing, with pain in the knee most of the time. The Veteran reported flare-ups of his disability are precipitated by prolonged standing, walking, and driving and are severe to moderate, lasting five to six days. He reported the flare-ups are alleviated by pain medication and rest. The Veteran reported functional loss or impairment due to pain with activities. Upon examination, flexion was to 120 degrees and extension was from 120 degrees to 0 degrees. Pain was noted on flexion and extension. There was no evidence of pain on weight-bearing and no crepitus. The examiner indicated that pain noted on exam does not result in or cause functional loss. The examiner also indicated that the Veteran was able to perform repetitive movements and had no functional loss after three repetitions. He indicated pain significantly limited functional ability with repeated use over time, resulting in a decrease in flexion to 110 degrees. Regarding flare-ups, the examiner indicated pain significantly limited functional ability with flare-ups, also resulting in a decrease in flexion to 110 degrees. The examiner noted the Veteran had left leg radiculopathy of a mild severity, and no other neurological findings related to the back disability is noted. Muscle strength testing was 5/5. There was no muscle atrophy, no ankylosis, history of subluxation, instability, or effusion. Joint stability testing was normal. The examiner noted the Veteran underwent arthroscopic partial meniscectomy in 2011. The examiner indicated the Veteran uses a cane for his right leg prosthesis, a walker when not wearing right leg prosthesis, and a hinged brace for his left knee regularly. An X-ray notes old healed fracture deformities near the mid shaft of the tibia and fibula, post-surgical clips adjacent to the proximal tibial metaphysis, and mild to moderate osteoarthritis of the left knee. In regard to Correia, the examiner indicated there was objective evidence of pain on passive range of motion testing of the left knee, and no evidence of pain on non-weight bearing testing of the left knee. The examiner opined that the Veteran’s back disability impacted his ability to work because of left leg pain with prolonged standing or walking. He further concluded that the left leg disability does not otherwise interfere with activities of daily living except as noted above. Based on the foregoing, the Board finds throughout the appellate period, the Veteran’s healed fracture in the tibia and fibula has manifested evidence of a malunion with at least a slight knee or ankle disability. The Veteran has consistently reported pain with persistent standing or walking. Although the Board notes the Veteran’s nonservice-connected impairments significantly impact his left leg’s functional capacity, the residuals of the left tibia/fibula fracture reasonably contribute to at least a slight impairment of functioning, consistent with a 10 percent disability rating. The Board finds that a rating in excess of 10 percent for a healed fracture of the tibia and fibula is not warranted. In this regard, there is no evidence of malunion resulting in a moderate knee or ankle disability as a result of the service-connected impairment. Specifically, the 2009 examiner found no swelling, redness, or other evidence of any infection and the Veteran was able to bear weight without difficulty and noted no discomfort or difficulty with range of motion testing. The April 2013 VA treatment record also noted he had functional strength in his knees, and range of motion was noted as functional. The 2016 VA examiner noted no flare-ups of the knee or lower leg, and there was no functional loss or functional impairment of the extremity including but not limited to repeated use over time and noted only a slight deformity. Here, the evidence reflects that, for the entire period under consideration in connection with this claim, the Veteran’s primary problem with his left leg tibia and fibula disability has been pain, and not weakness, stiffness, swelling, heat or redness, or fatigability, as indicated by the multiple VA examination reports. Although the Veteran reported limitation of the left knee and muscle strength reduction, the 2017 VA opinion reflects the functional impact of the Veteran’s left leg, to include imbalance and strength reduction, is mainly due to nonservice-connected left knee degenerative joint disease and meniscectomy, and the nonservice-connected above the right knee amputation with prosthesis. In addition, the examiner provided further rationale that the 1984 left tibia/fibula X-ray showed a distal fibula fracture, which does not affect the left knee joint, which is anatomically proximally located. The examiner’s findings are consistent with the VA treatment records, detailed above, reflecting persistent complaints and treatment for his left knee osteoarthritis and tear of lateral meniscus with meniscectomy. As noted in the January 2010 VA treatment record, the physician noted the Veteran’s flexion of his left knee was limited to 50 percent due to pain and provided an assessment osteoarthritis of his left knee, and a large meniscal tear and the March 2010 VA treatment record noted meniscotomy surgery was required to facilitate his walking. Further, the 2016 VA examiner determined that the Veteran’s left tibia and fibula resulted in a mild functional limitation and showed evidence of chronic osteomyelitis by X-ray and noted only a slight deformity. Finally, the 2019 VA examiner indicated that the Veteran had flexion of the knee to 120 and only a decrease in 10 degrees to 110 degrees after flare-ups and repeated use over time. Collectively, this evidence indicates that the Veteran’s symptoms have resulted in disability more closely approximating overall slight foot disability, for which a 10 percent rating is assigned under Diagnostic Code 5262. Here, the pain in his left leg has been the primary manifestation, as X-rays and other tests have not identified any abnormalities related to his left tibia and fibula disability. Although the Veteran experiences pain, after prolonged standing and walking, the December 2019 examiner noted there was no impact on the Veteran’s daily activities. There is no muscle atrophy, muscle strength, and stability testing were normal. The Board points out that lay assertions made in support of a claim for a higher rating typically are not entitled to more weight than the objective findings rendered by trained medical professionals. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir, 2007). Thus, applying Diagnostic Code 5262 to the facts of this case, the Board finds that no more than an overall slight tibia and fibula disability is shown. The Veteran has competently and credibly reported pain after prolonged standing or walking; however, as noted above, the examiners have concluded that the Veteran’s disability is of a mild severity with slight limitation in flexion, consistent with the record. Thus, a rating greater than 10 percent for left tibia and fibula disability is not warranted under Diagnostic Code 5262. 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5262. The evidence weighs against a finding that the overall severity of the Veteran’s left tibia and fibula disability is moderate or greater. Id. In the clinical assessments, the examiners have indicated that pain is generally associated with prolonged standing or walking and is not shown to cause significant physical deformity. The ambulation devices are limited to a brace. For these reasons, the clinical descriptions generally weigh against a finding of a moderate or more severe foot disability. Id. Further, the Board notes the June 2016 rating decision awarded the Veteran with a 20 percent disability rating under Diagnostic Code 5000 for osteomyelitis, secondary to the healed fracture of the tibia and fibula. Thereby, any additional limitation as a result of the healed fracture has already been compensated by the additional secondary service connection grant. III. TDIU VA will grant a total disability rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of his service- connected disabilities, from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. A TDIU 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. 38 C.F.R. §§ 3.340, 3.341, 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; (2) disabilities resulting from common etiology or accident; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. Id. The central inquiry is, “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” 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 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, 363 (1993). In Geib v. Shinseki, 733 F.3d 1350 (2013), the Federal Circuit held that VA’s duty to assist did not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities. “Indeed, applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner.” Id. at 1354. The record reflects that the Veteran is currently service connected for osteomyelitis, chronic, left leg associated with healed fracture of the left tibia and fibula (rated as 20 percent disabling from June 16, 2016), mechanical low back pain, with osteophytic formation (rated as 10 percent disabling from September 24, 2003 and as 20 percent disabling from January 23, 2009), a healed fracture of the left tibia and fibula (rated as 10 percent disabling), apparent respiratory insufficiency, mild (rated as noncompensable), and left leg radiculopathy (rated as 10 percent disabling from December 9, 2019). He currently has a 50 percent combined rating from December 9, 2019. Accordingly, because the Veteran does not have a single service-connected disability rated at 60 percent or more, or a combined disability rating of 70 percent or more, to include after consideration of the § 4.25(b) regarding disabilities arising from a single disease entity, he does not meet the percentage requirements for a TDIU under 38 C.F.R. § 4.16(a). As such, the claim of entitlement to TDIU on a schedular basis must be denied. The Board has considered whether referral for consideration of TDIU on an extraschedular basis is warranted. See 38 C.F.R. § 4.16(b). However, the competent evidence of record does not indicate that the Veteran is unemployable due solely to his service-connected disabilities. First, the Board must determine whether the Veteran is actually unemployed. The Veteran’s statements in March 2009 and April 2012 indicate that the Veteran has not been working throughout the appellate period. The Veteran has not provided a VA Form 21-8940 Application for a TDIU, nor has he provided any additional detail regarding his work history and educational background. In a July 2008 VA treatment record, the Veteran stated he could not work since he had his right leg amputated. In a March 2009 statement, the Veteran stated he cannot work much due to pain, which sometimes results in an inability to get out of bed. The Veteran stated his pain in his back, knee, and hip prevent him from performing any activities. In an April 2012 statement, the Veteran stated that the loss of his non-service- connected right leg has impacted his back and left leg resulting in an inability to stand for prolonged periods and pain in his back and left leg. Further, the Veteran stated his back pain would result in needing two to three days to recover after any kind of activity. In an April 2014 VA treatment record, the Veteran stated he has one leg and a bad back and knee, and thus, he cannot work. On VA examination in June 2016, the examiner found the Veteran’s mechanical low back pain would result in pain with prolonged bending, standing and walking. The examiner also noted the Veteran stated he must lean forward when sitting down due to back pain, and reported difficulty walking up and down five steps in his garage. Upon a file review in May 2017, a VA physician opined that in relation to the Veteran’s service-connected mechanical low back pain and healed fracture of the left tibia and fibula, the Veteran is able to perform light physical activity or sedentary desk work if he so chooses. The December 2019 examiner opined that the Veteran’s back disability impacted his ability to work because it limited low back pain with stooping, lifting, prolonged standing and sitting, which is also complicated by non-service-connected right leg and left leg/knee diagnoses. He further concluded that the low back condition does not otherwise interfere with activities of daily living except as noted above. With regard to the left tibia and fibula disability, the examiner indicated the Veteran experienced pain after prolonged standing and walking, but that the condition does not otherwise interfere with activities of daily living and that his limitations are mainly due to his nonservice-connected left knee and right knee and leg disabilities, as described in detail above. The Board finds that the symptomatology associated with the service-connected disabilities is appropriately compensated by the currently assigned ratings. Loss of industrial capacity is the principal factor in assigning schedular disability ratings, and a high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 specifically states the following: “Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.” See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Here, the Board finds no evidence suggesting that the Veteran’s case is outside the norm and thus requiring extraschedular consideration. None of the examiners has described total occupational impairment, and the weight of the clinical evidence does not support his contentions that his service-connected mechanical low back pain and healed fracture of the tibia and fibula are of such severity so as to preclude his participation in any form of substantially gainful employment. Notably, the Veteran uses a right leg prothesis due to an amputation of his right leg (nonservice-connected), which requires use of a cane, as well as a walker, and the examiners have indicated this disability as well as his nonservice-connected left knee disabilities contribute significantly to his limitations in functional impairment, to include balance issues and strength reduction. The Veteran, himself, has indicated in the July 2008 VA treatment that he stopped working after his right leg amputation, and in the April 2014 VA treatment record, he indicated he could not work as a result of his right leg amputation, bad knee, and back. The Board finds statements made for the purpose of treatment, to include reports of prior medical history pertaining to a current medical issue, tend to be highly reliable, as it is in the patient’s best interest to provide information as accurate as possible to receive the most appropriate treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Here, the record does not support a finding that a combination of all of his service-connected disabilities alone prohibit substantially gainful employment. Thus, there is no basis for referral of the TDIU claim to the Director of Compensation Service for extraschedular consideration. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert; 1 Vet. App. at 53-56. Mary E. Rude Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah Campbell, 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.