Citation Nr: 21003694 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 10-26 157 DATE: January 22, 2021 ORDER Entitlement to service connection for removal of the gallbladder is granted. Entitlement to service connection for erectile dysfunction is granted. Entitlement to service connection for a skin disorder, claimed as genital itching is denied. Entitlement to a compensable rating for a low back disorder prior to April 2, 1998, and in excess of 10 percent prior to September 28, 2019, is denied. From September 28, 2019, entitlement to a rating in excess of 40 percent for a low back disorder is denied. Entitlement to an increased rating in excess of 10 percent for right patellofemoral pain syndrome with degenerative arthritis is denied. Entitlement to an increased rating in excess of 10 percent for left knee retro patellar pain syndrome is denied. Entitlement to a compensable rating for right knee, limitation of flexion is denied. Entitlement to a total disability rating for individual unemployability is denied. FINDINGS OF FACT 1. The Veteran's gallbladder removal was related to service. 2. The Veteran's erectile dysfunction is secondary to his service-connected PTSD. 3. The Veteran does not have a skin disorder that manifests as genital itching that is etiology related to service. 4. Prior to April 2, 1998, there was no characteristic pain on motion of the low back; prior to September 28, 2019, the Veteran did not have less than 60 degrees of flexion of the lumbar spine. 5. From September 28, 2019, the Veteran's flexion of the lumbar spine was, at worst, limited to 30 degrees. 6. The Veteran's right knee was, at worst, limited to 50 degrees of flexion. 7. The Veteran’s left knee was, at worst, limited to 80 degrees of flexion. 8. The Veteran does not have instability or subluxation of the bilateral knees or limitation of extension. 9. The Veteran had shin splints but no additional knee or ankle disability for which he is not compensated. 10. Prior to December 31, 2018, the Veteran was gainfully employed. 11. From December 31, 2018, the Veteran was in receipt of a 100 percent combined disability rating. CONCLUSIONS OF LAW 1. The criteria for service connection for gallbladder removal are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for erectile dysfunction, as secondary to posttraumatic stress disorder (PTSD) are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a skin disorder, claims as genital itching are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. Prior to April 2, 1998, the criteria for a compensable rating for a low back disorder were not met; prior to September 28, 2019, the criteria for entitlement to a rating in excess of 10 percent for a low back disorder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5295, (2002) 5237 (2019). 5. From September 28, 2019, the criteria for entitlement to a rating in excess of 40 percent for a low back disorder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 6. The criteria for entitlement to an increased rating in excess of 10 percent for right patellofemoral pain syndrome with degenerative arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5260. 7. The criteria for entitlement to an increased rating in excess of 10 percent for left knee retro patellar pain syndrome is denied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5260. The criteria for entitlement to a compensable rating for right knee, limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257, 5261, 5262. 8. The criteria for entitlement to a total disability rating for individual unemployability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Marine Corps from January 1981 to December 1988 and in the United States Army from March 1989 to February 1996. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for removal of the gallbladder 2. Entitlement to service connection for impotence The Veteran was afforded a VA examination in February 2015. The examiner noted that the Veteran has a cholecystectomy in February 1997. The examiner opined that it was less likely due to service because the gallbladder was removed after service. At the September 2020 VA examination, the examiner opined that the Veteran's gallbladder [disorder] is directly related to service and unrelated to any of his service connected conditions. Exam today reveals a diagnosis of status post cholecystectomy with residuals bowel disturbances. Veteran's medical records reveal [he] was diagnosed with a gallstones about 13 months after discharge from service. However, his STR do reveal gallbladder symptoms of right upper quadrant pain and abdominal pain in 1986. Veteran was diagnosed with chest pain at this time. Medical literature reveals Seventy to 80% of symptomatic patients complain of episodic and severe epigastric pain; less commonly, it is located in the right upper quadrant, left upper quadrant, precordium, or lower abdomen (Hopkins,2013). The interval between gallbladder attacks/pain are unpredictable and may range from days to months or years (Hopkins,2013). I believe the Veteran's initial symptoms of gallbladder pain begin in service. After service, the gallstones caused gallbladder inflammation and infection requiring surgical removal. Veteran continues to have bowel disturbances related to gall bladder removal. The claimed status post gallbladder removal was at least as likely as not caused by service. A nexus has been established. Regarding his erectile dysfunction, the September 2020 VA examiner opined that his erectile dysfunction has resulted from his SC PTSD. The Board notes that an October 23, 2020 deferred rating decision indicated that there was to be a full grant for these issues; however, no rating decision has been issued granting these claims. In an October 28, 2020 rating decision code sheet, service connection for gallbladder removal and impotence were listed as “not service connected/not subject to compensation.” Therefore, the Board presently grants these claims. 3. Entitlement to service connection for a skin disorder, claimed as genital itching The Veteran was afforded a VA skin examination in February 2015. The Veteran reported rashes on his body that had come and gone since 1991. He did not undergo treatment. The examiner conducted an examination and concluded “no current pathology to warrant a diagnosis. No objective evidence of any chronic skin disability.” A review of the Veteran's treatment records does not show a diagnosis or treatment for a skin disorder or genital itching. Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Absent evidence of such a current disability, a claim for service connection must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As there is no evidence of a skin disorder or genital itching since the inception of this appeal, service connection is not warranted. Increased rating claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R .§4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, otherwise the lower rating will apply, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found-a practice known as “staged” ratings. In general, all disabilities, including those arising from a single disease entity, are rated separately, and disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disabilities. 38 C.F.R.§4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the Veteran’s service-connected disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to the absence of part, or all, of the necessary bones, joints, and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. 4. Prior to April 2, 1998, entitlement to a compensable rating; prior to September 28, 2019, entitlement to a rating in excess of 10 percent for a low back disorder 5. From September 28, 2019, entitlement to a rating in excess of 40 percent for a low back disorder Disabilities of the spine are evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating is warranted when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more at the height. A 20 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Diagnostic Code 5237. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). For VA compensation purposes, normal range of motion for the thoracolumbar spine is 90 degrees of forward flexion, 30 degrees of extension, 30 degrees of left and right lateral flexion, and 30 degrees of left and right lateral rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees, consisting of the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right lateral rotation. 38 C.F.R. § 4.71a, General Rating Formal, Note (2) and Plate V. The Veteran was in receipt of a 10 percent rating for lumbosacral strain under Diagnostic Code 5295, and later 5237. The latter code is appropriate for consideration in this appeal. Prior to 2003, a lumbar strain was rated 10 percent disabling where there was characteristic pain on motion. In the absence of such findings a noncompensable rating was warranted. Service connection for a low back disorder with a noncompensable rating was granted effective February 24, 1996. A 10 percent rating was assigned effective April 2, 1998 when examination findings confirmed characteristic pain on motion. This finding was not previously made and as such, a compensable rating prior to that time was not warranted. The 10 percent rating remained in effect until September 2019, as discussed more fully below. The Veteran was afforded a VA examination of his back in February 2015. The Veteran reported that his previous VA examination was in 2004. Since that time, his pain gradually increased and was presently constant pain. He gave up shooting sports due to his back pain. He reported occasional numbness in his legs. He denied flare ups. Functional loss was described as limitation in bending, lifting, and twisting. Range of motion testing showed flexion limited to 80 degrees, extension limited to 15 degrees, and normal bilateral flexion and rotation. There was pain noted in all ranges but no evidence of pain with weight bearing, localized tenderness, or pain with palpation. The Veteran was able to perform repetitive use testing with no additional limitations. The examiner noted guarding not resulting in abnormal gait or spinal contour. Muscle strength testing was normal with no atrophy. Reflex and sensory examinations were normal and straight leg raising test was negative. There were no signs or symptoms of radiculopathies. The examiner also noted that “during [the] examination, the veteran [was] able to bend to 90° without obvious difficulty to remove his socks. Sitting straight leg raising to 90° causes no pain.” The Veteran's spine disorder did not impact his ability to work. In a statement received in September 2019, the Veteran stated that he experienced pain, stiffness, weakness, and muscle spasms that cause him to walk more guarded to prevent additional pain. However, bending, leaning, twisting, prolonged standing, walking, or sitting, squatting, and laying still all heighten the pain in his back. The Veteran also stated that within the prior year, he had at least 20 separate instances where his back pain severely limited movement that he spent the majority of his day in his couch or bed. The Veteran submitted an independent evaluation regarding lumbosacral strain from G.U., APRN, dated in September 2019. Ms. U. noted the Veteran's August 2019 primary care note in which the Veteran was documented with chronic low back pain. He was noted to have lower back spasms and limited range of flexion and extension. She also noted the Veteran's January 2019 statement regarding pain and limited function. Ms. U. opined that based on the Veteran's “credible lay statement, it is evident that he suffers from muscle spasms and guarding that have led to an abnormal gait as the Veteran walks with a limp.” The Veteran was afforded a VA examination of his spine in October 2019. The examiner noted a diagnosis of lumbosacral strain with left lower radiculopathy. The Veteran reported symptoms of sharp, radiating pain and stiffness and that it impacts his daily activities. He also reported daily flare ups that are moderate to severe and last several hours. Functional impairment includes limited range of motion and difficulty with bending, prolonged standing, walking, or sitting. Range of motion testing showed flexion to 45 degrees, extension to 20 degrees, bilateral flexion to 20 degrees, and bilateral rotation to 20 degrees. Pain and functional loss were noted on examination and there was evidence of pain with weight-bearing. The Veteran was able to perform repetitive use testing but was limited an additional 5 degrees in all ranges. Functional loss is a result of pain and pack of endurance. With repeated use over time, the Veteran was limited to 35 degrees of flexion, 10 degrees of extension, 10 degrees of bilateral flexion, and 10 degrees of bilateral rotation. Finally, during a flare up, the examiner described his flexion to be limited an additional 5 degrees to 30 degrees. The other ranges of motion were not additionally limited. The Veteran did not have guarding or muscle spasm. Muscle strength testing was 5 out of 5 with no atrophy and a reflex examination was normal. A sensory examination showed a normal right side and decreased sensation on the left lower extremity. Straight leg raising test was positive for the left leg. The Veteran was also found to have a radiculopathy of the left lower extremity with severe intermittent pain and moderate paresthesias and numbness of the sciatic nerve. There was no ankylosis and the Veteran did not have IVDS. The examiner opined that his spine disorder impacted his ability to work due to back pain, stiffness, limited range of motion, and difficulty with prolonged walking and bending to lift heavy items. In a November 2019 rating decision, the Veteran's rating was increased to 40 percent, effective September 28, 2019. The Veteran underwent a VA examination of the spine in September 2020. The examiner noted diagnoses of lumbosacral strain and degenerative arthritis of the spine. The Veteran reported symptoms of sharp, radiating pain and stiffness and that impact his daily activities. He also reported weekly flare ups that are severe and last several days. Functional impairment included difficulty with prolonged standing and sitting. Range of motion testing showed flexion to 35 degrees, extension to 20 degrees, right lateral flexion to 20 degrees, left lateral flexion to 15 degrees, and bilateral rotation to 20 degrees. Pain and functional loss were noted on examination and there was evidence of pain with weight-bearing. The Veteran was able to perform repetitive use testing with no additional limitations. Functional loss is a result of pain and pack of endurance. Although the Veteran was not examiner after repetitive use over time or during a flare up, the examiner determined that under these circumstances, the Veteran was limited to 30 degrees of flexion, 15 degrees of extension, 15 degrees of bilateral flexion, and 15 degrees of bilateral rotation. The Veteran had muscle spasm not resulting in abnormal gait or spinal contour. Muscle strength testing was 4 out of 5 with no atrophy and a reflex examination was hypoactive on the bilateral knees but normal of the ankles. A sensory examination was normal and straight leg raising tests were positive bilaterally. The Veteran was also found to have bilateral radiculopathies of the lower extremity with moderate intermittent pain, paresthesias, and numbness of the femoral and sciatic nerves. There was no ankylosis and the Veteran did not have IVDS. The examiner opined that his spine disorder impacted his ability to work due to difficulty walking, standing, running, and sitting, lifting heavy objects, bending, and squatting These limitations result in decreased occupational productivity and efficiency. Upon review of the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted prior to September 28, 2019 for the Veteran's lumbosacral strain. The February 2015 VA examination showed flexion to 80 degrees, at worst, and mild effects on the Veteran's recreation. There was no evidence of flexion limited to less than 60 degrees, abnormal spinal curvature, or incapacitating episodes of more than two weeks. The Veteran's pain and functional limitation were considered in the 10 percent rating. Therefore, no higher rating is warranted prior to that time. From September 28, 2019, the Board finds that a rating in excess of 40 percent is not warranted. During that period, the Veteran's flexion was limited, at worst, to 30 degrees. The Veteran was limited in walking, sitting, and standing and these functional limitations have been considered, consistent with the criteria of a 40 percent evaluation. At no point during any of the periods on appeal does the evidence show ankylosis of the thoracolumbar spine or incapacitating episodes required doctor-prescribed bedrest. Therefore, ratings in excess of those currently assigned are not warranted. The Board has also considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.40 and 4.45 would warrant higher ratings for the Veteran's lumbar spine disorder. However, the VA examinations documented the Veteran limitations due to pain or repetitive use testing and those limitations are reflected in the currently assigned ratings. Therefore, the Veteran's claims for increased ratings for his lumbar spine disorder are denied. 6. Entitlement to an increased rating in excess of 10 percent for right patellofemoral pain syndrome with degenerative arthritis 7. Entitlement to an increased rating in excess of 10 percent for left knee retro patellar pain syndrome 8. Entitlement to a compensable rating for right knee, limitation of flexion The Veteran's patellofemoral pain syndrome of the left knee is rating under Diagnostic Code 5003-5260. The Veteran’s patellofemoral pain syndrome of the right knee is rating under Diagnostic Code 5003-5261. The Veteran is separately assigned a noncompensable for limitation of flexion of the right knee under Diagnostic Code 5003-5260. Ratings are essentially assigned for complaints of painful motion with noncompensable limitation of motion. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. The Veteran underwent a VA examination of his knees in February 2015. The examiner noted a diagnosis of bilateral patellofemoral pain syndrome. The Veteran reported pain in the right knee, worse than left and symptoms of popping with bending and excessive standing, sitting, or walking. He has difficulty with stairs, squats, and kneeling. There was no history of swelling or flare ups. Range of motion was from 5 to 140 degrees on the right and 0 to 135 degrees on the left. There was no crepitus noted, but no pain on examination, no pain with weight bearing, and no localized tenderness or pain on palpation. The Veteran was able to perform repetitive use testing with no additional limitations. The Veteran was not examined after repeated use over time or during a flare up. Muscle strength testing was 5 out of 5 with no atrophy. There was no ankylosis. Joint stability tests were normal, and the examiner noted no history of subluxation or lateral instability. He had no meniscal condition or tibial or fibular impairment. The examiner commented that “bilaterally, straight leg raising with inferior pressure against the patella and quadriceps contraction causes crepitus. Pain is subjectively present.” His knee disorder did not impact his ability to perform occupational tasks. The Veteran submitted a disability benefits questionnaire regarding his knees from his private physician, J.J., M.D., in February 2018. Dr. J diagnosed bilateral osteoarthritis secondary to bilateral retro patellar pain syndrome. The Veteran reported that he has flare ups that cause consideration pain, requiring Tylenol, heat, and laying down. Range of motion measurements were noted to be 150 degrees of flexion on the right and 140 degrees of extension. On the left, the report showed 120 degrees of flexion and 155 degrees of extension. The Veteran was able to perform repetitive use testing but was limited on the right to 100 degrees of flexion and 140 degrees of extension and no additional limitation on the left. There was pain on motion and with weight bearing. The Veteran had focal medial, lateral, and anterior/posterior tenderness. Functional loss was due to pain on movement, swelling, disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength testing was 4 out of 5 with no atrophy. There was no ankylosis. Joint stability tests were normal, and the examiner noted no history of subluxation or lateral instability. He had no meniscal condition, but the physician noted shin splints, bilaterally. The Veteran required regular use of a brace. The Veteran was afforded a VA examination of the knees in March 2018. The VA examiner noted diagnoses of bilateral patellofemoral pain syndrome and degenerative arthritis. The Veteran reported pain, popping, and grinding. He also reported flare-ups with prolonged standing, walking, stairs, and driving. His functional loss includes limiting shooting, inability to run, and difficulty squatting. Active range of motion testing showed 0 to 50 degrees on the right knee and 0 to 90 degrees on the left knee. Passive range of motion was 0 to 80 degrees on the right and 0 to 110 degrees on the left. The Veteran had difficulty squatting and pain was noted on flexion and extension. There was no objective evidence of location tenderness or pain on palpation, no evidence of pain with weight-bearing, and no evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional limitations. Although the Veteran was not examined immediately after repetitive use over time, the examiner stated that the Veteran has painful and decreased ROM of the bilateral knees without repetitive use over time and therefore further decreased ROM would be expected with repetitive use over time. The amount of decrease however cannot be defined in terms of specific degrees secondary to variations in each person's tolerance for pain and the variation in type and length of activity. Muscle strength testing was 5 out of 5 with no atrophy. There was no ankylosis. Joint stability tests were normal, and the examiner noted no history of subluxation or lateral instability. He had no meniscal condition or tibial or fibular impairment. The Veteran required regular use of a brace. There was no objective evidence of pain on non-weight bearing. In an April 2018 rating decision, bilateral 10 percent ratings for patellofemoral pain syndrome were continued under Diagnostic Code 5003-5260 and service connection was separately granted for right knee, limitation of flexion with a noncompensable rating. The Veteran underwent a VA examination of the knees in September 2020. The VA examiner noted diagnoses of bilateral degenerative arthritis and limitation of flexion. The Veteran reported pain, stiffness, popping, and swelling. He also reported daily, severe flare-ups with prolonged walking. His functional loss includes limiting shooting, inability to run, and difficulty squatting. Active range of motion testing showed 0 to 100 degrees on the right knee and 0 to 90 degrees on the left knee. The Veteran had difficulty squatting and pain was noted on flexion and extension. The examiner noted evidence of pain with weight-bearing and crepitus, but no objective evidence of location tenderness or pain on palpation. The Veteran was able to perform repetitive use testing and was additionally limited to 90 degrees of flexion on the right. Although the Veteran was not examined immediately after repetitive use over time or during a flare-up, the examiner stated that the Veteran would be limited to 90 degrees of flexion on the right after repetitive use over time and to 85 degrees of flexion during a flare up, bilaterally. Muscle strength testing was 4 out of 5 with no atrophy. There was no ankylosis. Joint stability tests were normal, and the examiner noted a history of recurrent effusion. He had no meniscal condition or tibial or fibular impairment. The Veteran required constant use of a brace. Regarding function impact on employment, the Veteran's knee disorders result in difficulty with standing, walking for long periods as well as squatting, kneeling, climbing/descending stair and or running/jumping due to pain, weakness, and stiffness of the knees. Upon review of the evidence, the Board finds that higher ratings than those assigned are not warranted. Regarding limitation of flexion, the Veteran is assigned a 10 percent rating. To warrant a higher rating, flexion would need to be limited to 30 degrees. At worst, with consideration of pain, flare ups, and repetitive use, the Veteran's right knee was limited to 50 degrees of flexion and his left knee was limited to 80 degrees of flexion at the March 2018 VA examination. Therefore, a higher rating is not warranted under Diagnostic Code 5260. Regarding limitation of extension, at no point was either knee limited to 10 degrees of extension or more, as required for a compensable rating under Diagnostic Code 5261. The Board has considered whether a separate rating is warranted under one of the other Diagnostic Codes pertaining to the knee. The evidence does not show instability. The Veteran has not reported instability and joint stability tests have been consistently normal. Therefore, a separate rating under Diagnostic Code 5257 is not warranted. In the February 2018 DBQ, Dr. J. noted shin splints. As the Veteran is already compensated for a slight knee disability and the evidence does not show an ankle disability, a separate rating of 10 percent under Diagnostic Code 5262 is not warranted, as the Veteran's pain and limitation of motion is already compensated under Diagnostic Codes 5260. There is no argument or indication that the Veteran has ankylosis, a meniscal disorder, or genu recurvatum, to warrant separate or higher ratings under any other diagnostic code applicable to the knees. Diagnostic Codes 5256-5263. There is also no indication of circumstances for which the Veteran's symptoms are the functional equivalent to the criteria for a higher rating under any applicable rating code. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The Board has considered the Veteran's lay statements regarding his symptoms, including during flare up and after repeated use after time and finds the ratings assigned adequately reflect his symptoms. Therefore, higher ratings are denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 9. Entitlement to a total disability rating for individual unemployability Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2019). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.34 (2019). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15 (2019). 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. 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. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2019). From December 31, 2018, the Veteran was in receipt of a combined 100 percent rating. Therefore, consideration of a TDIU from that date is moot. Prior to that date, the Veteran was service connected for PTSD, rated at 70 percent; obstructive sleep apnea, rated at 50 percent; lumbosacral strain, rated at 10 percent; hemorrhoids, rated at 20 percent; patellofemoral pain syndrome of the left knee, rated at 10 percent; patellofemoral pain syndrome of the right knee, rated at 10 percent;. The Veteran had a combined rating of 80 percent, effective January 16, 2013. Therefore, the Veteran met the threshold for schedular consideration for TDIU under 38 C.F.R. § 4.16 (a). Therefore, the question is whether his service-connected disabilities precluded him from obtaining or engaging in substantially gainful employment, per 38 C.F.R. § 4.16 (b). 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). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19 (2016); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran's June 2020 rehabilitation needs inventory form indicated that he was employed as a contract specialist from November 2011 to June 2015, a procurement analyst from June 2015 to December 2018 and in customer service from June 2019 to December 2019. There is no legal entitlement to a TDIU rating during a period in which the Veteran is gainfully employed. Because the Veteran was employed during the period on appeal, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 (b). Therefore, the claim of entitlement to TDIU must be denied. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shana Z. Siesser, 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.