Citation Nr: 21005158 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 15-12 122 DATE: January 29, 2021 ORDER A disability rating in excess of 10 percent for cerebral concussion residuals is denied. A separate rating of 50 percent, but not higher, for a neurocognitive disorder, secondary to the service-connected cerebral concussion, is granted. A disability rating in excess of 10 percent for degenerative arthritis of the right knee with instability is denied. An initial rating in excess of 20 percent for right knee instability is denied. A maximum separate rating of 10 percent for right knee symptomatic residuals after removal of the semilunar cartilage is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. For the entire rating period on appeal, the Veteran’s service-connected cerebral concussion residuals concussion are primarily productive of more subjective symptoms that mildly interfere with work, instrumental activities of daily living, or work, family, or other close relationships, but not productive of subjective symptoms which moderately so impair him. 2. Resolving any doubt in the Veteran’s favor, for the entire rating period on appeal, the service-connected neurocognitive disorder secondary to the service-connected cerebral concussion is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but not productive of occupational and social impairment, with deficiencies in most areas. 3. For the entire initial rating period on appeal, the Veteran’s service-connected degenerative arthritis of the right knee with instability is productive of knee flexion no worse than 110 degrees, including during repetitive use and flare ups. 4. For the entire rating period on appeal, the Veteran’s service-connected right knee instability is productive of moderate anterior, posterior, and medial-lateral instability, but not productive of severe subluxation or lateral instability. 5. For the entire rating period on appeal, the Veteran’s service-connected symptomatic post-removal of semilunar cartilage from the right knee is productive of frequent episodes of joint locking, joint effusion, and pain. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for cerebral concussion residuals are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.124a, Diagnostic Code 8045 (2019). 2. The criteria for a separate rating of 50 percent for a neurocognitive disorder are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.130, Diagnostic Code 9304 (2019). 3. The criteria for a rating in excess of 10 percent for degenerative arthritis of the right knee with instability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5003, 5260 (2019). 4. The criteria for an initial rating in excess of 20 percent for right knee instability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5257 (2019). 5. The criteria for a separate 10 percent rating for symptomatic post-removal of semilunar cartilage from the right knee are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.59, 4.71a, Diagnostic Code 5259 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1973 to May 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Veteran and his spouse testified in a Board video-conference hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. In June 2019, the Board remanded the claims for additional development, to include affording the Veteran VA examinations for his right knee and cerebral concussion disabilities. Pursuant to the remand, the Veteran was scheduled for VA knee and cerebral concussion examinations; however, the record reflects that the Veteran did not show up for any of the scheduled examinations. Although copies of notifications of the scheduled examinations are not of record, the presumption of regularity states that VA and other government officials perform their duties correctly, fairly, in good faith, and in accordance with law and governing regulations. Marsh v. Nicholson, 19 Vet. App. 381, 386-87 (2005). As the record includes no evidence that rebuts this presumption the Board presumes that VA properly notified the Veteran of the scheduled examinations. Indeed, in the November 2020 appellate brief, the Veterans’ representative acknowledged that the Veteran failed to show up for the scheduled examinations. Accordingly, the Board finds substantial compliance with its June 2019 remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Board remand). To date, the Veteran has not requested to reschedule the examination, or provided a reason for his failure to report. Indeed, the Veteran notified the Board in September 2020 that he had no further evidence to submit and requested that the Board proceed with adjudication of his claims. Due to the Veteran’s failure attend the scheduled VA examinations or provide a date for which he can attend examinations, there is no further duty to provide any more VA examinations relating to this claim. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1993). The Board emphasizes that the Veteran maintains the ultimate burden to establish entitlement to VA benefits. See Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). Moreover, VA’s duty to assist is a two-way-street; if the Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the relevant evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board is aware of the Court’s decision in Quinn v. Wilkie, 31 Vet. App. 284, 292 (2019), which held that each time a legacy appeal (an appeal adjudicated prior to enactment of the Appeals Modernization Act) is returned to the Board the claimant is entitled to a Board hearing, even if a hearing was held previously. In this case, the Veteran appeared at a Board hearing before the undersigned in September 2018 as noted above. To date, the Veteran has not requested another hearing. Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Ratings Applicable Laws and Regulations Generally, disability ratings are determined by applying the rating criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.  The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment.  38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation, as well as the whole recorded history of the Veteran’s disability.  38 C.F.R. §§ 4.1, 4.2; see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  Where there is a question of which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating.  38 C.F.R. § 4.7.  Otherwise, the lower rating is assigned. Id. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes (DC or DCs), 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 DCs; however, the critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Hyphenated codes are used when a rating under one DC requires use of an additional DC to identify the specific basis for the evaluation assigned. The additional DC is shown after a hyphen. 38 C.F.R. § 4.27. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as “mild,” “moderate,” “moderately severe,” and “severe.” Spellers v. Wilkie, 30 Vet. App. 211, 219-20 (2018). (“DC 8520 does not define ‘mild,’ ‘moderate,’ ‘moderately severe,’ or ‘severe,’ or generally associate those terms with specific symptoms”). Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). In evaluating the probative value of a medical opinion, the Board will assess whether (1) the medical opinion is based on sufficient facts and data, (2) the medical opinion is the product of reliable principles and methods, and (3) the medical expert has applied the principles and methods reliably to the case.  Nieves-Rodriguez, 22 Vet. App. at 302.  Specifically, the Board will determine whether the medical expert was aware of the critical medical facts in the Veteran’s medical history and whether the expert provided the sort of factually accurate, fully articulated, and sound reasoning for the opinion that allows the Board to assess whether the expert applied valid medical analysis to the facts of the particular case.  Id. at 303-05. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A claimant bears the burden of presenting and supporting his or her claim for benefits.  See 38 U.S.C. § 5107(a). Cerebral Concussion Residuals In December 1976, the RO granted service connection for the Veteran’s cerebral concussion, and assigned a 10 percent rating under DC 8045, effective May 8, 1976. See Rating Decision dated December 14, 1976. Rating Criteria DC 8045 provides evaluation for three main areas of dysfunction that may result from traumatic brain injury and have profound effects on functioning: Cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, DC 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is to be evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Id. Emotional/behavioral dysfunction is to be evaluated under § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Id. Subjective symptoms may be the only residual of traumatic brain injury or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of traumatic brain injury are evaluated, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified.” However, any residual with a distinct diagnosis that may be evaluated under another DC, such as migraine headache or Meniere’s disease, may be separately evaluated even if that diagnosis is based on subjective symptoms, rather than under the “Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified” table. Physical (including neurological) dysfunction is to be evaluated based on the following list, under an appropriate DC: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate DC. Each condition should be evaluated separately as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Id. The need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. should also be considered. Id. Under DC 8045, the table titled “Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified” contains 10 important facets of traumatic brain injury related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 4th level, the highest level of impairment, labeled “total.” A 100 percent evaluation will be assigned it “total” is the level of evaluation for one or more facets. If no facet is evaluated at “total,” the overall evaluation is based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and, 3 = 70 percent. However, not every facet has every level of severity. The “subjective symptoms” facet, for example, provides for an impairment level of 0, 1, or 2, which corresponds to 0 percent; 10 percent; and 40 percent, respectively. Notes are included with DC 8045. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled “Evaluation of Cognitive Impairment and Other Residuals of Traumatic Brain Injury Not Otherwise Classified” with manifestations of a combined mental or neurologic or other physical disorder that can be separately evaluated under another DC. In such cases, more than one evaluation is not to be assigned based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions is to be assigned. However, if the manifestations are clearly separable, a separate evaluation for each condition will be assigned. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): “Instrumental activities of daily living” refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from “Activities of daily living,” which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms “mild,” “moderate,” and “severe” traumatic brain injury, which may appear in medical records, refer to a classification of traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under DC 8045. Rating Analysis Turning to the evidence for the rating period on appeal, private outpatient treatment records dated August 2013 through March 2014 reflect that the Veteran denied having headaches and no cognitive or memory impairments were noted. In August 2014, the Veteran was afforded VA traumatic brain injury (TBI), headaches, and mental disorder examinations. During the VA TBI examination, the examiner noted diagnoses of TBI and post-concussive syndrome with short term memory loss and headaches. The Veteran described receiving a skull fracture during service when he was struck in the head by a truck door caught by the downwash from a helicopter that landed nearby. During the examination, the Veteran endorsed loss of memory for words during conversation as well as mild headaches and stiff neck he attributed to the in-service injury. The examiner noted that the Veteran was not taking continuous medication for his condition. On examination, it was noted that the Veteran complained of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing. He was always oriented to person, time, place, and situation, his judgment was normal, and his social interaction was described as routinely appropriate. Motor activity and visual spatial orientation were both normal. The Veteran was negative for neurobehavioral effects. The VA examiner concluded that the Veteran’s had three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships, specifically “memory loss, lack of ability to complete required tasks, and inability to remember trained work procedures.” The examiner added that the main impact of the Veteran’s symptoms is on “work performance.” The examiner noted that residuals of the Veteran’s cerebral concussion residuals caused anxiety, which increased the symptoms and affected work performance. The VA examiner concluded that the Veteran’s main problems were memory loss, lack of ability to complete required tasks, inability to remember trained work procedures, and work performance. See VA Residuals of Traumatic Brain Injury examination report dated August 22, 2014. During the VA headaches examination, the examiner, noted a diagnosis of post-concussion headaches. The Veteran endorsed symptoms of headache pain across his forehead, stiff neck, nausea, and sensitivity to light typically lasting one to two days, although the frequency of these headaches is not indicated. The Veteran denied prostrating attacks of headache pain. The examiner concluded that the Veteran’s headaches impacted his ability to work in that stress from works increases his headaches, which caused memory loss. See VA headaches examination report dated August 22, 2014. During the VA mental disorders examination, the examiner, a VA psychologist, diagnosed mild neurocognitive disorder due to TBI. In terms of social impairment, the examiner noted that the Veteran, the Veteran reported that he is one of eight children. He married prior to entering military service and he and his wife have five children. At the time of the examination he and his wife resided with his mother-in-law. In terms of occupational impairment, the examiner noted that the Veteran said he graduated from high school and worked as a draftsman and restaurant worker while attending college. He completed a year and a half of college prior to entering the service. It was noted that the Veteran’s military occupational specialty (MOS) was Missile System Analyst Specialist, which, according to the Veteran, involved working with inter-continental ballistic missiles and air-to-air missiles, and he said he completed electronics training. Following separation from service, the Veteran said he worked in air conditioning and sold vacuum cleaners. He also worked in restaurants and then went back to college, completing a two-year course in radiological technology. He found employment doing x-rays and nuclear medicine at two different hospitals over the next nine years. He said he then owned a company that did electronic assembly for about seven years, then worked for an office supply company for about seven years. After that he operated a home for delinquent adolescents. He and his wife then operated a group home for teenage girls. Following this he worked in customer service for a technology company for about seven years, and at the time of the examination he was working at a call center for a large telecommunications company. He said he completed a bachelor’s degree in technology after separation from service but noted that there was nothing he could do with this degree where he lived at that time. On examination, the Veteran was oriented to person, place, and time. His mood was defensive, and his affect was flat. He was able to remember three items given to him five minutes later. He was knowledgeable about his past and able to articulate events easily and readily. He was able to effectively give abstract interpretations of three proverbs. He indicated that he would become anxious and shut down whenever a supervisor micro-managed him, such as when a supervisor monitored his calls with customers. In this type of situation, he said he had difficulty under stressful work conditions. The examiner identified symptoms of anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner concluded that the Veteran’s neurocognitive disorder resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner determined that the Veteran was capable of handling his financial affairs. See VA mental disorders examination report dated September 8, 2014. There is no evidence that the examination reports are not competent or credible, and therefore it is entitled to significant probative weight concerning the severity of the Veteran’s cerebral concussion residuals during the rating period. See Nieves-Rodriguez, 22 Vet. App. at 304. In remarks included with his November 2014 Notice of Disagreement, the Veteran asserted that he was no longer able to fulfill the duties of agent for a large telecommunications company that required speaking to up to 38 customers over an eight-hour period, during which he had to recall customer names, previous offers, current promotions, current pricing under multiple pricing plans and to be able to timely locate the information during each telephone call. Specifically, the Veteran stated that he was unable to “remember words that apply to how the items are stored in the database” and he was unable to remember customer names or differentiate between specific customer information and conversations, which he had been “written up for[.]” In remarks included with his April 2015 appeal to the Board, the Veteran again noted memory problems and added that at the beginning of his work day he was sharper and did better, but as the day progressed, his impairment was more evident, and some days “I cannot determine what to do when the phone rings.” The Veteran asserted that the August 2014 VA examinations did not take into account the problems he had while working. See Appeal to Board of Veterans’ Appeals and attached statement (pg. 1) received April 15, 2015. VA treatment records reflect that the Veteran denied headaches during outpatient appointments in May 2015 and December 2016. During a VA outpatient visit in September 2017, it was noted that the Veteran had a prior history of TBI and that his condition was “stable.” During VA outpatient appointments in October 2017, February 2018, May 2018, and August 2018, the Veteran denied headaches and dizziness. VA treatment notes dated January 2019 and January 2020 reflect that the Veteran was taking medication for headaches and he was instructed to check his blood pressure when he experienced a headache. During the January 2020 VA appointment, the Veteran’s cranial nerves were intact, there were no sensory or motor deficits, deep tendon reflexes were present bilaterally, and cerebellar signs were negative. During the September 2018 Board hearing, the Veteran said he had “the staggers” and that he did not feel comfortable driving a vehicle any longer. Hearing Transcript at pg. 5. He also stated that he had trouble speaking and finding words, and his memory had grown worse. Id. He said he had retired since the 2014 VA examination, and believed that his job performance was impacted by memory impairment, which rendered him unable carry out the duties of his job: “I would setup video conferences, such as we’re having, with major corporations and be able to track what’s going on for them. For issues that they wanted fixed with their software that our company had provided.” Id. at pg. 6. Thus, with regards to the specific criteria facets under DC 8045, Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Specified, the Board finds the following: (1) Memory, Attention, Concentration, Executive Functioning: The Veteran is assessed a “1” for some complaints of memory deficiencies, cognitive dysfunction and executive functions, but without objective evidence on testing, as reflected in the August 2014 VA TBI examination, which is consistent with other objective medical evidence of record. Although the Veteran is competent to describe memory and cognitive symptoms, he has personally experienced, see Layno, supra, he has not been shown to be competent to objectively diagnose memory deficiencies, cognitive dysfunctions, or impairment of executive functions. The Board finds the objective evaluations by private and VA clinicians to be the most probative evidence of record in this regard. Accordingly, the Board finds that the evidence of record warrants a “1” for this TBI facet. (2) Judgment: The Board finds that the Veteran’s judgment is normal throughout the appeal period, as demonstrated in the above evidence. Such corresponds to a “0” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “1” is not warranted unless the Veteran demonstrates mildly impaired judgment, including for complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. At no time throughout the appeal period has the Veteran demonstrated mildly impaired judgment. Thus, the Board is unable to assign a higher level of severity for this facet. (3) Social Interaction: The Board finds that the Veteran is routinely able to socially interact appropriately throughout the appeal period, as demonstrated in the above evidence. Such corresponds to a “0” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “1” is not warranted unless the Veteran demonstrates social interaction that is occasionally inappropriate. At no time throughout the appeal period is the Veteran deemed to be even slightly inappropriate in his social interactions by any treating physician or examiner; nor does the Veteran assert that he has any inappropriate behavior during the appeal period. The Board is therefore unable to assign a higher level of severity for this facet. (4) Orientation: The Board finds that the Veteran’s orientation was oriented to person, time, place and situation throughout the appeal period as reflected in the treatment records and August 2014 VA TBI and mental disorders examinations. Such corresponds to a “0” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “1” is not warranted unless there is evidence of being occasionally disoriented to one of the four aspects (person, time, place, and situation) of orientation. At no time throughout the rating period on appeal is the Veteran deemed to have been occasionally disoriented to one of the four aspects of orientation. Thus, the Board cannot assign a higher level of severity for this facet. (5) Motor Activity: The Board finds that the Veteran’s motor activity is normal throughout the appeal period, as demonstrated in the above evidence. Such corresponds to a “0” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “1” is not warranted unless the evidence demonstrates that his motor activity is mostly normal, but mildly slowed at times due to apraxia. The evidence does not indicate that the Veteran’s motor activity throughout the appeal period has met this facet. Thus, the Board is unable to assign a higher level of severity for this facet. (6) Visual Spatial Orientation: The Board finds that the Veteran’s visual spatial orientation is normal throughout the appeal period, as demonstrated in the above evidence. Such corresponds to a “0” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “1” is not warranted unless the evidence demonstrates mild impairment, such as occasionally getting lost in unfamiliar surroundings, having difficulty reading maps or following directions, but is able to use a Global Positioning System (GPS). The above record does not support a finding that the Veteran has been mildly impaired in his visual spatial orientation. Thus, the Board is unable to assign a higher level of severity for this facet. (7) Subjective Symptoms: The Board finds that three or more of the Veteran’s subjective symptoms mildly interfere with work, instrumental activities of daily living, or work, family or other close relationships throughout the appeal period, as demonstrated in the above evidence. Such corresponds to a “1” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “2” is not warranted unless there are three or more subjective symptoms that moderately interfere with those areas of the Veteran’s functioning, such as marked fatigability, blurred or double vision, or headaches requiring rest periods during most days. The August 2014 VA TBI examination report lists the Veteran’s subjective symptoms as memory loss, lack of ability to complete required tasks, and inability to remember trained work procedures, which do not meet the level of severity for this facet. (8) Neurobehavioral Effects: Although the 2014 VA TBI examination reflects a finding of no neurobehavioral effects, the 2014 VA mental disorders examination reflects a diagnosis of mild neurocognitive disorder due to TBI, symptoms of which include disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting, and the resulting finding that the Veteran’s symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. This places the question of whether the Veteran has neurobehavioral effects in equipoise. Resolving reasonable doubt as to this question, the Board finds that the Veteran’s neurobehavioral effects corresponds to a “1” score, i.e. one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both, but do not preclude them, rather than the “0” score assigned by the RO in the September 2014 rating decision. A higher level of severity of “2” is not warranted unless the Veteran’s neurobehavioral effects frequently interfere with workplace or social interaction, or both, but does not preclude them; examples of neurobehavioral effects include irritability, impulsivity, unpredictability, lack of motivation, verbal or physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. While the August 2014 VA mental disorders examiner identified disturbances of motivation and mood among the Veteran’s psychiatric symptoms, the record does not reflect that such disturbances frequently interfere with the Veteran’s workplace or social interaction. Thus, the Board is unable to assign a score of “2” for this facet. (9) Communication: The Board finds that the Veteran is able to communicate by and to comprehend spoken and written language throughout the appeal period, with only occasional impairment as demonstrated in the above evidence. Such corresponds to a “1” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “2” is not warranted unless comprehension or expression, or both, of either spoken or written language is impaired more than occasionally but less than half of the time, and the Veteran is generally able to communicate complex ideas. No such impairment in either spoken or written language, in either comprehension or expression, is shown throughout the rating period on appeal, nor is the Veteran unable to communicate complex ideas throughout the rating period. Thus, the Board is unable to assign a higher level of severity for this facet. (10) Consciousness: The Board finds that the Veteran’s consciousness is normal throughout the appeal period, as demonstrated in the above evidence. Such corresponds to a “0” score for this facet, and does not result in an evaluation in excess of that currently assigned. A higher level of severity of “Total” is not warranted unless there is evidence of persistently altered state of consciousness, such as a vegetative state, minimally responsive state, or coma. The evidence of record demonstrates that the Veteran is not in a persistently altered state of consciousness throughout the appeal period. Thus, the Board is unable to assign a higher level of severity for this facet. In short, the Veteran has been assigned a “1” as the highest severity level with regards to any of the ten facets, as discussed above. Such an evaluation is commensurate to a 10 percent evaluation under DC 8045. See 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.124a, DC 8045. Consequently, regarding the overall rating the benefit-of-the-doubt rule does not apply, and an evaluation in excess of 10 percent for the Veteran’s cerebral concussion residuals under DC 8045 is not warranted. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Nevertheless, the Board must also consider whether the Veteran is entitled to a rating under any other potentially applicable DC. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991) (regardless of the precise basis of a veteran’s disability rating, the Board has a duty to acknowledge and consider all regulations and DC s that are potentially applicable). Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as none of the symptomatology for one condition is “duplicative of or overlapping with the symptomatology” of the other disability. See Esteban, 6 Vet. App. at 262. Under DC 8100, a 10 percent rating is assigned when the Veteran has migraines with less frequent attacks. A 30 percent rating is assigned for migraines with characteristic prostrating attacks occurring on an average once a month over a several month period. A 50 percent rating, the maximum schedular rating allowed, is assigned for migraines with very frequent completely prostrating and prolonged attacks that are productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. Here, the Veteran’s VA treatment records and VA examination report reflect that the Veteran experiences infrequent or occasional headaches, as shown above, which approximates a noncompensable rating. A compensable rating is not warranted as the record does not demonstrate that the Veteran experiences characteristic prostrating attacks. Id. The Board also considers a separate rating for psychiatric symptoms associated with the Veteran’s service-connected concussion residuals. Under the General Rating Formula for mental disorders, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decreases work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if the evidence establishes there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Here, the 2014 VA mental disorders examiner concluded that the Veteran has a “mild neurocognitive disorder due to a TBI,” which results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Therefore, resolving reasonable doubt in the Veteran’s favor, a 50 percent rating under DC 9304 for mild neurocognitive disorder due to TBI is warranted for the entire rating period. A higher rating of 70 percent is not warranted as there is no evidence occupational and social impairment, with deficiencies in most areas. 38 C.F.R. § 4.130. Right Knee Disabilities The Veteran is service-connected for right knee degenerative arthritis and right knee instability. See Rating Decision Dated December 14, 1976; Rating Decision dated September 24, 2014. His right knee degenerative arthritis is assigned a 10 percent disability rating under DC 5003-5260, effective May 8, 1976 and his right knee instability is assigned a 20 percent rating under DC 5003-5257, effective June 24, 2014. The Veteran seeks higher ratings for each right knee disability. See Notice of Disagreement received November 23, 2014. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). DC 5003 sets forth the rating criteria for degenerative arthritis. This is appropriate for the Veteran’s right knee as the record reflects a diagnosis of degenerative arthritis of the right knee. However, as the record does not establish that the Veteran’s right knee is limited in motion at any time during the period on appeal, a separate evaluation for arthritis is not warranted. See VA General Counsel held in VAOPGCPREC 23-97. DC 5257 provides ratings of 20 and 30 percent for recurrent subluxation or lateral instability of the knee, which is moderate or severe, respectively. 38 C.F.R. § 4.71a. DC 5259 provides for the assignment of a single 10 percent rating for removal of semilunar cartilage, symptomatic. Id. DC 5260 provides for the evaluation of limitation of flexion of the knee. 38 C.F.R. § 4.71a. A noncompensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. Id. Normal range of motion (ROM) of a knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Rating Analysis Turning to the evidence, private treatment notes dated December 2013 reflect that the Veteran was “having such severe pain in his thighs and knees that he can hardly walk.” The VA clinician further noted: “Will have him go off Fenofibrate and then potassium citrate to make sure the drugs are not causing the pain.” February 2014 private progress notes reflect that the Veteran had been experiencing right knee flare-ups since January. He said prolonged standing and walking was not possible due to knee pain. He reported that his right knee “hurts continuously and grinds.” He said his right knee occasionally buckled and that he was unable to kneel. During a March 2014 private outpatient visit, it was noted that the Veteran continued to experience knee pain and that he said the pain made it almost impossible for him to walk. The clinician noted that the Veteran was using “compound cream on his knees and thigh for his pain.” The veteran was provided with a VA knees examination in August 2014. The diagnoses were degenerative arthritis of the right knee and right knee meniscus tear with meniscectomy. The examiner noted that the Veteran’s left knee joint had been replaced in 2010, and that “the right knee is close to needing to re replaced as well.” The examiner recorded that the Veteran had a right meniscectomy in 2012. The examiner also noted that the Veteran’s left knee was not evaluated because the joint had been replaced. The examiner noted that the Veteran complained of pain and difficulty standing and walking. The Veteran reported occasional use of a cane and wheelchair to assist in locomotion and motorized chairs at grocery stores due to his right knee. The Veteran endorsed flare-ups he described as pain, weakness, stiffness, and increased instability that occurred daily due to standing and walking and lasting as long as he was standing. He said an extreme increase in right knee pain occurred if he twisted the knee, which resulted in incapacitation lasting a few minutes. During initial ROM testing, the Veteran had right knee flexion to 110 degrees and extension to 0 degrees, with no objective evidence of pain in either plane. The examiner theorized that the reduction in flexion was due to the Veteran’s obesity. Notably, after repetitive use testing, the Veteran had right knee flexion to 115 degrees; extension to 0 degrees. The VA examiner said there was no pain on movement during the examination because it was not done with weight-bearing but noted that the Veteran said the majority of his knee pain occurs with weight-bearing activities, and results in less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The examiner concluded that pain, weakness, fatigability, and incoordination significantly limited functional ability of the Veteran’s right knee during flare-ups or when used repeatedly over a period of time, but did not result in additional loss of ROM. The Veteran’s right knee was painful on palpation of the medial aspect of the knee joint. Muscle strength testing was normal, and the examiner noted that the Veteran had “surprisingly good strength in the lower extremities.” The Veteran was positive for anterior instability, posterior instability, and medial-lateral instability of the right knee joint. The right knee joint was negative for patellar subluxation/dislocation; however, it was positive for meniscal tear, frequent episodes of joint locking, frequent episodes of joint pain, and frequent episodes of joint effusion. The Veteran denied pain due to the 2012 meniscectomy. The examiner noted that she was unable to find a right knee scar from the meniscectomy. The examiner concluded that the Veteran’s right knee disabilities impacted his ability to perform occupational tasks in that he was unable to: walk more than one-half city block; sit for more than one to two hours or stand more than 10 to 15 minutes; sit for more than eight hours a day without taking breaks every hour; stand no longer than about 30 minutes broken up throughout the day; or lift more than 80 pounds at one time or repeated lifting of 25 pounds. See VA knee and lower leg conditions examination report dated August 22, 2014. There is no evidence that the August 2014 VA knees examination report is not competent or credible, and therefore it is entitled to significant probative weight concerning the severity of the right knee disabilities during this period. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In remarks included with his November 2014 Notice of Disagreement, the Veteran said his right knee pain limited his ability to walk and made it impossible to ascend or descend stairs without difficulty. He said he had to use a motorized cart when shopping due to right knee pain. He said he was unable to attend family outings or go to museums, parades, or the park, and he was unable to stroll down a street due to his right knee pain. He said he had given up the pastimes of hiking, camping, fishing, and photography due to his right knee pain and difficulty walking. He said his employment opportunities were limited to sedentary occupations due to his knee problems and inability to walk. VA treatment notes dated May 2015 reflect that the Veteran reported being unable to step off a curb with his right knee due to pain and because it would give out. VA treatment notes dated October 2015 reflect that the Veteran was approved for right knee arthroplasty surgery. However, VA treatment notes dated December 2016 reflect that, while he continued to experience right knee pain, he had not undergone surgery because his weight exceeded 300 pounds. In remarks submitted with his April 2015 appeal to the Board, the Veteran again emphasized that his right knee pain limited his ability to walk and made it impossible to ascend or descend stairs without difficulty, required that he use a motorized cart when shopping due to right knee pain. He said he was unable to attend family outings or go to museums, parades, or the park, and he was unable to stroll down a street due to his right knee pain. He said he had given up the pastimes of hiking, camping, fishing, and photography due to his right knee pain and difficulty walking. He again noted that his employment opportunities were limited to sedentary occupations due to his knee problems and inability to walk. See Appeal to Board of Veterans’ Appeals and attached statement (pgs. 2-3) received April 15, 2015. During a May 2017 VA outpatient appointment, the Veteran reported that his knee pain “is too much.” December 2017 VA progress notes reflect that the Veteran was taking Hydrocodone and Baclofen for knee pain. Bilateral knee tenderness was noted. During the September 2018 Board hearing, the Veteran stated that because of his right knee disabilities, he could walk only about 25-40 feet before he had to rest, and about once a month he experienced stabbing pain that caused him to fall when his right knee gave out. See Board hearing transcript dated September 26, 2018 (Hearing Transcript) at pg. 3-4. Additionally, he stated that his right knee was painful while sitting and that he experienced flare-ups that are triggered by prolonged walking. Id. The Veteran’s spouse testified that in 2016, the Veteran had to start using a cane or a wheelchair. Id. at pg. 4. During a February 2020 VA urology consultation, the Veteran denied new onset of joint pain, swelling, decreased ROM, and leg discomfort. Based on review of the record, both lay and medical evidence, the Board finds that a rating in excess of 10 percent for right knee degenerative arthritis is not warranted. Because the Veteran’s range of right knee motion in flexion, to include during repetitive use testing and in consideration of flare-ups, has been no worse than 110 degrees (see August 2014 VA examination report), ratings higher than 10 percent are not warranted under DC 5260. The record is negative for flexion findings that would warrant a 20 percent rating based on the schedular criteria. The Veteran has been noted to have pain and functional loss, but these factors, in combination with limitation of flexion do not, in the view of the Board, represent a degree of disability commensurate with that contemplated by a 20 percent evaluation for loss of motion. DeLuca, 8 Vet. App. 202, 206-08; 38 C.F.R. § 4.45. Further, as noted in the 2014 VA knee examination report discussed above, the Veteran has been able to fully extend the right knee; as such, a separate compensable rating under DC 5261 is also not warranted. For these reasons, a rating in excess of 10 percent for under DC 5003-5260 is not warranted, nor is a separate rating for limited extension of the right knee under DC 5261. As there is no basis for a rating in excess of 10 percent; therefore, the claim for a rating in excess of 10 percent must be denied as there is no doubt to be resolved in the Veteran’s favor. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7. Additionally, the Board finds that an initial rating in excess of 20 percent for right knee instability is not warranted. During the August 2014 VA examination, the Veteran was negative for patellar subluxation/dislocation; however, his right knee was positive for anterior, posterior, and medial-lateral instability, which the VA examiner opined was of “moderate” severity based on symptoms, e.g., pain, weakness, and stiffness and the Veteran’s use of a wheelchair and cane, as well as objective examination of his right knee joint. See Spellers, supra. The Board notes that a separate rating for knee scars is not warranted at any stage during this appeal. Notably, the August 2014 VA examiner observed no scars visible on the Veteran’s right knee, and the VA treatment records do not reflect that the Veteran has a visible right knee scar. A scar for which the Veteran is service-connected is related to a laceration of the leg three inches below the right patella and therefore does not involve the right knee. See Chronological Record of Medical Care entry dated November 20, 1974; Rating Decision dated December 14, 1976 at pg. 1. Based upon these findings, the Board concludes that there is no basis for a separate rating for surgical scars. 38 C.F.R. § 4.118. The Board recognizes the Veteran’s reports of continued right knee pain, as reflected in the outpatient treatment records and 2014 VA examination report discussed above. The Board considered this knee pain, as well as any additional limitations of motion due to pain (including difficulty with prolonged sitting, walking, climbing, kneeling, and bending). However, even considering additional limitation of motion or function of the right knee due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination (see 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), the evidence still does not show that the right knee disability more nearly approximates the criteria for higher ratings under DCs 5257 or 5260. Repetitive-use testing during the 2014 VA examination discussed above showed no decreased ROM and after repetitive use testing, and right knee flare-ups resulted in no additional loss of ROM. Moreover, there is no evidence of any right knee ankylosis, malunion of the right tibia and fibula, or genu recurvatum to support higher or separate ratings under DCs 5256, 5262, or 5263. The Board also considers whether a separate initial rating of 10 percent is warranted for the service-connected right knee disability, due to removal of symptomatic right knee semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. The Veteran’s treatment records reflect that he underwent a meniscectomy in August 2012 by a private orthopedic surgeon during which most of the medial meniscus was removed. See Operative Report dated August 27, 2012. By August 2014 when the Veteran underwent a VA examination, he was positive for frequent episodes of joint locking, joint effusion, and pain. While it appears that the Veteran’s symptoms may have fluctuated in severity throughout the pendency of the claim, he overall continued to endorse these symptoms, which he is capable of reporting as a lay person. See Layno v. Brown, 6 Vet. App. 465 (1994). Therefore, resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s right knee symptomatology warrants a separate 10 percent rating under DC 5259 for removal of symptomatic right knee semilunar cartilage for the entire period on appeal. No higher rating is provided for under DC 5259. 38 C.F.R. § 4.71a, DC 5259. The Board also considers whether the assignment of separate ratings under three different DCs 5257, 5259, and 5260 violates the rule against pyramiding. DC 5259 contemplates symptomatic residuals of surgical removal of damaged cartilage of the knee while DC 5257 pertains to knee instability and subluxation. DCs 5260/5003 for arthritis and limitation of motion contemplate painful limited motion of the knee in various directions. The evaluation of the same disability or the same manifestations under various diagnoses is prohibited. 38 C.F.R. § 4.14. However, in Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court held that separate ratings are not precluded for limitation of motion (DCs 5003, 5260 and 5261), meniscal disability (DCs 5258 and 5259) and instability (DC 5257). The Board also finds that the symptomatology contemplated by the three DCs is separate and distinct in this case. It is possible that DC 5259 and 5257 may consider similar disability manifestations. DC 5259 contemplates symptomatic residuals of removal of damaged cartilage of the knee joint. Similarly, DC 5257 relates to instability and subluxation of the joint, i.e., incomplete or partial dislocation. See Dorland’s Illus. Med. Dictionary at 1817 (31st Ed. 2007). Hence, rating the Veteran’s knees under both DCs would violate the rule against pyramiding detailed in 38 C.F.R. § 4.14 if the symptomatology contemplated by the DCs is not separate and distinct. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In this case, however, the Board finds that the DCs refer to sufficiently separate symptomatology. While the September 2014 rating decision reflects that the Veteran’s symptomatic residuals of semilunar cartilage removal are contemplated by the 20 percent evaluation under DC 5257 for right knee instability, actually DC 5257 considers only recurrent subluxation and instability. 38 C.F.R. § 4.71a, DC 5257. Looking to the plain meaning of the term “symptomatic” used in the rating criteria under DC 5259 suggests a broader application of the criteria since the term “symptomatic” means indicative, relating to, or constituting the aggregate of symptoms of disease. See Dorland’s Illus. Med. Dictionary at 1843 (31st Ed. 2007). A symptom is any morbid phenomenon or departure from the normal in a structure, function, or sensation, experienced by a patient and indicative of disease. Id. at 1742. Thus, the DC 5259 requirement of being “symptomatic” is broad enough to encompass all symptoms, including locking, pain, and joint effusion. As discussed above, the Veteran underwent a right knee meniscectomy in August 2012 during which most of the medial meniscus was removed, and the August 2014 VA knees examination reflects that the Veteran’s right knee was positive for frequent episodes of joint locking, frequent episodes of joint pain, and frequent episodes of joint effusion. See VA knee and lower leg conditions examination report dated August 22, 2014. While these symptoms are not contemplated by the rating criteria under DC 5257, they are contemplated by DC 5259 as explained herein. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for right knee instability under DC 5257, and a rating in excess of 10 percent for degenerative arthritis under DC 5260. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. However, the Board finds that a preponderance of the evidence warrants a separate maximum 10 percent rating for symptomatic residuals of surgical removal of damaged cartilage of the right knee joint under DC 5259 for the entire rating period on appeal. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). REASONS FOR REMAND In August 2020, the RO denied entitlement to a TDIU, noting that the Veteran did not meet the schedular criteria for TDIU and citing the Veteran’s failure to report for VA examinations. See Supplemental Statement of the Case dated August 21, 2020. However, with the rating decisions herein, the Veteran’s service-connected disabilities appear to meet the threshold for a schedular TDIU under 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.25, Table I (Combined Ratings). Upon review of the electronic claims file, it does not appear that the Veteran has been provided with a VA TDIU application form despite the Board recognizing in its June 2019 Remand an inferred claim for entitlement to a TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009). During the September 2018 Board hearing, the Veteran asserted that he is unable to work because of memory impairment and cognitive problems associated with his service-connected cerebral concussion disability. See Board hearing transcript dated September 26, 2018 at pgs. 5-7. The Veteran stated that he retired “approximately last year, 2017.” Id. at pg. 6. However, the record does not reflect precisely when the Veteran stopped working. Additionally, the Veteran has described completing a two year course in radiological technology and earning a bachelor’s degree, and employment in a number of fields, including health care, electronic assembly, office supplies, video-conferencing, sales, photography, and he stated that he operated a home for delinquent adolescents. Therefore, additional information and clarification regarding the Veteran’s employment and educational history are needed prior to adjudication of entitlement to a TDIU. Accordingly, on remand, the Veteran should be provided an Application for Increased Compensation based on Unemployability (VA Form 21-8940) with instructions to complete and return the application form, and the RO should then undertake all further appropriate actions for development of this claim. The matter is REMANDED for the following action: 1. Implement the Board’s decisions herein granting a separate 50 percent rating for a neurocognitive disorder due to TBI, and a separate 10 percent rating for symptomatic residuals of surgical removal of damaged cartilage of the right knee joint. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Provide the Veteran with a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability with instructions to complete and return the form to the RO. 4. After completing any additional development deemed necessary, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Farrell, Associate Attorney 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.