Citation Nr: 21061288 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 15-08 819 DATE: October 1, 2021 ORDER Entitlement to a rating of 10 percent, but no higher, from September 6, 2013, but no earlier, for left knee ligamentous strain and degenerative joint disease (DJD) on the basis of limitation of motion is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to a uniform rating of 20 percent, but no higher, from July 16, 2014, but no earlier, for left knee ligamentous strain and DJD on the basis of recurrent subluxation or lateral instability is granted, subject to the laws and regulations controlling the award of monetary benefits. REMANDED Entitlement to a total disability based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the entire initial rating period, the Veteran's left knee ligamentous strain and DJD did not more nearly approximate flexion limited to 45 degrees or extension limited to 10 degrees; even with consideration to functional impairment. 2. On September 6, 2013, within the one year look back period for the left knee increased disability claim, the Veteran reported increased left knee pain. 3. From July 16, 2014, the Veteran's left knee ligamentous strain and DJD more nearly approximated moderate recurrent subluxation or lateral instability; at no time did it more nearly approximate severe symptoms. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating, but no higher, from September 6, 2013, but no earlier, for left knee ligamentous strain and DJD on the basis of motion loss have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5260, 5261. 2. From July 16, 2014, the criteria for a uniform 20 percent, but no higher, increased rating for left knee ligamentous strain and DJD on the basis of recurrent subluxation or lateral instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1-4.7, 4.10, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1982 to December 2002. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board has previously remanded these issues in November 2018 and February 2021. The remand development has been completed to the extent possible, and the issues are ready for appellate review. There are reports that the Veteran left his longstanding job due to his service-connected left knee disability. See May 2017 VA Posttraumatic Stress Disorder (PTSD) examination report. The Board has added the issue of entitlement to TDIU to the appeal, as it has been raised as part and parcel of the increased rating claim on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Board remanded the issues in November 2018 and February 2021 to satisfy these obligations by obtaining additional VA orthopedic examinations and providing the Veteran an opportunity to submit additional evidence. The RO obtained updated VA treatment records and furnished appropriate VA-contract orthopedic examinations in October 2019 and March 2021. Both VA contract physician provided estimated left knee motion loss in terms of degrees during periods of flare-ups and repeated use over time. The agency of original jurisdiction (AOJ) then readjudicated the claims with consideration to the newly generated evidence in June 2021. Regarding the VA orthopedic examinations, the Board finds that the Veteran is not prejudiced by any inadequacy in determining functional impairment for the left knee or absence of retrospective medical opinion concerning functional impairment. See Shinseki v. Sanders, 556 U.S. 396, 409-10 (2009); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). The demonstrated left knee joint motion at issue is significantly greater than that contemplated by the compensable or next higher rating criteria, as applicable. The Veteran's left knee functional impairment reports concern increased pain and limited activity. His reports do not refer to left knee motion loss in a plane of motion to facilitate a higher rating award based on motion loss with consideration to functional impairment. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of 38 C.F.R. § 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."). A remand for an additional retrospective opinion or more information as to left knee functional impairment due to pain, flare-ups or repeated use over time would not overcome the large gap from the specified motion loss to more nearly approximate higher ratings. Id. Accordingly, the Board finds that the Veteran is not prejudiced by any inadequacy from VA left knee examinations in determining functional impairment and any deficiency is harmless error. Accordingly, this rating issue may be considered on the merits without prejudice to the Veteran. Shinseki, 556 U.S. at 409-10. Increased Ratings Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia, 28 Vet. App. at 169-170. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran is service-connected for left knee limitation of flexion under DCs 5003-5260 with a 10 percent rating from July 16, 2014. He is also service-connected for left knee limitation of extension under DCs 5003-5261 with a noncompensable rating from October 29, 2019, and left knee instability under DC 5257 with a noncompensable rating from January 1, 2003, 20 percent rating from July 16, 2014 and noncompensable rating from October 29, 2019. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. DC 5003 pertains to Arthritis, degenerative. It is rated by analogy under DC 5260 for limitation of flexion and under DC 5261 for limitation of extension. 38 C.F.R. § 4.71a, DC 5260. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020). These amendments revised select diagnostic codes (DCs) "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. In this case, the relevant DC amendments are DC 5257 for knee instability. The amended DC 5257 is more restrictive, and the Board will only consider the former version of DC 5257 as noted below. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Id.; 38 U.S.C. § 5110(g); 38 C.F.R. § 4.71a, DC 5257 (2020). The potentially applicable knee DCs include DC 5257, DC 5260, and DC 5261. DC 5257 provides ratings for recurrent knee subluxation or lateral instability. It provides a 10 percent rating for slight impairment of either knee, a 20 percent rating for moderate impairment, and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a, DC 5257. The terms "slight," "moderate," and "marked" are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. DC 5260, limitation of flexion of a leg, provides a 10 percent rating if flexion is limited to 45 degrees, and a 20 percent rating if flexion is limited to 30 degrees. A maximum 30 percent rating is warranted for knee flexion that is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. DC 5261, limitation of extension of a leg, provides a 10 percent rating when extension is limited to 10 degrees and a 20 percent rating when extension is limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees and a 40 percent rating for extension limited to 30 degrees. A maximum 50 percent rating applies when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Normal ROM of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Factual background September 2013 VA primary care records showed that the Veteran reported increased bilateral knee pain with the left knee greater than the right knee. He described it as a dull knee ache that worsened with prolonged standing or exertion. Physical examination revealed bilateral knee crepitus. The Veteran received an injection for the left knee. X-rays showed minimal DJD. July 2014 VA primary care records reported that the Veteran had ongoing left knee pain. He tried an injection and physical therapy (PT) without improvement. Physical examination showed a full range of motion (ROM) in all extremities. The clinician assessed left knee pain and recommended a computerized tomography (CT) scan and orthopedic referral. In October 2014, the Veteran had a VA left knee examination. The clinician diagnosed left knee ligamentous strain and medial knee joint compartment DJD. The Veteran reported significant left knee problems. He used a cane and had tried one injection. He also tried a brace and PT without relief. He planned to have a knee replacement after he lost weight. He also noted left knee weakness. He reported flare-ups of pain with activity. Left knee flexion was to 100 degrees with endpoint pain and extension was to 0 without pain. Repetitive use testing did not reveal additional motion loss. Functional loss included the following: less movement than normal; weakened movement; pain on movement; swelling; deformity, instability of station and disturbance of locomotion. Pain to palpation was found. Muscle strength testing showed 4/5 strength for both left knee flexion and extension. Stability testing was normal. Subluxation was moderate. No meniscal conditions were indicated. The clinician noted September 2013 X-ray report confirming minimal degenerative narrowing of the medial compartment left knee. Functional impairment was reported as slowness moving at work. In the November 2014 notice of disagreement (NOD), the Veteran reported that his left kneecap had rotated making it very difficult to bend the knee and putting significant pressure on his left leg. Walking was very painful because of overcompensation with the right leg and foot. He expressed concern that the VA examiner assumed both knees had the same problem and did not consider the left knee X-rays showing additional arthritis. January 2015 VA primary care records reflected that the Veteran had a follow up consultation for left knee DJD. The orthopedic clinic recommended weight loss before any surgery. The Veteran reported significant difficulty with ambulation. Physical examination showed a full ROM in all extremities with noted left knee degenerative changes. The clinician ordered a left knee brace and PT. April 2016 VA orthopedic clinic records reported chronic bilateral knee pain with no history of injury. Physical examination showed mild medial joint line tenderness, mild patellofemoral (PF) tenderness, and no effusion. Left knee ROM was 0-120 degrees with no signs of collateral or cruciate ligament laxity. A range of treatment modalities was discussed. The Veteran selected bilateral knee bracing and corticosteroid injection. In May 2017, the Veteran had another VA knee examination with a nurse practitioner (NP). The NP diagnosed ligamentous strain and medial knee joint compartment DJD. The Veteran reported his left knee disability had worsened. He continued to have pain despite losing weight and using a knee brace. He had partial pain relief with knee injections. Left knee flexion was to 90 degrees and left knee extension was to 0 degrees. Pain was noted for both flexion and extension. There was evidence of pain with weight-bearing and tenderness to soft tissues anterior and lateral aspects. No crepitus was found. Repetitive motion testing did not show additional motion loss. The clinician declined to comment on additional functional loss during periods of repeated use over time and flare-ups. Left knee muscle strength was complete. Muscle atrophy was not found. Left knee joint stability testing was normal. Meniscal conditions were not indicated. The Veteran reported using a brace and cane on a regular basis. Functional impairment was noted as the Veteran taking an August 2015 retirement from his job as a building manager. The Veteran reported that he could no longer keep up with his job duties in part due to his left knee condition. In October 2019, the Veteran had a VA-contract examination with a physician. The physician diagnosed left knee ligamentous strain with DJD, limitation of flexion, and instability. The Veteran reported a gradual onset of knee pain since active service. His knee pain had progressed over the years. He received an arthritis diagnosis as well as PT and injections. His symptoms had not improved, and he was under consideration for knee replacement surgery. He had knee pain on a daily basis with flare-ups. He described his flare-ups as increased pain and stiffness. It would last around 24 hours and caused him to limp. It occurred 1 to 2 times per week. He had mild flare-ups with prolonged standing, which happened almost daily. Cortisone injections and PT were ineffective. Flare-ups were described as increased pain and stiffness. Functional impairment was difficulty climbing stairs or ladders, difficulty bringing knee down and difficulty with prolonged sitting or standing. Left knee flexion was to 90 degrees and extension was to 0 degrees. Functional loss was reported as inability to kneel or bend down. Pain was found with flexion and extension. Moderate tenderness was found. Repetitive use testing did not reveal additional motion loss. The physician reported that during periods of repeated use over time and flare-ups left knee flexion would be to 70 degrees and extension would be to 5 degrees. Additional contributing factors of disability were swelling, instability of station, disturbance of locomotion, and interference with sitting and standing. The physician reported that the Veteran could not sit or stand for long periods. Swelling was found upon examination, and the Veteran had to use a table or wall to brace himself when he stood. Left knee muscle strength was complete and muscle atrophy was not indicated. Left knee joint stability testing was notable for 1+ medial instability. Meniscal conditions were not indicated. The Veteran used a cane on a regular basis due to left knee pain. Functional impact was reported as no prolonged standing, walking, squatting, kneeling, stooping and bending. The Veteran had to avoid prolonged sitting and was unable to use stairs or ladders. Pain was found with left knee use in non-weight bearing position. The physician reported that passive ROM either could not be performed or was not medically appropriate. He also stated that there was a worsening of the Veteran's disability but no change in diagnosis. He reported that the occupational impairment was the same as functional impairment. In March 2021, the Veteran had another VA-contract examination with a physician. The physician diagnosed left knee ligamentous strain with DJD, limitation of flexion, and limitation of extension. He stated that he did not have medical treatment for either knee. He denied sensing left knee instability but reported weakness. He denied flare-ups. He reported functional impairment as inability to kneel and to rise without assistance. Instability was indicated with these functional limitations. Effusion was reported with kneeling. Left knee flexion was to 105 degrees and extension was to 0 degrees. Pain was noted with flexion and extension. Pain was reported with weight-bearing, active motion and caused functional loss. The physician reported that pain prevented the Veteran from fully challenging the ROM of the left knee joint. Mild patella tenderness was found. Repetitive use testing did not show additional motion loss. Functional loss during repeated use over time was reported as pain and weakness. During repeated use over time and flare-ups, left knee flexion was estimated to 100 degrees and extension was estimated to 0 degrees. Muscle atrophy was not indicated. Recurrent subluxation or persistent instability was not indicated. Meniscal disorder or surgical history was not indicated. Functional impact was reported as inability to stand or walk with weight bearing. Chair use was needed as an accomodation. The physician commented that the Veteran denied sensing instability but rather left knee weakness. His examination was unremarkable for instability. Analysis Below, the Board will separately analyze the relevant knee rating criteria based upon limitation of motion (DCs 5260, 5261) and instability (DC 5257). (a) Limitation of motion For the following reasons, the Board finds that a 10 percent rating, but no higher, from September 6, 2013, but no earlier, is warranted for the service-connected left knee disability based upon limitation of motion. The Veteran currently has a 10 percent rating from July 16, 2014 for left knee pain with noncompensable motion loss. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011). In order to receive a single rating in excess of 10 percent for motion loss, knee motion loss must more nearly approximate the 20 percent rating criteria in either flexion or extension leg plane. 38 C.F.R. § 4.14. This is because the currently assigned 10 percent rating for noncompensable motion loss contemplates knee pain without compensable motion loss and would be incorporated into any 10 percent rating for compensable motion loss. Id. However, the Veteran may demonstrate compensable motion loss in both the flexion and extension leg planes to warrant separate compensable ratings without pyramiding symptoms. VAOPGCPREC 9-2004. The Board has considered that the VA and VA-contract examination reports were deemed inadequate in prior remands because of the clinicians' assessment of functional loss in terms of degrees during flare-ups and repeated use over time as well as motion loss with passive motion and pain with weight bearing. Then, the March 2021 VA-contract physician did not provide retrospective opinions about functional impairment. Nonetheless, the reports from the Veteran and observed joint motion studies found in these VA examination reports may be considered with the limitation that functional impairment due to pain during flare-ups or repeated use over time is not adequately stated in these reports. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("even if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight"; "it may be given some weight based upon the amount of information and analysis it contains"). The clinically observed ROM showed that left knee flexion was to 90 degrees, at worst and extension was to 0 degrees, at worst. For separate compensable ratings, the Veteran would have to demonstrate flexion motion loss more nearly approximating 45 degrees, in addition to extension motion loss more nearly approximating 10 degrees. Thus, the available ROM studies show that left knee flexion and extension are appreciably greater than the compensable leg flexion and extension motion loss rating criteria under DCs 5260 and 5261. 38 C.F.R. §§ 4.71a, DCs 5260, 5261. However, the Board must consider functional impairment from flare-ups and repetitive use over time. English v. Wilkie, 30 Vet. App. 347 (2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups); 38 C.F.R. § §§ 4.40, 4.45, 4.59. The Veteran is competent to describe knee functional impairment. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds his reports about general functional impairment credible since joint pain is closely associated with service-connected left knee DJD. The precise amount of additional left knee motion loss during periods of repetitive use or flare-ups is unclear. The observed left knee flexion and extension must be considered as a baseline to ascertain whether additional knee motion loss during flare-ups or repeated use over time more nearly approximates the compensable criteria for knee flexion or extension motion loss. Thompson, 815 F.3d at 785 ("[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."). The Veteran's reports primarily consist of limiting his activities due to increased left knee pain and difficulty with squatting, bending, climbing stairs, among other similar movements. At the October 2019 VA-contract examination, the Veteran also referred to stiffness. The October 2019 VA-contract physician estimated that during repeated use over time or flare-ups periods would result in left knee motion loss with flexion to 70 degrees and extension to 5 degrees. The observed left knee ROM must be considered as a baseline with consideration to the estimated motion loss during flare-ups and repeated use over time from the VA contract physician as well as the Veteran's descriptions. The VA contract physician's description is probative because it was given by an examining medical professional. The Veteran's descriptions of increased left knee pain with activity is too vague to infer additional compensable motion loss from flare-ups or repeated use over time when considered with the above examination findings as a baseline and the October 2019 VA-contract physician's estimates. Id.; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 5260, 5261. Therefore, even considering estimated motion loss from functional impairment, a rating in excess of 10 percent or separate compensable ratings for left knee flexion and extension motion loss is not warranted at any time during claims period. However, the Board finds that the 10 percent rating for left knee motion loss should be effective September 6, 2013. Again, this issue originates from an increased rating claim filed on July 16, 2014 and the rating period includes the one year look back period. 38 C.F.R. § 3.400(o). VA treatment records from September 6, 2013 showed that the Veteran complained about increased left knee pain. The Board considers this report to be evidence of an increase in left knee disability within the one year look back period. His report by itself is sufficient to warrant a 10 percent rating for left knee disability based joint pain without compensable motion loss. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011); see also Sowers v. McDonald, 27 Vet. App. 472, 480 (2016); Petitti v. McDonald, 27 Vet. App. 415, 428-29 (2015) (a compensable rating is warranted for joint pain pursuant to 38 C.F.R. § 4.59 for orthopedic disabilities rated under diagnostic codes containing a 10 percent rating, and the criteria for such a rating can be satisfied with lay and other non-medical evidence). For the foregoing reasons, the Board finds that a 10 percent rating, but no higher, from September 6, 2013, the first report of increase within the one year look back period for increased rating claims, is warranted. A rating in excess of 10 percent is not warranted at any time, and the benefit of the doubt doctrine is thus not for application in this regard. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. (b) Instability The Veteran's service-connected left knee ligamentous strain and DJD with instability is currently rated as noncompensable from January 1, 2003, 20 percent disabling from July 16, 2014, and noncompensable from October 29, 2019. For the following reasons, the Board finds that a 20 percent rating for moderate left knee recurrent subluxation or lateral instability is warranted from October 29, 2019, but higher ratings or an earlier effective date for a 20 percent rating is not warranted. Joint stability testing from the October 2019 VA-contract examination was positive, and the October 2019 VA-contract physician commented that the disability was worsening. Although the March 2021 VA-contract physician did not find evidence of instability, the Veteran reported that the symptoms previously assessed as instability were actually weakness. The Board finds that March 2021 VA-contract report to be an outlier compared with prior October 2014, May 2017 and October 2019 VA and VA-contract examination report indicating the presence of left knee instability or subluxation. The Board also notes that the weakness reported by the Veteran could reasonably be construed as producing symptoms mimicking instability or subluxation. The Board has considered whether an effective date within the one year look back period from July 16, 2014 is warranted. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015); 38 C.F.R. § 3.400(o). Prior to July 16, 2014, there are September 2013 VA treatment records noting increased left knee pain. However, the Veteran described the increased symptoms as a dull ache, rather than any increase or new onset of instability or subluxation. There is no other evidence suggesting an increase in left knee subluxation or instability, and an effective date prior to the July 16, 2014 claim is not warranted for left knee instability. Id. The Board has also considered whether a rating in excess of 20 percent under DC 5257 is warranted at any time. The joint stability test findings from the VA and VA-contract examination reports from October 2014, May 2017, October 2019 and March 2021 do not indicate left knee instability or subluxation symptoms more closely approximating severe. The October 2014 VA clinician specifically characterized the Veteran's subluxation as moderate. The Veteran's reports about knee instability or subluxation have been considered. English, supra. His reports are generalized. He does not otherwise assert a greater severity of impairment beyond moderate or specific impairment attributable to instability and subluxation, rather than DJD. The Board construes this background to be suggestive of moderate, rather than severe, left knee instability or subluxation. In sum, the examination reports and lay statements, considered together, weigh against severe impairment from left knee instability or subluxation. For the foregoing reasons, a uniform 20 percent rating, but no higher, for left knee instability or subluxation from July 16, 2014 is warranted. As the preponderance of the evidence is against a rating in excess of 20 percent for left knee instability or subluxation, the benefit of the doubt doctrine is not for application and this portion of the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. REASONS FOR REMAND Entitlement to a TDIU is remanded. The issue of entitlement to a TDIU is raised as part of the increased rating claim for a left knee disability. The evidence indicates that the Veteran left work in 2015 due to medical disability. In his May 2017 VA knee examination, the Veteran identified the left knee disability as one of several disabilities causing him to leave his longstanding job as a building manager. Then, in his May 2017 VA PTSD examination, the Veteran stated that the service-connected left knee disability was a substantial factor as why he stopped working. The Veteran has not submitted a formal TDIU claim and he should be given an opportunity to do so to obtain more information about his occupational status during the claims period and fully develop his claim. This matter is REMANDED for the following action: Furnish and instruct the Veteran to complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability with his occupational history since July 2014. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. D. Simpson, 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.