Citation Nr: 21065227 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 10-01 491 DATE: October 25, 2021 ORDER Entitlement to a 20 percent rating, but no higher, for left knee instability under Diagnostic Code 5257, from March 1, 2013, is granted. Entitlement to a rating in excess of 30 percent for left knee limitation of flexion due to degenerative arthritis under Diagnostic Code 5260, from March 1, 2013, to October 1, 2020, is denied. Entitlement to a 10 percent rating, but no higher, for left knee limitation of flexion due to degenerative arthritis under Diagnostic Code 5260 from October 1, 2020, is granted. Entitlement to a separate 10 percent rating, but no higher, for left knee limitation of flexion due to degenerative arthritis under Diagnostic Code 5261, from March 1, 2013, is granted. Entitlement to a rating in excess of 20 percent for symptomatic removal of left knee semilunar cartilage under Diagnostic Code 5258, from March 1, 2013, is denied. Entitlement to a referral of the claims for increased ratings for the left knee disorders to the Director, Compensation System for extraschedular consideration is denied. Entitlement to a total disability rating due to individual unemployability (TDIU) as a result of service-connected disabilities is denied. FINDINGS OF FACT 1. From March 1, 2013, the preponderance of the evidence shows that the Veteran's left knee instability is manifested by moderate recurrent subluxation or lateral instability, but not severe recurrent subluxation or lateral instability. 2. From February 7, 2021, while the Veteran is prescribed both an assistive device and brace for ambulation the preponderance of the evidence shows that his left knee instability is neither due to and unrepaired or failed repair of complete ligament tear causing persistent instability or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair. 3. From March 1, 2013, to October 1, 2020, the Veteran's left knee limitation of flexion due to degenerative arthritis received the maximum rating possible under Diagnostic Code 5260 for lost flexion. 4. From October 1, 2020, the preponderance of the evidence shows that the Veteran's left knee limitation of flexion due to degenerative arthritis is manifested by painful motion but not flexion limited to at least 30 degrees even when considering his complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. 5. From March 1, 2013, the preponderance of the evidence shows that the Veteran's left knee limitation of extension due to degenerative arthritis is manifested by flexion limited to 10 degrees but not 15 degrees even when considering his complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. 6. From March 1, 2013, preponderance of the evidence shows that none of the Veteran's left knee disorders are manifested by adverse symptomatology that equates to ankylosis even when considering his complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. 7. From March 1, 2013, the Veteran already receives the maximum 20 percent rating possible under Diagnostic Code 5258 for symptomatic removal of left knee semilunar cartilage. 8. From March 1, 2013, the schedular criteria adequately describes the severity and symptoms of the Veteran's left knee disabilities and doesn't present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 9. The Veteran does not meet the schedular requirements of 38 C.F.R. § 4.16(a) and the preponderance of the evidence shows that he does not meet the criteria for referral of his claim to the Under Secretary for Benefits or the Director, Compensation Services for extraschedular consideration under 38 C.F.R. § 4.16(b) at any time during the appeal. CONCLUSIONS OF LAW 1. From March 1, 2013, the criteria for a 20 percent rating, but not higher, for left knee instability under Diagnostic Code 5257 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Code 5261; 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). 2. From March 1, 2013, to October 1, 2020, the criteria for a rating in excess of 30 percent for left knee limitation of flexion due to degenerative arthritis under Diagnostic Code 5260 as well as any other Diagnostic Code have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Codes 5003, 5256, 5259, 5260, 5261, 5262, and 5263. 3. From October 1, 2020, the criteria for a 10 percent rating, but no higher, for left knee limitation of flexion due to degenerative arthritis under Diagnostic Code 5260 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Codes 5003, 5256, 5259, 5260, 5261, 5262, and 5263. 4. From March 1, 2013, the criteria for a separate 10 percent rating, but no higher, for left knee limitation of extension due to degenerative arthritis under Diagnostic Code 5261 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Codes 5261. 5. From March 1, 2013, the criteria for a rating in excess of 20 percent for symptomatic removal of left knee semilunar cartilage under Diagnostic Code 5258 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Code 5258. 6. From March 1, 2013, the criteria for a referral of the claims for increased ratings for the left knee disorders to the Director, Compensation System for extraschedular consideration have not been met. 38 C.F.R. § 3.321(b)(1). 7. The criteria for TDIU have not been met at any time during the appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army National Guard and had a period of initial active duty for training from August 1990 to November 1990. He also had verified Army National Guard service from February 1996 to March 1996, during which he sustained a disability for which service connection has been granted. That period of service is therefore deemed active duty. The Veteran had additional periods of verified and unverified active and inactive duty for training until he separated from the Army National Guard in April 1998. In April 2014, now Chairmen Cheryl L. Mason issued a Board of Veterans' Appeal (Board) decision that granted the Veteran a separate 10 percent rating for left knee degenerative arthritis and a separate 10 percent rating for symptomatic removal of left knee semilunar cartilage as well as denied a rating in excess of 10 percent for left knee instability. The Veteran appealed the April 2014 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2014 order, which incorporated the parties Joint Motion for Partial Remand (JMPR) the Court vacating and remanded the April 2014 Board decision to the extent that it denied grant higher ratings for the Veteran's left knee disorders because the decision did not consider the Veteran was entitled to an extraschedular evaluation for his left knee disorders pursuant to 38 C.F.R. § 3.321(b) and because it did not consider a claim for a TDIU which (the parties believe) was raised under Rice v. Shinseki, 22 Vet. App. 447 (2009). In August 2015, a Veterans' Law Judge not the undersigned remanded the appeal for additional development. In March 2017, a Veterans' Law Judge not the undersigned issued a decision that granted the Veteran a 20 percent rating for symptomatic removal of left knee semilunar cartilage under Diagnostic Code 5258, from January 29, 2009, to December 14, 2012, denied a rating in excess of 10 percent for left knee instability under Diagnostic Code 5257, from January 29, 2009, to December 14, 2012, denied a rating in excess of 10 percent for left knee limitation of flexion due to degenerative arthritis under Diagnostic Code 5260 from January 29, 2009, to December 14, 2012, and denied the claim to refer the Veteran's left knee disorder rating claim to the Director of Compensation Service for an extraschedular rating under 38 C.F.R. § 3.321(b). In March 2017, the Board also Remanded the remaining claims for a rating in excess of 10 percent for symptomatic removal of left knee semilunar cartilage under Diagnostic Code 5258, from March 1, 2013, for a rating in excess of 10 percent for left knee instability under Diagnostic Code 5257, from March 1, 2013, for a rating in excess of 30 percent for left knee limitation of flexion due to degenerative arthritis under Diagnostic Code 5260 from March 1, 2013, and the claim for a TDIU. In September 2017, a Veterans' Law Judge not the undersigned again remanded the appeal for additional development. In a May 2018 rating decision, the RO granted the Veteran's symptomatic removal of left knee semilunar cartilage a 20 percent rating under Diagnostic Code 5258, from March 1, 2013. In August 2018, a Veterans' Law Judge not the undersigned again remanded the appeal for additional development. A July 2020 rating decision reduced the rating for the Veteran's left knee degenerative arthritis from 30 percent disabling to 0 percent disabling effective October 1, 2020, because of clear and unmistakable error in the August 2016 rating decision that granted the 30 percent rating. In July 2020 and March 2021, Veterans' Law Judges not the undersigned again remanded the appeal for additional development. A June 2021 rating decision granted the Veteran's left knee instability a 20 percent rating effective from May 14, 2021. The evaluation of knee disabilities using the most recent decisions of the Court is intricate. It is important for the Veteran to understand that the law changed during the appeal period. The Board apologies for the delays in the full adjudication of this case. The Board believes that a further remand of this case, in light of the delays in the case, must be avoided if possible. Characterization of the issues on appeal Initially, the Board notes that rating knee disorders are inherently complex, and this complexity was made even worse in the current appeal given the multiple remand to provide the Veteran with VA examinations to obtain needed medical opinions that considered case law such as Correia v. McDonald, 28 Vet. App. 158 (2016), Sharp v. Shulkin, 29 Vet. App. 26 (2017), and Chavis v. McDonough, No. 18-2928 (2021) as well as the recent changes to the Diagnostic Codes for rating musculoskeletal disabilities which were not even in existence at the time of the initial Board decision. In fact, none of the Court cases cited above existed when the Chairman (the leader of our organization) herself adjudicated this case in 2014. The Court decisions were applied retroactively, leading to Board remands and delay. Next, given the long and complicated procedural history outline above, before adjudicating the appeal the Board will first explain the above characterization of the issues being appeal. First, and as noted above, the final March 2017 Board decision already adjudicated the issues of the appropriate schedular rating as well as whether the criteria for referral for an extraschedular rating were met for all of the Veteran's left knee disorder from January 29, 2009, to December 14, 2012. Moreover, because the record shows that the Veteran was assigned a temporary 100 percent evaluation for his left knee disorders under 38 C.F.R. § 4.30 at all times from December 14, 2012, to March 1, 2013, the final March 2017 Board decision characterized the remaining left knee rating claims as only including he post-March 1, 2013, time period. Therefore, the Board finds that the scope of the current decision as to the claims for increased ratings for the left knee disorders is limited to the post-March 1, 2013, time period. See 38 U.S.C. § 7104; Also see AB v. Brown, 6 Vet. App. 35 (1993) (in an appeal in which the veteran expresses general disagreement with the assignment of a particular rating and requests an increase, the RO and the Board are required to construe the appeal as an appeal for the maximum benefit allowable by law or regulation); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Second, given the May 2018 rating decision that granted the Veteran's symptomatic removal of left knee semilunar cartilage a 20 percent rating under Diagnostic Code 5258, from March 1, 2013, the Board finds that this issue is as characterized above. See Fenderson, supra; Also see AB, supra. Third, because a July 2020 rating decision reduced the rating for the Veteran's left knee degenerative arthritis from 30 percent disabling to 0 percent disabling effective October 1, 2020, the Board has characterized this issue as it appears above. Id. Fourth, because a June 2021 rating decision granted the Veteran's left knee instability a 20 percent rating effective from May 14, 2021, even though the appeal has been pending since before that time, the Board has characterized this issue as it appears above. Id. The Concerns Raised by the JMPR and Post-Remand Development Initially, the Board finds that the post-Remand development substantially complied with the JMPR and Remands including addressing the Court's concerns in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board has reached this conclusion because the below decision will consider if the Veteran is entitled to an extraschedular evaluation for his left knee disorders pursuant to 38 C.F.R. § 3.321(b) as well as if he meets the criteria for a TDIU. The Board has also reached this conclusion because it finds that the opinions obtained at the July 2018, January 2021, and/or June 2021 VA examinations/addendums provide all needed information to rate his left knee disorders under all applicable rating criteria including range of motion studies that considered the Veteran's complaints of pain, provided the knee's range of motion during flare-ups as well as with and without weight bearing and resistance in passive and active range of motion and considered instability. See 38 U.S.C. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The Board also finds that the post-Remand development substantially complied with the Remands because while the appeal was at the regional office (RO) it obtained and associated with the record all identified and available VA and private treatment records. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request is required). Therefore, the Board finds that further delay by remanding these issues to provide the Veteran with a new VA examination or to obtain additional records is not required. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Rating Claims The Veteran contends that his left knee disorders are more severely disabling than represented by the ratings assigned at all times during the appeal. In this regard, disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by a Diagnostic Code. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Veteran's left knee instability is rated as 10 percent disabling March 1, 2013, and 20 percent rating disabling from May 14, 2021, under 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Veteran's left knee degenerative arthritis is rated as 30 percent disabling from March 1, 2013, and 0 percent disabling from October 1, 2020, under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5260. (Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen.) The Veteran's symptomatic removal of left knee semilunar cartilage is rated as 20 percent disabling from March 1, 2013, under 38 C.F.R. § 4.71a, Diagnostic Code 5258. i. The Recent Amendments to the Musculoskeletal Rating Criteria Initially, the Board notes that during the pendency of the appeal VA amended some of its' criteria for rating musculoskeletal disabilities effective February 7, 2021. See 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board cannot apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003 ). In this case, the regulation does not provide for retroactive application. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). Moreover, the Board finds that none of the amendments change how this Veteran's left knee disabilities are rated. The Board has reached this conclusion because the specific rating criteria were not amended or because the Veteran's disabilities are not ratable under the amended criteria. Therefore, the Board finds that a Remand to provide the Veteran with notice of these new rating criteria and have the claims adjudicating applying them is not required. See Sabonis, supra. ii. The Old and New Rating Criteria Under 38 C.F.R. § 4.71a, Diagnostic Code 5003 degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent is assigned for each such major joint or group of minor joints, with occasional incapacitating exacerbations, affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Under 38 C.F.R. § 4.71a, Diagnostic Code 5256, ankylosis at a favorable angle in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent rating; ankylosis with flexion between 10 degrees and 20 degrees warrants a 40 rating; ankylosis with flexion between 20 degrees and 45 degrees warrants a 50 rating; and extremely unfavorable ankylosis (flexion at an angle of 45 degrees or more) warrants a 60 percent rating. Under old 38 C.F.R. § 4.71a, Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling. And, severe recurrent subluxation or lateral instability, warrants a 30 percent rating. The terms "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Effective February 7, 2021, VA amended Diagnostic Code 5257. For recurrent subluxation or lateral instability, a 10 percent rating is assigned for a sprain, incomplete ligament tear or complete ligament tear causing persistent instability without prescribed assistive device or bracing for ambulation. A 20 percent rating is warranted when a) a sprain, incomplete ligament tear, or repaired complete ligament tear causes persistent instability; or b) an unrepaired or failed repair of a complete ligament tear causes peristent instability. A prescribed assistive device or bracing for ambulation is required. A 30 percent rating requires unrepaired or failed repair of complete ligament tear causing persistent instability and a prescription for both an assistive device and bracing for ambulation. For patellar instability also rated under Diagnostic Code 5257, a 10 percent rating is assigned for a diagnosed condition that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted when there is a diagnosed condition with a prescription for either a brace, cane, or walker. A 30 percent rating requires a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription for brace and either a cane or a walker. Id. NOTE 1 following the criteria provides, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. NOTE 2 following the criteria provides a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, removal of the semilunar cartilage when symptomatic warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. If extension of the knee is limited to 30 degrees a 40 percent rating is in order. If extension of the knee is limited to 45 degrees a 50 percent rating is in order. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Under old 38 C.F.R. § 4.71a, Diagnostic Code 5262, impairment of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating; with moderate knee or ankle disability warrants a 20 percent rating; with marked knee or ankle disability warrants a 30 percent rating; and with nonunion (loose motion requiring brace) warrants a 40 percent rating. Effective February 7, 2021, VA amended Diagnostic Code 5262. Medial tibial stress syndrome (MTSS), or shin splints is rated as 0 percent disabling with treatment less than 12 consecutive months, one or both lower extremities; 10 percent disabling when requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities; 20 percent disabling when requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity; and 30 percent disabling when requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. Tibia and fibula are rated as 40 disabling with nonunion with loose motion, requiring brace. Tibia and fibula with malunion are evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. Prior to February 7, 2021, the Board will apply the prior rating criteria. From February 7, 2021 onward, the Board applies the criteria that is more favorable to the Veteran. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2016); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell 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, 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. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 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. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Moreover, the United States Court of Appeals for Veterans Claims (Court) in Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016) held that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. Furthermore, in Jones Shinseki, 26 Vet. App. 56, 61-63 (2012) the Court held that the Board may not deny entitlement to an increased rating on the basis of relief provided by medication when those effects are specifically contemplated by the rating criteria. Lastly, in Chavis v. McDonough, No. 18-2928 (2021) the Court held that ankylosis of the spine may be shown based on symptoms of fixation of the joint equivalent to ankylosis. In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), that Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In this regard, VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disorder includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disorder includes both arthritis and instability, provided of course, that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-97 (July 1, 1997). iii. Correia, and Sharp Compliance Next, in adjudicating below whether the Veteran meets the criteria for higher evaluations for his left knee disorders, the Board has not overlooked the Court's holdings in Correia, supra, and Sharp, supra. Tellingly, the Board finds that the record is adequate to address the concerns raised by the Court in both these cases because at the January 2021 VA examination the Veteran reported that he did not have flare-ups and the examiner considered his complaints of pain with and without weight bearing and resistance in passive and active range of motion and the June 2021 VA examiner specifically considered the range of motion of the left knee considering the Veteran's complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. Therefore, the Board finds that further delay by remanding this issue to provide the Veteran with a new VA examination is not required. See Sabonis, supra. iv. The Merits of the Left Knee Rating Claims a. Left knee instability i. Left knee instability rated as 10 percent disabling from March 1, 2013, to May 14, 2021, under old Diagnostic Code 5257 As to higher rating for the Veteran's left knee instability under old Diagnostic Code 5257, rated as 10 percent disabling March 1, 2013, to May 14, 2021, the Board notes that the Court has held that, "it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date." See Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010) (discussing assignment of an effective date for a reduction in disability rating under Diagnostic Code 7528); see also Young v. McDonald, 766 F.3d 1348, 1352-53 (Fed. Cir. 2014) (holding that a medical opinion can diagnose the presence of the condition and identify an earlier onset date based on preexisting symptoms). Therefore, the Board finds that the most probative evidence of record includes the July 2018 VA examination report and an addendum to the June 2021 VA examination, also dated in June 2021, in which it was opined that the Veteran's left knee disorder was manifested by moderate lateral instability. See Owens, supra; Tatum, supra; Young, supra. Accordingly, the Board finds that the Veteran's symptoms met the criteria for at least a 20 percent rating at all times from March 1, 2013, under Diagnostic Codes 5257 because his disability is manifested by adverse symptomatology that equates to at least moderate instability or subluxation since that time. 38 C.F.R. § 4.71a; Also see Hart, supra; Fenderson, supra; Tatum, supra; Young, supra. ii. Left knee instability rated as 20 percent disabling from March 1, 2013, under old Diagnostic Code 5257 As to a rating in excess of 20 percent for left knee instability under old Diagnostic Code 5257 from March 1, 2013, the Board notes that that, at its' worst, the Veteran's VA examiners characterized his instability, if any, as moderate and these medical opinions are not contradicted by any other medical evidence of record. See, e.g., private BDQ examination dated in July 2013; VA examinations dated in May 2016, March 2017, July 2018, and June 2021; addendums to the June 2021 VA examination, also dated in June 2021; Also see Colvin, supra. Moreover, the Board notes that while treatment records document the Veteran's complaints and treatment for left knee problems, nothing in these records contradicts the above examiners findings. See Colvin, supra. Therefore, the Board finds that the most probative evidence of record are the VA examiners findings that the Veteran's left knee is not manifested by more than moderate instability at any time from March 1, 2013, because they are supported by the other evidence of record as well as by the findings at the examinations. See Owens, supra. Accordingly, the Board finds that the criteria for a rating in excess of 20 percent ratings for left knee instability are not met at all times from March 1, 2013, under old Diagnostic Code 5257. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Fenderson, supra; Hart, supra. iii. Left knee instability rated as 20 percent disabling from February 7, 2021, under new Diagnostic Code 5257 As to a rating in excess of 20 percent for left knee instability under new Diagnostic Code 5257 from February 7, 2021, the Board notes that in addendums to the June 2021 VA examination, also dated in June 2021, it was opined that the Veteran had prescriptions for an assistive device and bracing for ambulation. The June 2021 addendums also opined that the Veteran had moderate left knee instability. However, June 2021 VA examiner also opined that the Veteran did have a recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or any other tibial or fibular impairment. It was also noted that the Veteran's only meniscal condition is a meniscal tear with continues with joint pain and locking of knee with walking. The examiner also noted that the Veteran was status post multiple meniscectomies with the first in 19890. The examiner thereafter noted that the Veteran provided him a May 2021 letter from a Dr. Douglas Shoenberger in which it was reported that the Veteran is under his care for left knee pain and left knee instability from an anterior cruciate ligament tear and is pending total knee replacement surgery. Lastly, the VA examiner noted that a June 2020 left knee magnetic resonance imaging evaluation (MRI) showed an anterior cruciate ligament graft with a thin appearance but low T2 signal and no finding suggestive four thickness graft retail as well as no evidence of municipal tear and mild joint effusion. The June 2021 VA examiner's medical opinions are not contradicted by any other medical evidence of record. See Colvin, supra. Likewise, the Veteran's treatment records are negative for adverse symptomatology worse than what was reported by the June 2021 VA examiner. Id. Furthermore, the Board finds that the Veteran is not qualified to say he had left knee instability is neither due to and unrepaired or failed repair of complete ligament tear causing persistent instability or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair because these are medical findings. See Davidson, supra. Therefore, the Board finds that the preponderance of the evidence shows that the Veteran's left knee instability is neither due to and unrepaired or failed repair of complete ligament tear causing persistent instability or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair. See Owens, supra. Accordingly, the Board finds that the criteria for a rating in excess of 20 percent ratings for left knee instability are not met at all times February 7, 2021, under new Diagnostic Code 5257. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Fenderson, supra; Hart, supra. b. Left knee degenerative arthritis i. Left knee degenerative arthritis rated as 30 percent disabling from March 1, 2013, to October 1, 2020, under Diagnostic Code 5260 As to higher rating for the Veteran's left knee degenerative arthritis at any time from March 1, 2013, to October 1, 2020, under Diagnostic Code 5260, the Board notes that the disability rating already assigned the Veteran's service-connected left knee disorder meets the maximum rating possible under this code sections. See 38 C.F.R. § 4.71a. Therefore, the Board finds that an increased rating under Diagnostic Code 5260 is not warranted at any time from March 1, 2013, to October 1, 2020. See 38 C.F.R. § 4.71a; Hart, supra; Fenderson, supra. ii. Left knee degenerative arthritis rated as rated as 0 percent disabling from October 1, 2020, under Diagnostic Code 5260 As to a compensable rating for the Veteran's left knee degenerative arthritis at any time from October 1, 2020, under Diagnostic Code 5260, the Veteran has reported problems with left knee flexion pain and the Board find's these reports both competent and credible because it is something he can feel and it is consistent with the nature of his service-connected disability. See Davidson, supra. Likewise, the Board notes that left knee flexion pain with motion was objective confirmed by the Veteran's VA examiners. See VA examinations dated in January 2021 and June 2021. Therefore, considering 38 C.F.R. §§ 4.40, 4.45, 4.59 and the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, as well as when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), the Board finds that the Veteran's symptoms met the criteria for at least 10 percent ratings at all times from October 1, 2020, under Diagnostic Code 5260. 38 C.F.R. § 4.71a; Also see Hart, supra; Fenderson, supra. iii. Left knee degenerative arthritis rated as rated as 10 percent disabling from October 1, 2020, under Diagnostic Code 5260 As to a rating in excess of 10 percent for the Veteran's left knee degenerative arthritis at any time from October 1, 2020, under Diagnostic Code 5260, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), his functional losses do not equate to the criteria required for at least a 20 percent rating because flexion of the left knee is not limited to at least 30 degrees because it was 120 degrees at the January 2021 VA examination and 70 degrees at the June 2021 VA examination. Moreover, while the Veteran's treatment records document his complaints and treatment for left knee problems, the Board finds that above VA examiners ranges of motion are not contradicted by any other medical evidence of record because treatment records never document less flexion in the left knee. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra, Colvin, supra. iv. Entitlement to a higher or a separate compensable rating for lost extension due to left knee degenerative arthritis from March 1, 2013, under Diagnostic Code 5261 As to a higher rating and/or a separate compensable rating for lost extension due to left knee degenerative arthritis from March 1, 2013, under Diagnostic Code 5261 and VAOPGCPREC 9-2004, as noted above, the Court has held that, "it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date." See Tatum, supra; Young, supra. Therefore, when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), the Board finds that the most probative evidence of record are the findings by the January 2021 and June 2021 VA examiners that the appellant's left knee extension was limited to 10 degrees. See Owens, supra; Tatum, supra; Young, supra. Accordingly, the Board finds that the Veteran's symptoms met the criteria for at least a separate 10 percent rating at all times from March 1, 2013, under Diagnostic Codes 5261 See 38 C.F.R. § 4.71a; Also see Hart, supra; Fenderson, supra; Tatum, supra; Young, supra. v. Entitlement to a separate rating in excess of 10 percent for lost extension due to left knee degenerative arthritis from March 1, 2013, under Diagnostic Code 5261 As to a separate rating in excess of 10 percent for lost extension due to left knee degenerative arthritis from March 1, 2013, under Diagnostic Code 5261, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), his functional losses do not equate to the criteria required for a 20 percent rating. See Owens, supra. The Board has reached this conclusion because extension of the left knee is not limited to the 15 degrees required for a higher at all times from March 1, 2013, because at its' worst it was only limited to 10 degrees. Specifically, left knee extension was 0 degrees at the July 2013 DBQ examination; 0 degrees at the May 2016 examination; 0 degrees at the March 2017 VA examination; 0 degrees at the July 2018 VA examination; 10 degrees at the January 2021 VA examination; and 10 degrees at the June 2021 VA examination. Moreover, while the Veteran's treatment records document his complaints and treatment for left knee problems, the Board finds that above VA examiners ranges of motion are not contradicted by any other medical evidence of record because treatment records never document less extension in the left knee. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra, Colvin, supra. c. Left knee removal of semilunar cartilage rated as 20 percent disabling from March 1, 2013, under Diagnostic Code 5258 As to higher rating for the Veteran's symptomatic removal of left knee semilunar cartilage from March 1, 2013, under Diagnostic Code 5258, the Board notes that the disability rating already assigned the Veteran's service-connected left knee disorder meets the maximum rating possible under this code sections. See 38 C.F.R. § 4.71a. Therefore, the Board finds that increased rating under Diagnostic Code 5258 is not warranted at any time from March 1, 2013. See 38 C.F.R. § 4.71a; Hart, supra; Fenderson, supra. d. Other potentially applicable diagnostic codes for rating the left knee disorders from March 1, 2013 As to a higher evaluation for any of the Veteran's left knee disorders from March 1, 2013, under Diagnostic Code 5256 due ankylosis, the Board finds that even when considering the Veteran's reports of pain as per 38 C.F.R. §§ 4.40, 4.45, 4.59 and the Court's holding in Correia, Sharp, Mitchell, Burton, Southall-Norman, DeLuca, and Chavis, as well as when considering her competent reports of observable adverse symptomatology (see Davidson, supra), none of the left knee disabilities meet the criteria for a higher rating by rating it as ankylosis. See Owens, supra. The Board has reached this conclusion because the record is uniform in documenting at least some left knee motion and ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992); Also see Owens, supra. In fact, the May 2016, March 2017, July 2018, January 2021, and June 2021 VA examiners opined that the left knee was not ankylosed and these medical opinions are not contradicted by any other medical evidence of record even though his treatment records document numerous instances where he sought treatment for pain caused by his service connected left knee disabilities. See Colvin, supra. Moreover, the Board finds that the Veteran is not competent to provide the missing diagnosis of ankylosis because this is a medical finding. See Davidson, supra. Additionally, the Board finds the VA examiners opinions as to the Veteran's adverse symptomatology more probative than any lay claims to the contrary even though the symptomatology is observable by a lay person because the examiners have medical training. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). Consequently, the Board finds that a higher evaluation is not warranted for any of the Veteran's service-connected left knee disabilities under Diagnostic Code 5256 from March 1, 2013. See 38 C.F.R. § 4.71a; Fenderson, supra; Hart, supra. As to a higher evaluation for any of the Veteran's left knee disorders at any time during the appeal under Diagnostic Code 5259 for removal of the semilunar cartilage when symptomatic, under Diagnostic Code 5262 for impairment of the tibia and fibula, and/or under Diagnostic Code 5263 for Genu recurvatum, the Board notes that the disability ratings already assigned the Veteran's service-connected left knee disorder meet or exceeds the maximum rating possible under these code sections and/or the Veteran's left knee disorder do not includes these adverse symptomatology. See 38 C.F.R. § 4.71a. Therefore, the Board finds that increased ratings under these criteria are not warranted from March 1, 2013. See 38 C.F.R. § 4.71a; Butt's, supra; Hart, supra; Fenderson, supra. e. Extraschedular evaluation for the left knee disorders pursuant to 38 C.F.R. § 3.321(b) from March 1, 2013 In order to address the concerns raised in the JMPR, the Board will next consider if the Veteran meets the criteria for an extraschedular evaluation for his left knee disorders pursuant to 38 C.F.R. § 3.321(b) at any time from March 1, 2013, because the final March 2017 Board decision already addressed the pre-March 1, 2013, time period. In this regard, the Board first notes that it cannot in the first instance grant a an extraschedular rating but must refer the Veteran's claim to the Under Secretary for Benefits or Director of Compensation Service for this special consideration when the issue is raised either by the Veteran or by the evidence of record. See Thun, 22 Vet. App. 111; Barringer v. Peake, 22 Vet. App. 242 (2008). Only after the Director has determined whether an extraschedular evaluation is warranted or not warranted does the Board have jurisdiction to adjudicate the merits of the extraschedular aspect of the claim. Therefore, the Board finds that the first question it must address it whether the criteria for a referral is warranted under 38 C.F.R. § 3.321(b). In this regard, the Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the Veteran's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Thun v. Peake, 22 Vet. App. 111, 115 (2008) (citing Fisher v. Principi, 4 Vet. App. 57, 60 (1993), and Floyd v. Brown, 9 Vet. App. 88, 95 (1996)). "Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability...[I]f the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Thun, 4 Vet. App at 115. With the above criteria in mind, the Board finds that the criteria for a referral of the Veteran's claim for extraschedular consideration have not been met. See Owens, supra. The Board has reached this conclusion because, with respect to the first prong of Thun, supra, it finds that the preponderance of the evidence shows that the Veteran does not have such an exceptional disability picture that the available schedular evaluations for the Veteran's left knee disorders are inadequate. See Owens, supra. As discussed in detailed above, a comparison between the Veteran's competent and credible lay reports of his adverse left knee symptomatology (i.e., instability, pain, and limitation of motion) as well as the level of severity and symptomatology of the Veteran's left knee disorders as reported by the examiners (see private BDQ examination dated in July 2013; VA examinations dated in May 2016, March 2017, July 2018, and June 2021; addendums to the June 2021 VA examination, also dated in June 202) and in his treatment records (i.e., instability, pain, limitation of motion, and symptomatic removal of the left knee semilunar cartilage) with the established criteria (i.e., 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5256, 5257, 5258, 5260, 5261) shows that the rating criteria squarely contemplate the Veteran's disability level and symptomatology and compensates him for them because they compensate him for left knee instability, pain, limitation of motion, and symptomatic removal of the left knee semilunar cartilage. See 38 C.F.R. § 4.1; Owens, supra. Therefore, the Board finds that the preponderance of the evidence shows that the Veteran's adverse left knee pathology does not meet the first Thun, supra, criteria. Moreover, a review of the record on appeal shows that the Veteran's left knee disorders, acting alone, cause marked interference with employment or frequent periods of hospitalization. See Colvin, supra. Therefore, the Board finds that the preponderance of the evidence also shows that the Veteran's adverse left knee pathology does not meet the second Thun, supra, criteria. Next, the Board finds that it need not discuss herein the third Thun, supra, criteria because it would sever no useful purpose because, as discussed above, the Veteran has neither met the first or second Thun, supra, criteria, and the failure to meet even one of the three Thun, supra, criteria is enough to finds that the criteria for referral of the claim to the claim to the Director of Compensation Service for an extraschedular rating. See 38 C.F.R. § 3.321(b)(1). In this regard, while the Veteran's left knee disabilities clearly bother him a great deal, it is important for the Veteran to understand that this is the basis for the current findings. If there were no problems, there would be no basis for any compensation. The only question in this case is the degree of the problem based on the criteria above. Therefore, the Board finds that the preponderance of the evidence shows that the Veteran's left knee disorders do not present such an exceptional or unusual disability picture that rendered impractical the application of the regular schedular standards at any time from March 1, 2013. See 38 C.F.R. § 3.321(b)(1); Owens, supra. Accordingly, the Board finds that the criteria for referral of the claim to the Director of Compensation Service for an extraschedular rating have not been met at any time from March 1, 2013. See 38 C.F.R. § 3.321(b)(1); Thun, supra. Conclusion In reaching all of the above conclusions, the Board has also not overlooked the claims from the Veteran regarding his adverse symptomatology. See Davidson, supra. However, the Board finds the VA examiners opinions as to the Veteran's adverse symptomatology more probative than any lay claims from the appellant to the contrary even though his symptomatology is observable by a lay person because the examiner has medical training. See Black, supra. In reaching all the above conclusions, the Board also considered the doctrine of reasonable doubt. See 38 U.S.C. § 5107(b). However, as the preponderance of the evidence is against the claims, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert, supra. THE TDIU CLAIM The Veteran asserts, in substance, that his service-connected disabilities prevent substantial employment. Initially, and as noted above, under Rice, supra, the JMPR found that the Veteran's TDIU claims was part of the above claims for increased ratings for the left knee disorders which has been pending since January 29, 2009. Moreover, unlike the above left knee rating claims, the TDIU claim was not part of the final March 2017 Board decision which addressed the severity of the Veteran's pre-March 1, 2013, left knee disorders. Therefore, the Board adjudication must consider whether the Veteran met the criteria for a TDIU at all times from January 29, 2009. In this regard, total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of non-service connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). Furthermore, all Veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b). In cases where the schedular criteria are not met, an extraschedular rating is for consideration. 38 C.F.R. § 4.16(b). The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). It is imperative for the Veteran to understand that neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). With the above laws and regulations in mind, the Veteran in his VA Form 21-8940, Increased Compensation Based on Unemployability (TDIU Claim Form), dated in June 2018 and/or September 2020, reported that he became too disabled to work and had not worked full time because of his service-connected disabilities on April 1, 2017. He also reported that from June 2005 to April 2017 he had worked 40 plus hours a week as a road mechanic for a company and from March 2008 to April 2017 he also worked an additional 15 hours a week for himself as a road mechanic. His highest level of education was 2-years of college. Similarly, in a VA Form 21-4192 received from the Veteran's last employer in July 2018 it was reported that, while he remained as an employee until February 2018, he had not actually worked since April 2017 because of health problems and was receiving long term disability benefits. Next, the record shows the Veteran is service-connected for the following disabilities: left knee instability rated as 20 percent disabling from March 1, 2013; left knee limitation of flexion due to degenerative arthritis tinnitus rated as 30 percent disabling from March 1, 2013, to October 1, 2020, and 10 percent disabling from to October 1, 2020; left knee limitation of extension due to degenerative arthritis rated as 10 percent disabling from March 1, 2013; symptomatic removal of left knee semilunar cartilage rated as 20 percent disabling from March 1, 2013; left knee postoperative scar rated as noncompensable from December 14, 2021; and a right ankle disability rated as 10 percent disabling from January 29, 2009. a. A TDIU under 38 C.F.R. § 4.16(a) at all times January 29, 2009 As to the claim for a TDIU under 38 C.F.R. § 4.16(a) from January 29, 2009, the Board notes that the November 2013 rating decision granted service connection for the right ankle disability directly due to the Veteran's military service and therefore it cannot be counted as part of the left knee disorders. Therefore, as to a TDIU under 38 C.F.R. § 4.16(a), this record shows that the Veteran does not meet the schedular requirements of 38 C.F.R. § 4.16(a) at any time from January 29, 2009. The Board has reached this conclusion because the Veteran does not have two or more service-connected disabilities with one disability rated at 40 percent or higher with his combined rating being 70 percent or higher because, even when all of his left knee disorders are rated as one disability (see 38 C.F.R. § 4.16(a)(1) to(5)), he has two disabilities with the left knee disorders rated, at its' worst, as 60 percent disabling and a combined rating of 60 percent at all times during the pendency of the appeal. b. A TDIU under 38 C.F.R. § 4.16(b) As to a TDIU under 38 C.F.R. § 4.16(b) from January 29, 2009, the Board notes that in Bowling v. Principi, 15 Vet. App. 1, 10 (2001), the Court, citing its decision in Floyd v. Brown, 9 Vet. App. 88, 94-97 (1995), held that the Board cannot award a TDIU under 38 C.F.R. § 4.16(b) in the first instance because that regulation requires that the RO first submit the claim to the Director, Compensation Service, for extraschedular consideration. Therefore, the next question for the Board to consider is when, if ever, the Veteran met the criteria for a referral under 38 C.F.R. § 4.16(b) to the Under Secretary for Benefits or the Director, Compensation Services for extraschedular consideration. In this regard, the Board notes that the appropriate standard in considering whether a remand for referral of consideration of extraschedular TDIU under 38 C.F.R. § 4.16(b) is found in Ray v. Wilkie, 31 Vet. App. 58, 65-66 (2019). In this regard, the Court in Ray held that "the decision... to refer [a case for extraschedular consideration under § 4.16(b)] and to award a [TDIU] rating are fundamentally different." 31 Vet. App. 58, 65 (2019). The Court held in Ray that "the initial extraschedular referral decision under § 4.16(b) addresses whether there's sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities." Ray, 31 Vet. App. at 66; id. at 66 n. 38 (explaining that this standard (for initial extraschedular TDIU referral decision) was similar to and merely elaborates on the well-grounded claim standard used in Stanton v. Brown, 5 Vet. App. 563,570 (1993)). The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In this regard, it is imperative for the Veteran to understand that neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The sole fact that the Veteran is unemployed or has difficulty obtaining employment is not enough. The assignment of a rating evaluation is itself recognition of industrial impairment. i. TDIU under 38 C.F.R. § 4.16(b) from January 29, 2009, to April 1, 2017 As to the January 29, 2009, to April 1, 2017 time period, the record shows the Veteran was working full-time as a mechanic and he has never claimed otherwise. Moreover, the Veteran does not claim, and the record does not show, that he worked in a protected or sheltered environment from January 29, 2009, to April 1, 2017. See 38 C.F.R. § 4.16. Therefore, the Board finds that the most probative evidence of record shows that the Veteran was gainfully employed at all times from January 29, 2009, to April 1, 2017. See Owens, supra. Accordingly, because the Veteran was gainfully employed as a mechanic at all times from January 29, 2009, to April 1, 2017, the Board finds that the preponderance of the evidence shows that his service-connected disabilities did not render him unable to secure and follow a substantially gainful occupation during that time. See Ray, supra; Owens, supra. Given the above, the Board finds that the criteria for a referral of his claim to the Under Secretary for Benefits or the Director, Compensation Services for extraschedular consideration under 38 C.F.R. § 4.16(b) have not been met at all times from January 29, 2009, to April 1, 2017, and the claim is denied. ii TDIU under 38 C.F.R. § 4.16(b) from April 1, 2017 As to the post-April 1, 2017, time period, the Board notes that in April 2017 it received a letter from James C. Volpe, D.O., in which it was opined, in substance, that the Veteran was under his care and was unable to secure and follow substantially gainful employment, including sedentary employment, due to his service-connected left knee and right ankle disorders. This is a key issue in this case. Tellingly, because Dr. Volpe did not provide any rationale for this opinion, the Board finds that his opinion has limited probative value. See Black v. Brown, 5 Vet. App. 177, 180 (1995) (holding that a medical opinion is inadequate when it is unsupported by clinical evidence); Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Similarly, records received from the Social Security Administration (SSA) show that they found the Veteran disabled because of his nonservice-connected back and acquired psychiatric disorders. The Board finds that the SSA finding has limited probative value because the Board is not bound by these findings (see Murincsak v. Derwinski, 2 Vet. App. 363, 370 (1992)), the Veteran is not service-connected for back and acquired psychiatric disorders, and VA has a different legal standing for finding that the criteria for a TDIU have been met under 38 C.F.R. § 4.16. Also see Ray, supra. In any event, such evidence raises many questions as to why the Veteran is not working and provides limited evidence against this claim. Likewise, the Board notes that in September 2020 it received a letter from Joseph M. Daday, M.D., in which it was reported that the Veteran could not return to work at that time due to an anterior cruciate ligament tear in the left knee which is causing severe pain and weakness in the left lower extremity. Dr. Daday thereafter stated that the Veteran would be reevaluated in December 2020 and at that time his work restrictions would be addressed. Similarly, in May 2021 Dr. Daday notified VA that while the Veteran is awaiting left knee surgery he may not work, and he will be revaluated in August 2021. The Board also finds Dr. Daday's letters have limited probative value as to the current claim for finding that the criteria for a referral have been met under 38 C.F.R. § 4.16(b) because Dr. Daday never says that the Veteran will not be able to return to work due to his service-connected left knee disorders. Id. Additionally, also in in September 2020 the Board received a letter signed by M. Staska, MPA, and Eric Hume, M.D., in which it was reported as follows: Mr. Robert Campbell is a patient of the Orthopedic clinic at the MJCMC. His past surgical history is remarkable for an anterior cruciate ligament reconstruction of his left knee. He is status-post right hip replacement surgery and recently underwent Lumbar spine surgery on: 8/17/20. At this time, he continues to have pain and weakness of his right hip and lower extremities. He cannot stand for any length of time without experiencing increased pain and his ability to perform his activities of daily living are limited. He is currently unable to return to the workforce due to post-op pain and weakness. However, the Board again finds that the letter has limited probative value as to whether the Veteran meets the 38 C.F.R. § 4.16(b) criteria for a referral. The Board has reached this conclusion because when considering this claim, it cannot take into account the problems caused by nonservice-connected disabilities and the above letter relies, in great part, on the problems being caused by the Veteran's nonservice-connected right hip and back disabilities as the reason for his being unable to work and not his service-connected left knee and right ankle disorders. See Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators..."). Furthermore, in February 2021 the Board received a letter from Brooke H. Kunsman, CRNP, in which it was reported that the Veteran is under her care for an anterior cruciate ligament tear of the left knee and cannot return to work for three months. The Board again finds that the letter has limited probative value as to the whether the Veteran meets the 38 C.F.R. § 4.16(b) criteria for a referral because the nurse specifically says that the Veteran will return to work. See Ray, supra. Next, as to the Veteran's periodic lost time from work due to left knee surgery documented in the above letters, the Board notes that VA regulations specifically provide compensation for such lost time and this remedy lies at 38 C.F.R. § 4.30 and not 38 C.F.R. § 4.16(b). Moreover, the Board finds that even if it conceded that the Veteran has not had gainful employment since April 2017 as opined by Dr. Volpe, was disabled as reported by the SSA, could not work for a period of time in 2020 and 2021 as reported by Dr. Daday, cannot return to the workforce as reported by M. Staska, MPA, and Dr. Hume, and cannot return to work for three months as reported by Ms. Kunsman, these facts alone are not enough to meet the criteria for referral of his claim to the Under Secretary for Benefits or the Director, Compensation Services for extraschedular consideration because there is still insufficient evidence to substantiate a reasonable possibility that he is unemployable by reason of his service-connected disabilities. See 38 C.F.R. § 4.16(b); Owens, supra; Ray, supra. In this case, a detailed review of the post-service treatment records clearly reviews that the Veteran has several nonservice connected problems that keep him from working. This evidence is unambigious. It is important for the Veteran to understand that even if the Board did submit this case the Under Secretary for Benefits or the Director, Compensation Services for extraschedular consideration, the evidence contained in the records would make a finding that extraschedular is warranted in this case highly unlikely. The post-service treatment records provide particularly negative evidence against this claim on this limited issue. The Board has reached this conclusion because extraschedular consideration is only warranted when the adverse symptomatology caused by a Veteran's service-connected disabilities are not adequately compensated for by the rating criteria. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (providing, in substance, that disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity). In this regard, the Board finds that the most probative evidence of record in the form of the Veteran's VA examinations show that the adverse symptomatology caused by his service-connected left knee and right ankle disorders are both contemplated and consider by the rating criteria. See Owens, supra. The Board also finds that this evidence shows that there is not a reasonable possibility that he is unemployable by reason of his service-connected disabilities. See Ray, supra. Specifically, as to the left knee and right ankle disorders, the Board finds it significant that at all times during the appeal the Veteran has competently reported on having instability, pain, tenderness, and/or lost motion (i.e., observable adverse symptomatology) (see Davidson, supra.) and the medical record show his adverse symptomatology was limited to, in substance, instability, pain, tenderness, and/or lost motion. See, e.g., private BDQ examination dated in July 2013; VA examinations dated in November 2013, May 2016, March 2017, July 2018, February 2021, and June 2021; addendums to the June 2021 VA examination also dated in June 2021. The Board also finds that this evidence shows that there is not a reasonable possibility that he is unemployable by reason of his service-connected disabilities. See Ray, supra; Owens, supra. Lastly, the Board finds it significant that the adverse symptomatology reported by the examiners (see private BDQ examination dated in July 2013; VA examinations dated in November 2013, May 2016, March 2017, July 2018, February 2021, and June 2021; addendums to the June 2021 VA examination, also dated in June 2021) is contemplated by the rating criteria and limited to the criteria for a 20 percent rating for left knee instability, 30 percent and thereafter a 10 percent rating for left knee limitation of flexion due to degenerative arthritis, a 10 percent rating for left knee limitation of extension due to degenerative arthritis, a 20 percent rating for symptomatic removal of left knee semilunar cartilage, a noncompensable rating for a left knee postoperative scar, and a 10 percent rating for a right ankle disability. See 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5256, 5257, 5258, 5260, 5261, 5271. Given the above complaints and medical history, the Board finds that the preponderance of the evidence shows that the 30 percent, 20 percent, 10 percent, and noncompensable ratings he receives for the disabilities compensates him for the adverse symptomatology reported by the July 2013 BDQ examiner as well as the May 2016, November 2013, May 2016, March 2017, July 2018, February 2021, and June 2021 VA examiners and the adverse symptomatology documented in his medical records and/or reported by the appellant. Id. The best evidence in this case provides evidence against this claim because it shows that there is not a reasonable possibility that the Veteran is unemployable by reason of his service-connected disabilities at any time from April 1, 2017. See Ray, supra; Owens, supra. The Board has reviewed this case in some detail. The evaluations, overall, both VA and private, support the conclusion that the Veteran can not work due to his nonservice-connected problems. Such a finding by the Board, based on a review of treatment records, the private reports (many of the most probative providing highly probative evidence against this claim) and the many VA examinations in this case does not support a conclusion that this case should be remanded once against for extraschedular consideration. The finding above is not meant, in any way, to suggest that the Veteran does not have problems because of his service-connected disabilities. If there were no problems, there would be no basis for the current compensation levels from April 1, 2017. In this regard, it is important for the Veteran to understand that not all medical evidence in this case supports the current findings, let alone higher ratings. It is only with taking into consideration his complaints and all reasonable doubt that the current findings can be justified. The Board has considered, in detail, above if the Veteran's claim should be referred to the Under Secretary for Benefits or the Director, Compensation Services for extraschedular consideration. However, the Board finds that the preponderance of the evidence shows that the adverse symptomatology caused by the Veteran's service-connected tension left knee and right ankle disorders do not meet the criteria for referral for extraschedular consideration at any time at any time from April 1, 2017, because the preponderance of the evidence in the form of the above examinations shows that there is not a reasonable possibility that he is unemployable by reason of his service-connected disabilities because his only adverse symptomatology is both contemplated and consider by the rating criteria. See 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5256, 5257, 5258, 5260, 5261, 5271; Owens, supra; Ray, supra. Accordingly, the Board finds that the preponderance of the evidence shows that the Veteran does not meets the 38 C.F.R. § 4.16(b) criteria for a referral of his TDIU claim at all times from April 1, 2017. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16; Owens, supra. Conclusion In reaching all the above conclusions, the Board has once again considered the doctrine of reasonable doubt. See 38 U.S.C. § 5107(b). However, as the preponderance of the evidence is against the claim, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert, supra. John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.T. Werner, 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.