Citation Nr: 21065303 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 20-12 618 DATE: October 25, 2021 ORDER A disability rating greater than 10 percent for right knee limitation of flexion is denied. A disability rating greater than 10 percent for left knee limitation of flexion is denied. A disability rating greater than 10 percent for right knee instability is denied. A disability rating greater than 10 percent for left knee instability is denied. A separate disability rating of 20 percent for frequent episodes of swelling, locking, and pain of the right knee is granted, effective February 28, 2020. A separate disability rating of 20 percent for frequent episodes of swelling, locking, and pain of the left knee is granted, effective February 28, 2020. An increased disability rating of 30 percent, but no higher, for bilateral plantar fasciitis with left foot metatarsalgia is granted, effective August 25, 2016. A disability rating greater than 20 percent for left ankle Achilles tendinopathy is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. For the entire claim period, the Veteran's right and left knee conditions have not limited flexion of each knee to at least 30 degrees. Further, for the entire claim period, each disability has not caused more than slight instability of both knee joints. However, beginning February 28, 2020, the Veteran's bilateral knee disabilities caused frequent episodes of pain, locking, and swelling. 2. For the entirety of the claim period, the Veteran's bilateral plantar fasciitis with left foot metatarsalgia has produced symptoms analogous to severe acquired pes planus. However, a preponderance of the evidence does not indicate that the Veteran's bilateral plantar fasciitis with left foot metatarsalgia caused symptoms analogous to pronounced acquired pes planus. 3. A preponderance of the evidence does not demonstrate that the Veteran's left ankle Achilles tendinopathy produced ankylosis or its functional equivalent during any portion of the appeal period. 4. The Veteran is in receipt of a combined 100 percent disability rating beginning November 6, 2018. The evidence of record does not demonstrate that she was prevented from securing or following a substantially gainful occupation because of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 10 percent for limitation of flexion of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5260 (2020). 2. The criteria for a disability rating greater than 10 percent for limitation of flexion of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5260 (2020). 3. The criteria for a disability rating greater than 10 percent for right knee instability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5257 (2020). 4. The criteria for a disability rating greater than 10 percent for left knee instability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5257 (2020). 5. The criteria for a separate disability rating of 20 percent for frequent episodes of effusion, locking, and pain of the right knee are met, effective February 28, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.68, 4.71a, Diagnostic Code 5258 (2020). 6. The criteria for a separate disability rating of 20 percent for frequent episodes of effusion, locking, and pain of the left knee are met, effective February 28, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.68, 4.71a, Diagnostic Code 5258 (2020). 7. The criteria for an increased disability rating of 30 percent, but no higher, for bilateral plantar fasciitis with left foot metatarsalgia are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2020). 8. The criteria for a disability rating greater than 20 percent for left ankle Achilles tendinopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5024-5271, 5270. 9. The criteria for entitlement to a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2007 to June 2007, June 2007 to November 2007, January 2008 to January 2009, and January 2010 to April 2011, including service in Afghanistan and the Southwest Asia theater of operations. The Veteran also had service with the Army National Guard of Colorado. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2017 and November 2017 rating decisions issued by Department of Veterans Affairs (VA) Regional Offices (ROs). Jurisdiction of the Veteran's claims file resides currently with the Denver, Colorado RO. In July 2020, the Veteran testified at a Board hearing before the undersigned. A transcript of the hearing is of record. Thereafter, in March 2021, the Board granted: (1) increased ratings of 60 percent prior to November 6, 2018, and 100 percent thereafter, for reactive airway disease; (2) a separate 10 percent rating for bilateral plantar fasciitis from February 7, 2021 onward; (3) an increased 20 percent rating for left ankle Achilles tendinopathy for the entire claim period; and (4) separate 10 percent ratings for right and left knee instability for the entire claim period. The Board then remanded the issues of entitlement to even higher ratings for the bilateral knees, feet, and left ankle, as well as entitlement to a TDIU, for further development. The case has returned to the Board for appellate review. Increased Ratings 1. Right and Left Knee Disabilities In addressing the Veteran's claim for increased ratings for her knee disabilities, the Board first notes that, effective February 7, 2021, VA revised the criteria for evaluating disabilities of the musculoskeletal system. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). This amendment affected evaluations of knee disabilities. VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for an increased rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. In the instant case, the Board finds the pre-2021 amendment criteria more favorable to the Veteran. Accordingly, it will apply them for the entirety of the claim periodi.e., from May 11, 2012 onward. Turning to the relevant rating criteria for the knees, under the pre-amendment version of 38 C.F.R. § 4.71a, Diagnostic Code 5260, noncompensable, 10 percent, 20 percent, and 30 percent ratings were assigned for flexion limited to 60, 45, 30, and 15 degrees, respectively. Relatedly, in regard to limitation of extension, under the pre-amendment version of 38 C.F.R. § 4.71a, Diagnostic Code 5261, noncompensable, 10 percent, 20 percent, 30 percent, and 40 percent ratings were assigned for extension limited to 5, 10, 20, 30, and 30 degrees, respectively. Additionally, Diagnostic Codes 5258 and 5259 were assigned for symptoms associated with removal or dislocation of semilunar cartilage. Specifically, Diagnostic Code 5258 was assigned for frequent episodes of locking, pain, and effusion of the knee joint. Diagnostic Code 5259 was assigned for symptoms of a lesser degree than those contemplated by Diagnostic Code 5258. Lastly, under Diagnostic Code 5257, disability ratings of 30 percent, 20 percent, and 10 percent were assigned for severe, moderate, or slight recurrent subluxation or lateral instability of the knee, respectively. In evaluating a disability based upon limitation of motionsuch as the kneeVA is to consider, in conjunction with the otherwise applicable diagnostic codes, any additional functional loss a veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran at issue. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Additionally, the intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 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 veteran or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In specific regard to rating disabilities of the knee, precedent opinions of VA's General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 Fed. Reg. 59988 (2004)). Further, in Lyles v. Shulkin, the Court recently held that evaluation of a knee disability under the diagnostic codes for recurrent subluxation or instability; limitation of extension; or limitation of flexion does not preclude as a matter of law a separate evaluation of a meniscal disability under Diagnostic Code 5258 or 5259the diagnostic codes for removal or dislocation of semilunar cartilage. 29 Vet. App. 107, 115-16 (2017). Accordingly, considering the above, when evaluating the Veteran's left knee disability, the Board may assign separate ratings for: (1) recurrent subluxation or lateral instability; (2) limitation of flexion; (3) limitation of extension; and (4) symptoms associated with the dislocation or removal of semilunar cartilage. Here, the Veteran is currently in receipt of 10 percent ratings for right and left knee limitation of flexion as well as 10 percent ratings for bilateral knee instability. These disability ratings were assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5257 and 5261 (2020). After reviewing the evidence of record, the Board declines to assign higher ratings for either knee for limitation of flexion or instability. However, the Board finds that separate 20 percent ratings for frequent episodes of pain, locking, and effusion are warranted in the instant case, effective February 28, 2020. Accordingly, to this extent, the Board grants the Veteran's claim. In support of this determination, the Board first notes that the Veteran underwent VA examinations concerning her knee disabilities during the claim period in May 2016, March 2018, October 2019, and June 2021. The Board observes that the May 2016 examination report's range of motion findings were inconsistent with the Court's holding in Correia v. McDonald, 28 Vet. App. 158 (2016). Accordingly, to this extent, the Board finds the May 2016 VA examination of lesser probative value. However, with respect to non-range-of-motion findings, the Board notes that the May 2016 VA examiner indicated that the Veteran did not display ankylosis of either knee joint. Additionally, after conducting joint stability testing, knee joint instability of either knee was not indicated. Lastly, the Veteran did not reportand the examiner did not indicatethat the Veteran experienced recurrent subluxation, lateral instability, or recurrent effusion. Thereafter, during the March 2018 VA examination, the Veteran reported increased stiffness in her knees, knee instability, a popping sensation in the knees, and a constant aching pain. The Veteran reported experiencing functional loss caused by her knee disabilities, which she described as diminished abilities to bend, squat, and use stairs. During initial range of motion testing, both knees flexed to 110 degrees and extension was not limited. The examiner indicated that painful motion was present during the flexion movement only for each knee. While the Veteran reported experiencing flare-ups of her knee disabilitiesdescribing such flares as occurring once per year, lasting about 2 weeks on each occasionthe examiner stated that she could not estimate without speculating whether functional ability was further limited during flare-ups. Lastly, the examiner indicated that ankylosis, recurrent subluxation, lateral instability, and recurrent effusion were not present. About 18 months later, the Veteran underwent another VA knee conditions examination in October 2019. On this occasion, the examiner noted current symptoms of gradual and progressive bilateral knee pain. The Veteran reported that she did not experience flare-ups or functional loss. During range of motion testing, both knees displayed normal flexion and extension. While painful motion was displayed during both tested movements of both knees, such pain did not result in functional loss. The examiner conducted knee joint stability testing, but no instability was demonstrated. Lastly, the examiner remarked that the Veteran did not have a history of recurrent effusion and did not display ankylosis. Lastly, the Veteran most recently underwent VA knee conditions examination in June 2021. On this occasion, the Veteran reported symptoms of chronic bilateral knee pain, knees giving way, and effusion upon exertion. The Veteran reported flare-ups of her knee disabilitiesdescribed as random in frequency, lasting hours to a day. The Veteran also reported functional impairment, described as losing her ability to run. Similar to the October 2019 VA examination, initial range of motion testing of both knees produced normal results, with painful motion exhibited only during the flexion movement. During flare-ups, the examiner estimated that only flexion of each knee would be additionally limitedto 120 degrees. Lastly, the examiner indicated that ankylosis, recurrent subluxation, or persistent instability of either knee was not present. Separate from these VA examination reports associated with the claims file, the record also contains a July 2020 evaluation concerning multiple disabilities completed by non-VA provider Dr. Bash. Regarding the knees, Dr. Bash stated that the Veteran's knee disabilities caused the following symptoms: painful range of motion; pain with weight-bearing; pain during sleep; popping and cracking sensations in the knees; stiffness; swelling, excess fatigability; and pain on movement. Lastly, Dr. Bash indicated that the Veteran's knee disabilities caused instability of station, disturbed locomotion, and impacted the Veteran's abilities to stand and sit. In addition to Dr. Bash's evaluation, VA treatment records associated with the claims file during the claim period also addressed the nature and severity of the Veteran's knee disabilities. Specifically, in an August 2018 VA nutrition note, the Veteran stated that she could only walk for 15 minutes before experiencing knee, ankle, and foot pain. The Veteran then stated that she liked to cook and had started sitting while doing prep work. Relatedly, in April 2015, the Veteran reported symptoms of a popping sensation in her knees to a VA primary care provider. A physical examination of the Veteran revealed medial and lateral joint line tenderness. However, no swelling, redness, or warmth of the knees was displayed. About one-and-a-half years earlier, during a December 2012 VA primary care visit, a physical examination of both knees revealed no swelling. Additionally, a drawer test was negative. Similar to the above evidence documented by VA providers, treatment records from private provider Physiotherapy Associates indicated that the Veteran reported pain and knee instability in 2012 and 2013. Lastly, the Board notes that the Veteran has also provided credible lay testimony concerning her knee symptoms during the claim period. Specifically, in February 2020, the Veteran reported falling several times due to knee instability and buckling. Additionally, she reported chronic knee pain, stiffness, and swelling. Thereafter, during the July 2020 Board hearing, the Veteran testified that she experienced symptoms of chronic pain, swelling, and frequent locking of her knees. Hearing Tr. at 16-17. In addition, the Veteran stated that she had ever-present feelings of instability in her knees. Id. at 21. From this evidence of record, the Board concludes that the Veteran is not entitled to ratings greater than 10 percent for limitation of flexion of the knees for any portion of the claim period. In reaching this conclusion, the Board finds that, even when considering functional impairment, flexion of either knee was not limited to at least 30 percent during the claim period. As such limitation is required for the assignment of the next higher rating of 20 percent under Diagnostic Code 5260 (2020), the Board denies the Veteran's claim to this extent. Additionally, while the Veteran may have consistently reported bilateral knee instability during the claim period, instability of either knee joint was not demonstrated during repeated physical examinations over the course of the claim period. For these reasons, the Board declines to assess the Veteran's bilateral knee instability as more than slight, warranting only 10 percent ratings pursuant to Diagnostic Code 5257 (2020). Thus, similar to limitation of flexion, the Veteran's claim is denied. However, the Board does find that the Veteran reported frequent episodes of swelling, locking, and effusion of both knee joints. As the Veteran first reported swelling of her knee joints on February 28, 2020and the criteria of Diagnostic Code 5258 are conjunctivethe Board finds that separate 20 percent ratings for each knee are warranted, effective February 28, 2020. See also 38 C.F.R. § 3.400(o). 2. Bilateral Plantar Fasciitis and Left Foot Metatarsalgia As an initial matter, the Board notes that prior to the Board's March 2021 decision and remand, the Veteran's service-connected bilateral plantar fasciitis and left foot metatarsalgia were rated as one disability and assigned a 10 percent rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5276. The use of Diagnostic Code 5276the diagnostic code for flatfeetindicates that the disability was rated by analogy. In its March 2021 decision and remand, the Board noted that the previously-mentioned 2021 amendment to the disabilities of the musculoskeletal system included the creation of a new diagnostic code specifically for plantar fasciitisDiagnostic Code 5269. The Board found that a separate 10 percent rating for plantar fasciitis only was warranted, effective February 7, 2021the date the new diagnostic code for plantar fasciitis became effective. However, in remanding the Veteran's foot disabilities for further development, the Board did not foreclose the possibility of bilateral plantar fasciitis and left foot metatarsalgia being again rated together if, under the pre-2021 amendment criteria, a higher rating could be assigned as opposed to both disabilities being evaluated separately. After reviewing the evidence of record, the Board finds that an increased rating of 30 percent, but no higher, is warranted for the Veteran's bilateral plantar fasciitis with left foot metatarsalgia. In assigning this increased 30 percent rating, the Board again rates the conditions as one disability and evaluates its severity by analogy under the pre-2021 amendment version of 38 C.F.R. § 4.71a (2020). Accordingly, to this extent, the Board grants the Veteran's claim. In making this determination, the Board first notes that the Veteran was provided VA examinations for her feet in February 2017, March 2018, November 2018, October 2019, and June 2021. In February 2017, the Veteran reported that she had received custom orthotics for foot pain, but was not presently using them. Additionally, she indicated that she had received injections in both of her feet in 2017 that provided significant relief. The Veteran reported pain in the arches and heels of her feet which limited her ability to walk or stand for long periods and prevented her from running or jumping. The examiner then indicated that the Veteran had accentuated pain on use of her feet, but no pain on manipulation of her feet. Next, the examiner stated that the Veteran did not have characteristic calluses or swelling of the feet. The examiner then remarked that: there was no marked pronation of either feet; there was no abnormality concerning the weight-bearing line a deformity; and inward bowing, inward displacement, and severe spasm were not present. Lastly, the examiner remarked that the Veteran's issued orthotics only resulted in partial relief of arch-related symptoms. Thereafter, in March 2018, the Veteran reported symptoms of increasing foot pain to a different VA examiner. The Veteran again stated that her foot disabilities limited her ability to walk and now affected her ability to use stairs. Additionally, the Veteran said that she now experienced foot pain even when sitting. After physically examining the Veteran, the March 2018 examiner made findings similar to those of the February 2017 examiner. However, in March 2018, the Veteran did display accentuated pain on manipulation of the feet. Lastly, the March 2018 examiner remarked that the Veteran's bilateral plantar fasciitis and left foot metatarsalgia caused the functional impairments of pain on weight-bearing and non-weight-bearing, disturbances of locomotion, and interference with standing. About 8 months later, in November 2018, the Veteran again presented for a VA foot conditions examination and was diagnosed with left foot metatarsalgia and bilateral plantar fasciitis. Again, the Veteran reported functional impairment, which she described as: falling, even while using an orthopedic boot; difficulty navigating stairs; difficulty with prolonged walking or standing without a walker; difficulty getting up from the floor; and an inability to run or jump. Upon conducting a physical examination, the November 2018 VA examiner made findings like those of the March 2018 examiner; however, the November 2018 examiner remarked that arch supports had relieved the Veteran's symptoms. Additionally, the November 2018 examiner indicated that the Veteran's diagnosed foot disabilities caused the additional functional losses of excess fatigability; incoordination; and an impaired ability to execute skilled movements smoothly. Dissimilar from the November 2018 VA examiner, an October 2019 VA examiner remarked that while the Veteran was issued orthotics, orthotics had no effect on relieving the Veteran's symptoms. On this occasion in October 2019, the Veteran continued to report receiving injections in her feet; falling due to her foot disabilities; and continuous pain in both of her feet. Consistent with the November 2018 examiner, the October 2019 examiner remarked that the Veteran had accentuated pain on use and on manipulation. Lastly, in June 2021, the Veteran reported the following as her current foot condition symptoms: chronic pain bilaterally that increased with weight-bearing and tightness in her arches in the morning. The Veteran stated that she continued to use orthotics, attended physical therapy, and wore an orthopedic boot to ameliorate her foot condition symptoms. Again, the Veteran remarked that she could not walk or stand very long due to her foot symptoms and reported that she could no longer run. After physically examining the Veteran, the examiner remarked that the Veteran should avoid long distance running and walking due to plantar fasciitis, left foot metatarsalgia, minimal degenerative arthritis of the 1st MTP joints, and bilateral hallux valgus. Separate from these VA examination reports of record, the Board notes that private provider Dr. Bash addressed the Veteran's plantar fasciitis and left foot metatarsalgia during the claim period. Specifically, in July 2020, Dr. Bash remarked that the Veteran's service-connected plantar fasciitis caused the following symptoms: foot swelling bilaterally; pain on movement; weakened movement; incoordination; impaired ability to execute skilled movements smoothly; pain on weight-bearing and non-weight-bearing; instability of station; disturbance of locomotion; interference with sitting and standing; excess fatigability; and pain during sleep. Additionally, Dr. Bash commented that the Veteran's foot disabilities contributed to her balance problems. Separate from Dr. Bash's July 2020 remarks, the Board notes that VA treatment records associated with the Veteran's claims file discussed the nature and severity of her plantar fasciitis and left foot metatarsalgia. Specifically, in October 2019, the Veteran reported for an appointment with a VA podiatrist. On this occasion, the Veteran stated that pain associated with her plantar fasciitis was close to resolved following physical therapy, injections, and new custom foot orthoses she received about 3 weeks prior. However, prior to the completion of her injections and receipt of new foot orthoses, the Veteran continued to experience constant bilateral foot pain, worsening throughout the day. See July 2019 VA Podiatry Treatment Record; June 2019 VA Podiatry Treatment Record. Lastly, during the July 2020 Board hearing, the Veteran testified that her bilateral plantar fasciitis caused sharp, stabbing pains in both feet. Hearing Tr. at 6. The Veteran then remarked that she could not walk very far and that even sitting was laborious. Id. In regard to her left foot metatarsalgia, the Veteran reported experiencing a constant dull pain that increased in severity when pressing down on her foot. Id. at 9-10. Lastly, the Veteran stated that her foot pain and limitations in walking were present since VA received her claim in 2016. Id. at 12. In light of the evidence of above, the Board finds that the Veteran's bilateral plantar fasciitis with left foot metatarsalgia is most analogous to severe flatfoot, warranting an increased 30 percent disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2020). Thus, to this extent, the Veteran's claim is granted. In assigning this 30 percent rating, the Board notes that this rating replaces the current separate 10 percent ratings for plantar fasciitis and left foot metatarsalgia. However, the Board also declines to assign the next higher rating of 50 percent. In support of this determination, the Board notes that marked pronation, extreme tenderness of plantar surfaces, marked inward displacement, and severe spasm of the tendo achillisor similar symptomswas not noted during any VA examination, by Dr. Bash in July 2020, by any other medical provider, or by the Veteran herself at any point during the claim period. While the October 2019 VA examiner remarked that the Veteran's orthotic inserts had not relieved her symptoms, this finding was inconsistent with the findings of the other VA examiners as well as VA podiatry records cotemporaneous with the October 2019 examination. As the Veteran experienced partial relief with the use of orthotics, physical therapy, and injections, the Board concludes that the Veteran's bilateral pes planus with left foot metatarsalgia is not most analogous with pronounced acquired flatfeet, a finding required for the assignment of the next higher rating of 50 percent under Diagnostic Code 5276 (2020). Accordingly, to this extent, the Veteran's claim is denied. 3. Left Ankle Achilles Tendinopathy Turning to the Veteran's claim for an increased rating for her left ankle Achilles tendinopathy, the Board finds that a rating greater than 20 percent is not warranted. Accordingly, the Board denies the Veteran's claim. In support of this determination, the Board first notes that the Veteran's left ankle is currently evaluated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5024-5271. The use of this hyphenated diagnostic code indicates that the affected body part, the ankle, was evaluated based on limitation of motion, identified by Diagnostic Code 5271. Currently, the Veteran is in receipt of the maximum disability rating available under Diagnostic Code 5271. The only other relevant diagnostic code under which the Board could assign a rating in excess of 20 percent is 38 C.F.R. § 4.71a, Diagnostic Code 5270 for ankylosis of the ankle. Under Diagnostic Code 5270, a 30 percent rating is assigned when the ankle is ankylosed at between 30 and 40 degrees in plantar flexion, or between 0 and 10 degrees in dorsiflexion. The maximum 40 percent rating is warranted when the ankle is ankylosed at more than 40 degrees in plantar flexion, or at more than 10 degrees in dorsiflexion, or with abduction, adduction, inversion, or eversion deformity. The Court has defined ankylosis as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Shipwash v. Brown, 8 Vet. App. 218, 221 (1995); Nix v. Brown, 4 Vet. App. 462, 465 (1993); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision). Additionally, the Court recently elaborated in the context of rating a disability of the spine that a finding of ankylosis may also be supported by symptoms resulting in the functional equivalent of ankylosis. See Chavis v. McDonough, 34 Vet. App. 1, 4 (2021). Turning to the evidence of record, VA examiners in February 2017, November 2018, October 2019, and June 2021 all explicitly found that ankylosis of the left ankle was not present. Similarly, a finding of ankylosis was not identified by any medical provider, both private and VA, during the claim period. Lastly, while a VA podiatrist in November 2016 diagnosed the Veteran with bilateral ankle equinus, the Veteran was still able to dorsiflex her left ankle to a small degreeidentified as less than 5 degrees. Thus, as the Veteran's left ankle remained slightly mobile and not fixed, the November 2016 VA podiatry note may not support a finding of ankle ankylosis. Thus, as ankylosis was not indicated during any portion of the claim period, the Board may not assign a rating greater than 20 percent for left ankle Achilles tendonitis. 38 C.F.R. § 4.71a. The Veteran's claim is denied. TDIU Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual Veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor). However, VA may not take into account the individual veteran's age or any impairment caused by nonservice-connected disabilities in determining whether TDIU is warranted. See 38 C.F.R. §§ 3.341 (a), 4.16(a), 4.19; see also Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Under certain circumstances, multiple disabilities may be considered as the sole 60 percent or 40 percent disability. Id. Where these criteria are not met, but the Veteran is nevertheless unemployable by reason of service-connected disabilities, VA shall submit the case to the Director, Compensation and Pension Service, for extra-schedular consideration. 38 C.F.R. § 4.16(b). As an initial matter, the Board notes that the Veteran is in receipt of a 100 percent schedular rating from November 6, 2018 onward. The Court recognized that a 100 percent rating under the Schedule for Rating Disabilities indicates that a veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a veteran to be totally disabled as a result of a particular service-connected disability or a combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to otherwise rate that veteran totally disabled on any other basis. See Locklear v. Shinseki, 24 Vet. App. 311, 314 n.2 (2011) (finding entitlement to TDIU mooted from the effective date of a 100% schedular disability rating); see also Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for TDIU moot where 100 percent schedular rating was awarded for the same period). Accordingly, in this case, the Board will only evaluate entitlement to a TDIU for the period prior to November 6, 2018. After reviewing the evidence of record, the Board concludes that a TDIU prior to November 6, 2018 is not warranted as the Veteran's service-connected disabilities did not prevent her from securing and following a substantially gainful occupation. Specifically, in August 2014, a copy of the Veteran's then-current resume was associated with her claims file. This document indicated that the Veteran was presently employed as a recruit sustainment specialist in an apparent full-time capacity. While the Veteran's employer informed VA that the Veteran was a contractor whose position could be terminated around December 2014, VA received a copy of the Veteran's updated resume in February 2021 which provided more information regarding her employment status. In this updated resume, the Veteran indicated that, from December 2014 to August 2018, she attended a university and obtained a Bachelor of Arts degree in psychology. Immediately following graduation, beginning in September 2018, she became a teacher in China, teaching multilingual educational classes of 25-30 students for 40 hours per week. This teaching position lasted until January 2020 upon which the Veteran then obtained another position as a regional deputy branch director affiliated with a nonprofit organization. The Veteran indicated that, in February 2021, she was still employed in this position and worked 54 hours per week. Accordingly, as the Veteran's service-connected disabilities did not prevent her from securing or following a substantially gainful occupation, the Board may not grant entitlement to a TDIU for the period prior to November 6, 2018. See 38 C.F.R. § 4.16. As such, the Veteran's claim is denied. S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.S. Pettine, 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.