Citation Nr: 21065710 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 14-02 043 DATE: October 27, 2021 ORDER Over the entire appeal period, entitlement to an increased rating of 30 percent, but no higher, for left knee instability is granted. Over the entire appeal period, entitlement to an increased rating of 20 percent, but no higher, for a meniscal injury with joint pain, under DC 5258, is granted. Over the entire appeal period, entitlement to an increased rating of 30 percent, but no higher, for left knee limitation of flexion is granted. Prior to June 13, 2016, entitlement to a total disability rating due to individual unemployability (TIDU) is granted. FINDINGS OF FACT 1. Over the entire appeal period, the Veteran used left knee supportive devices (braces, crutches, cane, walker) and his left knee gave way and caused falls indicating a severe level of left knee instability. 2. Over the entire appeal period, the Veteran had a diagnosed left knee meniscal injury which was associated with joint pain. 3. Resolving reasonable doubt in favor of the Veteran, over the entire appeal period, his left knee range of motion in flexion, was limited to 15 degrees or less. 4. Over the entire appeal period, the Veteran meets the schedular percentage requirements for TDIU, and prior to June 13, 2016, it is at least as likely as not his service connected back and left knee disabilities precluded him from engaging in substantially gainful employment. CONCLUSIONS OF LAW 1. Over the entire appeal period, the criteria for a 30 percent rating, but no higher, for left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5257. 2. For the entire appeal period, the criteria for a 20 percent rating under DC 5258, but no higher, for a left knee meniscus condition with symptoms of joint pain, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5258. 3. Over the entire appeal period, the criteria for a 30 percent rating, but no higher, for left knee limitation of motion in flexion are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.40, 4.45, 4.59, 4.71a, DC 5260. 4. Prior to June 13, 2016, the criteria for a TDIU rating have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1979 to October 1980. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2009 and November 2020 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned in July 2016. These matters were previously remanded by the Board in November 2017, August 2020, and May 2021. A November 2018 rating decision allowed service connection for a lumbar spine disability. This represents a complete grant of the benefit sought as to that claim. The issue of entitlement to service connection for a back disability is no longer before the Board. The November 2020 rating decision allowed entitlement to a TDIU from June 13, 2016. The issue remaining on appeal is whether entitlement to a TDIU is warranted prior to this date. 1. Entitlement to a rating in excess of 10 percent for left knee instability 2. Entitlement to a rating in excess of 10 percent for a left knee meniscal injury 3. Entitlement to a rating in excess of 20 percent for left knee limitation of flexion Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes (DCs). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. Wood v. Derwinski, 1 Vet. App. 190 (1991); Washington v. Nicholson, 19 Vet. App. 362 (2005). Where entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern; therefore, the more critical evidence consists of the evidence generated during the appeal period. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Yet, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts). Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.") Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Normal range of motion (ROM) of the knee is to zero (0) degrees (full extension ROM) to 140 degrees (full flexion ROM). 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable (0 percent) rating is warranted where flexion of the knee is limited to 60 degrees, and a 10 percent disability evaluation is warranted when flexion is limited to 45 degrees. A 20 percent disability rating is warranted when flexion is limited to 30 degrees, and a 30 percent rating is warranted when flexion of the leg is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable (0 percent) rating is warranted when extension of the knee is limited to 5 degrees, and a 10 percent disability rating is warranted when extension of the knee is limited to 10 degrees. A 20 percent disability rating is warranted when extension is limited to 15 degrees, and a 30 percent rating is warranted when extension limited to 20 degrees. A 40 percent disability rating is warranted when extension is limited to 30 degrees, and a 50 percent disability rating is warranted when extension of the leg is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Under DC 5257 a disability rating may be assigned for subluxation or lateral instability of the knee. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under DC 5257, and objective medical evidence cannot be categorically found more probative than lay evidence with respect to this DC. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Under DC 5258, dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5258. Under DC 5259, symptomatic removal of semilunar cartilage warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, DC 5259. Separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court of Appeals for Veterans Claims (Court) held that, as a matter of law, separate ratings are not precluded for limitation of motion (DCs 5003, 5260 and 5261), meniscal disability (DCs 5258 and 5259), and instability (DC 5257). During the pendency of the Veteran's claim and appeal, the criteria for rating musculoskeletal disabilities were changed by an amendment to the rating schedule that became effective on February 7, 2021. 85 Fed. Reg. 76, 453 (November 30, 2020). Diagnostic Code 5257 was amended to provide ratings for recurrent subluxation or lateral instability. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. The amended Diagnostic Code 5257 also provides for ratings based on patellar instability. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note [1] to DC 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to DC 5257 states that 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. Diagnostic Codes 5258, 5259, 5260 and 5261, applicable to meniscal conditions and limitation of motion in the knee, were unchanged by the February 2021 amendments. The Board will apply the new criteria for the period beginning February 7, 2021, if the new criteria are more beneficial to the Veteran than the prior version of the regulation. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (regulations may not have retroactive effect unless their language specifies so). In January 2009, the Veteran filed a claim seeking an increased rating for his left knee disability. Currently, a 10 percent rating for instability, a 10 percent rating for a meniscal condition, and a 20 percent rating for limitation of flexion are applied for the left knee condition over the entire appeal period. A VA examination was provided in March 2009 to evaluate the claim. The examiner identified the left knee disability as internal derangement. The Veteran reported left knee weakness, stiffness, giving way, and lack of endurance. He had difficulty standing and walking. The examiner noted he was "limping severely." On initial range of motion testing, full extension (to zero degrees) was observed, and flexion was limited to 30 degrees. With repetitive use, the examiner stated left knee joint function was further limited by fatigue, weakness, incoordination, and pain. No additional range of motion testing or estimated limitations were listed. The examiner observed the Veteran was limited in his ability to perform prolonged (more than 10 to 15 minutes) standing or walking. She observed the Veteran was not employed at the time of this examination. An October 2009 left knee x ray documented "no acute process." A November 2009 VA primary care treatment note included the Veteran's report that his left knee gave out and caused him to fall. March 2010 primary care records included the Veteran's continued reports of left knee pain and falls after the knee gave way. A March 2010 left knee MRI revealed chondromalacia patella and early degenerative changes of the menisci. An April 2010 VA orthopedic clinic consult noted the Veteran fell one to three times each week due to left knee and lower back pain. He used a knee brace and a cane. On examination, the Veteran could not flex his left knee past five to ten degrees due to increased pain. The examiner stated, with passive flexion of the left knee, the Veteran's "pain reaction seemed out of proportion for a knee injury." Stability and strength testing could not be performed due to pain. Following a cortisone injection, active flexion of the left knee was limited to 15 degrees. Passive flexion was increased to 30 degrees before being limited by pain. A May 2010 VA pain management notes include the Veteran's report of continuous and chronic left knee pain. The pain limited the Veteran's ability to dress and do household chores. Pain interfered with his ability to sleep. The Veteran reported pain with five to ten degrees of flexion. Stability testing could not be completed due to pain. September 2010 primary care notes reflect the Veteran continued to fall two or three times each month when his knee gave out. He was using a cane and a walker. In October 2011, the Veteran submitted a statement from Dr. D. S., his VA physician. Dr. D. S. reported the Veteran had recently undergone proctocolectomy surgery. He observed the Veteran used a cane and his activities were limited by left knee pain and stiffness. May 2012 VA treatment records show the Veteran fell on his right elbow after his left knee gave out. The Veteran was unable to sleep due to pain. In June 2012, the Veteran reported chronic pain, including left knee pain, which interfered with his ability to sleep. September 2012 and December 2012 VA treatment notes document a fall after the Veteran's left knee gave way. In April 2013, a second VA knee examination was provided. The examiner diagnosed left knee internal derangement. In an amendment to the examination report, the examiner also diagnosed left knee chondromalacia and early degenerative changes to the menisci. The Veteran reported constant left knee pain and falls caused by his left knee. His left knee symptoms flared with increased walking. Initial range of motion testing revealed full range of motion in extension (to zero degrees) with no evidence of painful motion. Flexion was limited to 40 degrees with pain noted at 40 degrees. After three repetitive motions, flexion was further limited to 20 degrees. Left knee function was impaired by reduced movement, weakened movement, incoordination, pain, and instability of station. In the report amendment, the examiner stated she was unable to evaluate the Veteran's symptoms during flares because the Veteran was not experiencing a flare at the time of the examination. The examiner was unable to perform joint stability tests. There was no evidence of patellar subluxation or dislocation. In the report amendment, she stated the Veteran had a left knee meniscal condition with frequent episodes of joint pain. The Veteran had not undergone any left knee surgeries. He used crutches and a cane constantly. Left knee arthritis was confirmed by imaging studies and the examiner noted the March 2010 MRI. In August 2014, a VA physical therapist evaluated the Veteran. She observed left knee active range of motion between zero and five degrees. The Veteran was unable to tolerate land-based exercises and the physical therapist recommended aquatic exercise. A June 2015 VA primary care note reflects the Veteran's reports of constant left knee pain. The Veteran reported difficulty sleeping due to pain. His primary care physician observed limited left knee range of motion with pain in active and passive testing. No joint effusion was observed. An August 2015 VA pain medicine note states the Veteran kept his knee fully extended and would not bend it due to pain. May 2016 VA primary care notes show the Veteran continued to report chronic left knee pain. In July 2016,, a VA examination was provided in association with a separate claim for an increased rating for the right knee. Initial left knee range of motion testing showed full extension (to zero degrees) and flexion limited to 40 degrees. Pain was noted in flexion. Range of motion was not reduced after three repetitive motions or with repeated use over time. The examiner did not provide any evaluation for flares. No ankylosis was noted. No recurrent subluxation or effusion was noted. Left knee stability tests were not performed. In July 2016, the Veteran testified to worsening left knee pain. He experienced falls when his left knee gave way. He reported using a cane, a walker, crutches, and braces which were issued by VA. A fourth VA knee conditions examination was provided in October 2018.. The Veteran reported constant moderate to severe throbbing pain and occasional shooting pain in his knees. He often fell when his knees gave out. He continued to use hydrocodone and knee braces. The Veteran did not report flares. On initial range of motion testing, the examiner observed full extension (to zero degrees) and flexion limited to 30 degrees. Pain was noted in flexion and in extension and with weight-bearing. After three repetitive uses, there was no additional loss of function or range of motion. The examiner observed, with repeated use over time, pain would additionally limit function and the Veteran's ability to tolerate weight bearing activities would be reduced. Passive range of motion testing was not performed because the Veteran was unable to tolerate the pain associated with this testing. The examiner observed pain with non-weight-bearing movement. No ankylosis was indicated. Joint stability testing was not performed due to knee pain. The examiner noted a left knee meniscal condition associated with frequent episodes of joint pain. The examiner observed the Veteran wore a hinged left knee brace, ambulated with a walker, had a stiff legged gait, sat with his knees extended, demonstrated difficulty rising from sitting to standing, and maintained his left knee near full extension. The examiner noted the Veteran used a brace daily and used a cane inside his home and a walker outside of his home. Left knee x-rays associated with this examination were within normal limits. The Veteran was limited to walking less than 30 minutes. He was unable to run, jump, climb stairs, squat, or knee. He was only able to sit for 20 to 30 minutes at a time. He was unable to drive. VA primary care treatment notes from October 2016, February 2017, December 2017, March 2018, July 2018, October 2018, January 2019, May 2019, October 2019, February 2020, June 2020, and October 2020 show continuing reports of left knee pain, treatment with hydrocodone, and reports of falls. In December 2017, the Veteran reported continuing sleep difficulty. In March 2018, the Veteran reported sleeping more (four to five hours each night.) In October 2018, the Veteran reported he was sleeping only two hours at night. A fifth VA knee conditions examination was provided in October 2020. At that time, the Veteran reported constant left knee pain. His knees popped and locked causing him to fall. Pain limited his ability to walk, and he used a walker for support. The Veteran continued to use hydrocodone to treat his bilateral knee pain. His ability to stand and sit was limited. He also reported difficulty sleeping because of pain in his knee. On initial range of motion testing, the examiner observed full extension (to zero degrees) and flexion to 105 degrees. Pain was noted in flexion and in extension. Range of motion was the same after three repeated motions. The examiner estimated left knee range of motion would continue from zero to 105 degrees with repeated use over time and during flares. No ankylosis was observed. Joint stability testing indicated left knee lateral instability. The examiner noted a meniscal condition of degenerative changes to the left knee menisci. This condition was associated with frequent episodes of joint pain. The Veteran had decreased ability to perform weight bearing activities like standing, walking, climbing, and lifting. In May 2021, the Board noted the range of motion testing documented in this examination was inconsistent with other testing of record and there was no evidence of treatment or intervention to explain the improvement. A sixth VA knee conditions examination was provided in June 2021. At the time of this examination, the Veteran reported constant left knee pain. This constant pain was described as level 10 on a scale of one to ten. He had difficulty walking, standing, climbing, and holding up his own weight. The Veteran walked with a limp. His symptoms did not flare. He used hydrocodone, a supportive brace, and a walker. On initial range of motion testing, the examiner observed full extension (to zero degrees) and flexion limited to 30 degrees. Pain was observed in extension and in flexion. Passive range of motion testing provided the same results. The examiner noted pain associated with weight bearing, non-weight beaming, active motion, passive motion, and with rest or non-movement. No additional reduction in range of motion or functional ability was observed after three repeated motions. With repeated use over time, pain, fatigability, weakness, lack of endurance, and incoordination would additionally limit the Veteran's functional ability. The examiner estimated his range of motion (from zero to 30 degrees) would not be limited any further with repeated use over time. As the Veteran reported no flares (his pain was constantly present at level 10 of 10 and he had continual difficulty standing, walking, and carrying his own weight), the examiner did not provide any additional evaluation for flares. The Veteran's left knee symptoms appear to have remained constant and flares are not indicated. This examination report provides the evaluation required under Correia and Sharp. Instability Over the entire appeal period, a 10 percent rating is applied under DC 5257 for instability. During the initial March 2009 VA knee examination, the Veteran reported his left knee was weak, gave way, and lacked endurance. In April 2013, a VA examiner was unable to perform joint stability testing, however she observed functional loss due to instability of station in the left knee. The July 2016 VA examiner was also unable to perform joint stability testing. The October 2018 VA examiner noted the Veteran's report that his left knee frequently gave way and caused falls. However, he was also unable to provide joint stability tests. The October 2020 VA examiner noted a medical history of pain and locking in the knees which resulted in falls. He reported a history of slight left knee lateral instability and performed tests which revealed some left knee lateral instability. The June 2021 VA examiner did not indicate left knee instability, but he noted the Veteran had difficulty carrying his own weight which suggests instability. As discussed above, VA treatment records include multiple reports over the appeal period of the Veteran falling after his left knee gave way. The evidence also shows the Veteran used braces, canes, walkers, and crutches over the entire appeal period. These devices provided external support to increase stability. As the Veteran has a significant history of falling and continually used supportive medical devices, a severe level of instability is demonstrated over the entire appeal period. A rating of 30 percent for left knee instability under DC 5257 is warranted. 38 C.F.R. § 4.71a, DC 5257. A rating in excess of 30 percent is not available under the amended rating criteria for DC 5257. Consideration of these amended criteria is not required. See Kuzma, supra. Meniscal Injury VA regulations provide that conditions not listed in the rating schedule will be rated by analogy and coded with the first two numbers of the schedule provisions for the most closely related body part and "99." Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." 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. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Over the entire appeal period, a 10 percent rating under DC 5299-5259 is applied for degenerative changes of the left knee menisci. In this instance, the hyphenated diagnostic code reflects an unlisted left knee condition which is rated by analogy to "cartilage, semilunar, removal of, symptomatic." Under DC 5259, a maximum 10 percent rating is provided. 38 C.F.R. § 4.71a. The Board notes, a 20 percent rating for a meniscal injury is available under DC 5258. DC 5258 denotes "cartilage., semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. Here, a March 2010 left knee MRI confirmed degenerative changes of the menisci. The April 2013, October 2018, and October 2020 VA examiners diagnosed a left knee meniscal injury associated with symptoms of joint pain. Over the entire appeal period, the Veteran has reported significant left knee pain. This pain limited his ability to stand, walk, run, jump, climb, and sleep. Pain prohibited his participation in land based physical therapy. In addition, there is no evidence the Veteran has undergone any left knee surgery, including removal of the meniscus or any portion of the meniscus. The Board finds the Veteran has a diagnosed left knee meniscal condition. This condition is associated with continuous left knee pain. His meniscus has not been surgically removed or repaired. Accordingly, the Veteran's meniscal condition is more appropriately rated under DC 5258 and warrants a 20 percent rating over the entire appeal period. The Board notes, application of DC 5258 rather than DC 5259 is more beneficial to the Veteran as it results in an increased rating not available under DC 5259. 38 C.F.R. § 4.71a, DC 5258; see also Butts, supra. Limitation of Motion Currently, a 10 percent rating under DC 5260 is applied over the entire appeal period for left knee limitation of flexion. Generally, VA knee examinations over the appeal period measured left knee range of motion in flexion between 20 and 40 degrees, including after repeated use testing. While the October 2020 VA examination reported 105 degrees of flexion, this report is inconsistent with all other evidence of record. However, other evidence of record indicates left knee flexion was limited to 15 degrees or less. April 2010 VA treatment records show, following a cortisone shot, active left knee flexion was limited to 15 degrees with no reference to pain. In August 2014, a VA physical therapist observed left knee active range of motion was limited to between zero and five degrees. Resolving reasonable doubt in favor of the Veteran, left knee flexion has been limited to 15 degrees or less. A 30 percent rating for limited left knee extension is warranted over the entire appeal period. 38 C.F.R. § 4.71a, DC 5260. Over the entire appeal period there is no evidence left knee extension was limited to 10 degrees or more. A rating for limitation of extension, under DC 5261 is not warranted. In denying a rating under DC 5261, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, DC 5261. Additional Ratings A rating under DC 5256 is not indicated because there is no evidence of ankylosis. There is no evidence of impairment of the tibia and fibula to warrant a rating under DC 5262. There is no evidence of genu recurvatum to warrant a rating under DC 5263. 4. Entitlement to a total disability rating due to individual unemployability (TDIU) prior to June 13, 2016 TDIU may be assigned where the schedular rating is less than total if it is found that the claimant is unable to secure or follow a substantially gainful occupation as a result of 1) a single service-connected disability ratable at 60 percent or more, or 2) as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In determining entitlement to a TDIU, 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). Substantially gainful employment is defined as work that is more than marginal and permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The ultimate issue of whether TDIU should be awarded is not a medical issue but is a determination for the adjudicator. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2015). (Continued on the next page) In January 2009, the Veteran filed a claim seeking an increased rating for his left knee disability. In November 2017, the Board found entitlement to a TDIU was raised by the record as part and parcel of this claim. Subsequently, a November 2020 rating decision allowed a TDIU from June 16, 2020. At the time of the rating decision, the Veteran met the schedular requirements for TDIU from that date. Following the increased left knee ratings provided above, the schedular requirements are met over the entire appeal period. While the RO previously referred the claim to the Director of Compensation for extraschedular consideration prior to June 13, 2016, this referral is no longer necessary. The Board will consider whether TDIU is warranted, on a schedular basis, prior to June 13, 2016. Prior to June 13, 2016, service connection was established for a lumbar spine disability and for a left knee disability. In September 2012, the Veteran submitted a TDIU claim form. He reported completing one year of college and prior employment as a machinist and as a truck driver. He did not indicate his last day of employment, but the form reflects his highest earnings were in 2007 and 2008. Records from the Social Security Administration (SSA) are also associated with the claims file. These records include the Veteran's report that he last worked as a machinist in June 2008 and then worked as a butcher until December 2008. SSA records include the Veteran's report of completing two years of business college. In March 2009, a VA examiner noted the Veteran was not working and his knee disability would limit his ability to do prolonged standing or to walk for more than 10 to 15 minutes. In October 2011,Dr. D. S.. observed the Veteran's activities were limited by left knee pain and stiffness. In April 2013, a VA general medical examination included the examiner's opinion that the Veteran was physically limited by his service connected back and left knee disabilities. The Veteran could not lift more than 25 pounds or repetitively lift more than 15-25 pounds more than six times in one hour. He could not climb ladders, operate machinery, or do repetitive back bending more than six times in one hour. He was unable to perform tasks with prolonged standing or walking. In addition, a May 2010 VA pain medicine consult note includes the Veteran's report that pain impacted his energy level (described as low) and his ability to sleep (difficulty initiating sleep, non-restorative sleep, averaging one to one and a half hours of sleep each night.) His pain medications caused increased somnolence. VA treatment records from May 2012, June 2012, and June 2015 include the Veteran's reports of sleep difficulty due to knee pain. In February 2012, the Veteran requested and was prescribed hydrocodone for his back and knee pain. In July 2016, the Veteran's wife testified that the Veteran's mind was affected by his use of pain medications. She described him as not being himself and as flipping out on her. As a layperson, the Veteran's wife is competent to report her observations of the Veteran's behavior. Accordingly, the Board finds the Veteran's service connected back and knee disabilities reduce his ability to perform physical tasks, concentrate, learn new skills, complete tasks, and interact with co-workers or customers. Resolving reasonable doubt in favor of the Veteran, prior to June 13, 2016, he was unable to secure or follow a substantially gainful occupation as a result of his service-connected back and left knee disabilities. Accordingly, the Board finds that a TDIU is warranted prior to June 13, 2016. 38 C.F.R. § 4.16. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.