Citation Nr: 21066205 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 15-15 837 DATE: October 28, 2021 ORDER From March 19, 2014, entitlement to a 30 percent rating for painful and limited flexion of the right knee is granted. From March 19, 2014, entitlement to a separate 10 percent rating for painful right knee extension is granted. From March 19, 2014, entitlement to a separate 10 percent rating for right knee instability is granted. From March 19, 2014, entitlement to a 20 percent rating for painful and limited flexion of the left knee is granted. From March 19, 2014, entitlement to a separate 10 percent rating for painful left knee extension is granted. From March 19, 2014, entitlement to a separate 10 percent rating for left knee instability is granted. Entitlement to a rating in excess of 10 percent each for the Veteran's bilateral genu recurvatum is denied. From March 19, 2014, entitlement to a total disability rating due to individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. Veteran's right knee disability has more nearly approximated painful flexion limited to 15 degrees, painful extension limited to 10 degrees, and slight instability throughout the appeal period. 2. The Veteran's left knee disability has been manifested by painful flexion limited to 25 degrees, painful extension limited to 10 degrees, and slight instability throughout the appeal period. 3. Throughout the appeal period, the Veteran's bilateral genu recurvatum has been manifested as weakness with objectively demonstrated insecurity of station in weight-bearing. 4. From March 19, 2014, the Veteran met the schedular criteria for a TDIU and his service-connected disabilities precluded him from securing or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 30 percent rating, but no higher, for right knee limitation of flexion are met from March 19, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5260. 2. The criteria for entitlement to a 10 percent rating, but no higher, for right knee limitation of extension are met from March 19, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5261. 3. The criteria for a separate 10 percent rating, but no higher, for the Veteran's right knee instability have been met from March 19, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 4. The criteria for entitlement to a 20 percent rating, but no higher, for left knee limitation of flexion are met from March 19, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5260. 5. The criteria for entitlement to a 10 percent rating, but no higher, for left knee limitation of extension are met from March 19, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5261. 6. The criteria for a separate 10 percent rating, but no higher, for the Veteran's left knee instability have been met from March 19, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 7. The criteria for entitlement to a rating in excess of 10 percent for right knee genu recurvatum are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DC 5263. 8. The criteria for entitlement to a rating in excess of 10 percent for left knee genu recurvatum are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DC 5263. 9. A TDIU is granted from March 19, 2014. 38 U.S.C. § 1155; 38C.F.R. §4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1965 to May 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2016, the Veteran testified before the undersigned. In November 2016 and June 2020, the Board remanded these matters for additional development. This appeal has been advanced on the docket pursuant to 38 C.F.R. § 20.902. 1. From March 19, 2014, entitlement to a 30 percent rating for painful and limited flexion of the right knee is granted. 2. From March 19, 2014, entitlement to a 10 percent rating for painful right knee extension is granted. 3. From March 19, 2014, entitlement to a separate 10 percent rating for right knee instability is granted. 4. From March 19, 2014, entitlement to a 20 percent rating for painful and limited flexion of the left knee is granted. 5. From March 19, 2014, entitlement to a 10 percent rating for painful left knee extension is granted. 6. From March 19, 2014, entitlement to a separate 10 percent rating for left knee instability is granted. 7. Entitlement to rating in excess of 10 percent each for the Veteran's bilateral genu recurvatum, to include on an extraschedular basis, is denied. The Veteran asserts that he is entitled to higher ratings for his left and right knee disabilities. See March 2014 Claim, March 2015 Notice of Disagreement (NOD). The Board agrees. The Veteran is currently in receipt of 10 percent rating prior to April 27, 2021 and a 20 percent rating thereafter for his right knee painful limitation of flexion and a 10 percent rating for slight instability from April 27, 2021. The Veteran's left knee is currently rated as 10 percent disabling prior to April 27, 2021 and a 20 percent rating thereafter for his painful left knee flexion and a 10 percent rating for slight instability of the left knee from April 27, 2021. The Veteran filed a claim for an increased rating on March 19, 2014; thus the appeal period for consideration is from that date, plus the one year look back period. 38 C.F.R. § 3.400(o)(2). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. If two disability ratings are potentially applicable, 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. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. 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; DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (Court) later 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. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); See also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. 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). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher 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. Thus, VA must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Accordingly, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. In this regard, the Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claims. Relevant to any discussion of knee disabilities are the criteria under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Initially, the Board notes that the only rating criteria affected by the February 7, 2021 amendments are DC 5257 and DC 5262. Under DC 5256, favorable ankylosis of the knee, in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent disability rating; ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent disability rating; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent disability rating. Under DC 5257, the pre-amended rating criteria award a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. Under the amended rating criteria for DC 5257, 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. 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 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. The amended DC 5257 also provides for ratings based on patellar instability. 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. 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 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. 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. Under DC 5258, a claimant is entitled to a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5260, flexion of the leg limited to 60 degrees is rated as 0 percent disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. Under DC 5261, extension of the leg limited to 5 degrees is rated as non-compensable (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Under DC 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. Under the amended DC 5262, a 40 percent rating is warranted for nonunion of the tibia and fibula, with loose motion, requiring brace. Malunion of the tibia and fibula are to be 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. Separate ratings are also provided for medial tibial stress syndrome (MTSS) or shin splints. Under DC 5263, a 10 percent rating is warranted for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). VA regulations define normal flexion of the knee of 145 degrees and extension as 0 degrees. 38 C.F.R. § 4.71, Plate II. Throughout the appeal period, the Veteran submitted to VA examinations of his bilateral knees in July 2014, October 2019, October 2020, and April 2021. Initially, the Board notes that the July 2014 VA examiner failed to report "range of motion testing" for pain on both active and passive motion [and] weight-bearing and nonweight-bearing." Correia v. McDonald, 28 Vet. App. 158, 170 (2016). Thus, the July 2014 VA examination report is inadequate for rating purposes. The July 2014 VA examiner diagnosed bilateral genu recurvatum with osteoarthritis. The Veteran reported he experiences flare-ups that result in increased pain and restricted ambulation. Initial range of motion testing demonstrated the Veteran's right knee was limited to 130 degrees of flexion (with objective evidence of painful motion) and due to his genu recurvatum, hyperextension was noted. The Veteran's left knee was limited to 135 degrees of flexion (with objective evidence of painful motion) and due to his genu recurvatum, hyperextension was noted regarding the left knee. There were no additional losses in range of motion during repetitive use testing though the examiner noted more movement than is normal, pain on movement, and instability of station contributing to functional loss of the Veteran's knees. While the July 2014 VA examiner reported the Veteran experiences flare-ups, he failed to report what, if any, additional functional losses resulted from either repeated use over time or during flare-ups. See 38 C.F.R. §§ 4.40, 4.45, 4.59. See also Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017), (VA Clinician's Guide instructs orthopedic examiners to inquire whether there are periods of flare and, if the answer is yes, to state their severity, frequency, and duration; name the precipitating and alleviating factors; and estimate, per [the] veteran, to what extent, if any, they affect functional impairment). The July 2014 examination is also inadequate in this regard. The Veteran's bilateral knee strength was normal on testing, joint instability was normal, there was no evidence of recurrent patellar subluxation, no tibial or fibular impairment, and no meniscal conditions detected. Notably, the July 2014 VA examiner observed bilateral arthritis on imaging and categorized the Veteran's genu recurvatum as the most profound case of genu recurvatum he has ever seen and noted that his left knee, without bracing, hyperextends to - 20 degrees. The July 2014 VA examiner concluded the Veteran required knee braces for stable ambulation. The October 2019 VA examiner confirmed the Veteran's diagnoses of bilateral knee degenerative arthritis with genu recurvatum. The examiner recorded that the Veteran requires braces to avoid having both his knees hyperextend backwards, affecting his balance. While the Veteran denied flare-ups, he did report that he has to stop and rest after walking about 100 feet, that when he walks his knees feel weaker and more instable, and that after going up 5 steps at home the pain in his knees worsens and prevents further walking. Thus, it is clear to the Board based on the Veteran's reports that he was unclear as to what a flare-up meant when queried by the examiner, as his reports of functional loss increasing with use represent flares. Initial range of motion testing demonstrated that the Veteran's right knee flexion and left knee was limited to 140 degrees and hyperextension of -10 degrees was noted. The examiner noted painful flexion and extension and that during weight bearing his hyperextension worsened to -25 degrees. There was no additional loss in range of motion on repetitive use testing. The October 2019 VA examiner opined that during repeated use over time, the Veteran's bilateral knee flexion would be limited to 120 with hyperextension remaining at -25 degrees due to pain an incoordination. Notably, the October 2019 examiner concluded that without braces, the Veteran's genu recurvatum lead to a loss of balance and a significant limp. The October 2019 VA examiner noted good strength bilaterally and determined there was no ankylosis of either knee or joint instability on testing. The October 2019 VA examiner noted there was no impairment of the tibia or fibula, no meniscal conditions, and no prior surgery conducted for either knee. The October 2019 VA examiner, Dr. C.B., noted that the Veteran's range of motion was not more restricted during passive motion testing. See Correia, supra. However, as noted above, the Veteran reported symptoms consistent with flare-ups and the examiner did not ask the Veteran to what extent these periods of increased weakness, pain, and instability affected his range of motion. See 38 C.F.R. §§ 4.40, 4.45, 4.59. See also Sharp, supra. The October 2019 VA examiner noted the Veteran's genu recurvatum requires the use of knee braces to prevent hyperextension and balance problems, noted a range of motion from -25 degrees to 120 degrees bilaterally, and categorized the Veteran's genu recurvatum (hyperextension) as profound. The VA examiner also concluded that without braces, the Veteran's genu recurvatum results in a loss of balance and a significant limp. The October 2020 VA examiner was directed by the RO to only examine the Veteran's right knee. See August 2020 examination request. In this regard, the examiner failed to answer questions necessary for rating the left knee. See, Sharp, supra. Thus, the October 2020 VA examination report is inadequate for rating purposes. The Veteran reported that he experienced flare-ups that present as worsening pain and the feeling that the instability of his knees worsens. Initial range of motion testing for the Veteran's right knee demonstrated his flexion was limited to 110 degrees and his extension, due to genu recurvatum, was - 10 degrees. The examiner observed the Veteran's right knee was painful in both flexion and extension. Left knee initial range of motion testing demonstrated flexion limited to 140 degrees and hyperextension to -10 degrees. The examiner noted the Veteran did not display evidence of painful motion. There were no additional losses in range of motion and no additional functional impairment noted during repetitive use testing. The October 2020 VA examiner noted the Veteran's left knee flexion would be limited to 140 degrees with hyperextension to -10 degrees during repeated use over time but failed to address whether flare-ups would result in any additional loss in range of motion and the examination is inadequate in this regard. See Sharp, supra. The October 2020 examiner noted objective evidence of loss of strength in the Veteran's right knee and concluded the Veteran's left knee strength was normal. The October 2020 VA examiner concluded the Veteran's knees were not instable in any plane, that there was no evidence of any ankylosis, no history or diagnosis of a meniscal condition, and no surgical procedures on either knee have ever been conducted. The October 2020 VA examiner noted the Veteran required the use of a brace due to his arthritis and genu recurvatum. In an attempt to correct the complete lack of predicted losses during flare-ups throughout the appeal period, the RO requested that a VA examiner opine as to the same. In December 2020, the RO referred the matter to a VA examiner who had never examined the Veteran who opined that for the last 6 years, the Veteran's flare-ups would have consistently and without variation or worsening been limited to 115 degrees of flexion with hyperextension to -25 degrees during flare-ups bilaterally. The Board finds this sweeping generalization unsupported by any medical rationale or in-person examination that did not consider the recent October 2020 VA examination report to be of very little probative value. In April 2021, the Veteran submitted to the only VA examination of record that is adequate for rating purposes. The April 2021 VA examiner confirmed the diagnosis of bilateral knee arthritis with genu recurvatum and rendered a diagnosis of bilateral knee instability. The VA examiner noted that the Veteran would be precluded from operating a motor vehicle due to his knee disabilities. The Veteran reported pain after standing for 5 minutes, walking for a short distance, while carrying or lifting, and that he was unable to participate in many of his favorite hobbies. Initial range of motion testing demonstrated that the Veteran's right knee flexion is limited to 30 degrees and extension is limited to 10 degrees accompanied by objective evidence of painful motion on weight-bearing, nonweight-bearing, and active motion. The Veteran's left knee was limited to 25 degrees in flexion and 10 degrees in extension, both painful, on initial range of motion testing. The April 2021 VA examiner noted that pain was demonstrated on weight-bearing, nonweight-bearing, active motion, and resulting in functional loss. There were no additional losses bilaterally in range of motion on repetitive use testing. The April 2021 VA examiner opined that during repeated use over time, the Veteran's right knee would experience pain, fatigability, weakness, lack of endurance, and incoordination that would result in flexion limited to 25 degrees with extension remaining the same at 10 degrees. The April 2021 VA examiner opined that during repeated use over time, the Veteran's left knee disability would result in increased pain, fatigability, weakness, lack of endurance, and incoordination that would result in flexion limited to 30 degrees with extension remaining the same at 10 degrees. The examiner opined that during flare-ups, the Veteran's right knee flexion would be limited to 20 degrees and extension limited to 10 degrees. The examiner also opined that the Veteran's left knee would be limited to 25 degrees of flexion and 10 degrees of extension during a flare-up. There was no muscle atrophy or ankylosis detected in either lower extremity. The examiner noted bilateral recurrent subluxation of the Veteran's knees categorizing them as both moderately instable, both measuring +2 in posterior, medial, and lateral instability testing. However, she also concluded the Veteran was not required by a medical provider to wear a brace for ambulation. The Board notes that a VA orthopedic surgeon ordered custom-made de-rotation braces to control the Veteran's instability due to genu recurvatum in March 2006. The Veteran denied and the examiner endorsed that he has never been diagnosed with any impairment of the tibia or fibula, any meniscal conditions, or had any surgical interventions. At his Board hearing, the Veteran testified when he walks, he "wobbles," that his knees feel like they are going to "give way," and that he has fallen due to instability in parking lots. See August 2016 Board Hearing Transcript at 6, 15. The Veteran has not asserted, and the evidence does not reflect, that he has experienced ankylosis, a meniscal condition, or any impairment of the tibia or fibula at any time during the appeal period. Thus, DCs 5256, 5258, 5259, and 5262 are not for application. Moreover, the Board finds that throughout the appeal period, or from March 19, 2014, the Veteran's right knee disability more closely approximated painful flexion limited to 15 degrees and a 30 percent rating is warranted. See 38 C.F.R. § 4.2, 4.3, 4.6, 4.7, 4.71a, DC 5260. The Veteran's left knee disability has more closely approximated painful flexion limited to 30 degrees; thus, a 20 percent rating is warranted from March 19, 2014. Id. The April 2021 VA examiner noted the Veteran's bilateral extension was limited, remarkably, to 10 degrees and was painful on motion and thus warrants a 10 percent rating for each knee from March 19, 2014. See 38 C.F.R. § 4.2, 4.3, 4.6, 4.7, 4.71a, DC 5261. In his March 2015 NOD, the Veteran asserted that his bilateral genu recurvatum, which is currently rated at the schedular maximum, was not appropriately being compensated. 38 C.F.R. § 4.71a, DC 5263. As genu recurvatum is a disorder specifically contemplated by the schedule of ratings for the musculoskeletal system in 38 C.F.R. § 4.71a, DC 5263, rating by analogy is not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 336 (2015). Additionally, the Board notes that the Veteran's genu recurvatum has had a profound effect on his ability to maintain employment, ambulate without falling, and is preventing him from engaging successfully in the activities of daily living, such as driving and engaging in hobbies. See, e.g., April 2021 VA examination report. The Board also notes that the January 2020 remand included a referral to the Director of Compensation Service for consideration of an extraschedular rating for the Veteran's bilateral genu recurvatum, and this was not accomplished. However, the RO's non-compliance with this particular remand directive is inconsequential here, as the instant decision awards a TDIU in relation to the Veteran's bilateral knee disabilities for the entire appeal period, and thus adequately compensates the Veteran for his bilateral genu recurvatum symptoms above and beyond the schedular criteria, rendering moot the need for extraschedular referral. See Morgan v. Wilkie, 31 Vet. App. 162, 164 (2019) (VA's duty to maximize benefits requires it to exhaust all schedular alternatives for rating a disability before the extraschedular analysis is triggered). Accordingly, a rating in excess of 10 percent each for the Veteran's right and left genu recurvatum must be denied. While joint stability tests were normal with a slight history of lateral instability in the bilateral knees noted in the April 2021 examination report, the Veteran has competently and credibly reported use of a cane and a brace and stated that his knees "give out" on occasion. Additionally, the Veteran has been diagnosed with instability of the bilateral knees since at least March 2006. See March 2006 VA orthopedic treatment records. Therefore, the evidence is at least evenly balanced as to whether the Veteran's right and left knee symptomatology more nearly approximates slight recurrent lateral instability, thus separate 10 percent ratings for both the Veteran's right and left knee lateral instability under DC 5257 is warranted from March 19, 2014. However, given the normal stability test findings and lack of any history of surgical repair, a rating higher than 10 percent for moderate recurrent subluxation or lateral instability is not warranted under the pre-amended or amended DC 5257. 8. A TDIU is granted from March 19, 2014. Entitlement to a TDIU has been raised by the record and is a component of the instant appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities, provided that he 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. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16 For the purpose of determining if there is one 60 percent disability or one 40 percent disability in combination, multiple disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, or arising from the same etiology, are counted as one disability. 38C.F.R. §4.16(a). As of this Board decision, the Veteran is in receipt of a 30 percent rating for his right knee flexion, a 20 percent rating for his left knee flexion, bilateral 10 percent ratings for limited extension, bilateral 10 percent ratings for slight instability, and bilateral 10 percent ratings for genu recurvatum, all effective the date of the Veteran's claim (March 19, 2014). These bilateral knee disabilities combine to an 80 percent rating. 38 C.F.R. §§ 4.16(a)(1), 4.25, 4.26. Thus, throughout the appeal period, the Veteran has met the schedular criteria for a TDIU. Id. The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran's ability to secure or follow substantially gainful employment, including factors such as the veteran's history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58 (2019). Here, Social Security Administration (SSA) records demonstrate that the Veteran has been in receipt of disability income since March 2004 primarily for osteoarthritis. See June 2006 SSA Disability Determination and Transmittal. Additionally, consistent with SSA records, the Veteran reports that he was employed with a local newspaper for 15 years driving a large truck and then subsequently with the Kentucky Department of Highways where he also drove a truck, retiring from all work in 2003. See December 2019, February 2020 VA examination reports. Thus, as he is not currently earning an income, the Board finds he meets the economic component of a TDIU. The Veteran's work history, as demonstrated above, required his ability to operate heavy trucks on highways. The Veteran has reported that he left high school in the tenth grade and completed a General Education Diploma (GED) while on active duty. See December 2019 VA examination report. Thus, the Board concludes that the Veteran's post-service employment was mostly that of operating heavy machinery, to include trucks. At his August 2016 Board hearing, the Veteran testified that while working as a truck driver with the Kentucky Department of Highways, he could not operate the truck safely or properly shift gears while wearing his knee braces. See August 2016 Board Hearing Transcript at 6. The braces are now medically necessary due to his service-connected bilateral genu recurvatum to prevent hyperextension and maintain balance. See June 2014, October 2019 VA examination reports. The June 2014 and April 2021 VA examiners also noted the Veteran could not drive a truck, could not stand or walk for more than 5 minutes without increasing pain, that he experiences pain after sitting or standing for 5 minutes, that he could not ambulate without custom-braces and risks falls without them, and experienced pain carrying or lifting objects due to his service-connected bilateral knee degenerative disabilities. In October 2019, the Veteran reported that whenever he walks, he experiences instability of station, cannot sleep due to pain, and cannot walk more than 5 stairs at a time due to severe pain. Given the Veteran's education level of high school graduate equivalency, his primary occupation as a truck driver post-service, his inability to operate a truck due to his service-connected bilateral knee disabilities which was his only reported source of income as an adult post-military and combined with the severe restrictions noted above regarding both ambulatory and sedentary positions and his SSA disability status primarily caused by arthritis, the Board now finds that the Veteran is unable to secure and maintain substantially gainful employment solely due to his bilateral knee disabilities. Accordingly, a TDIU is granted from March 19, 2014. Additionally, the Board notes that while the Veteran is in receipt of a TDIU based on his knee disabilities alone and has additional and separate disabilities that combine to 60 percent from June 26, 2019, he is not eligible for a grant of special monthly compensation pursuant to 38 U.S.C. § 1114(s)(1), as his bilateral knee disabilities do not constitute a single disability under 38 C.F.R. § 3.350(i). See also Bradley v. Peake, 22 Vet. App. 280 (2008). S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Rouse, Associate 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.