Citation Nr: 21066360 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 14-01 990 DATE: October 29, 2021 ORDER From May 31, 2011 to July 4, 2013, a rating in excess of 20 percent for arthritis and chondromalacia of the right knee is denied. From July 5, 2013 to September 17, 2013, a rating in excess of 30 percent for arthritis and chondromalacia of the right knee is denied. Prior to January 24, 2018, a rating in excess of 10 percent for arthritis and chondromalacia of the left knee is denied. Prior to September 17, 2013, a rating in excess of 10 percent for instability of the right knee is denied. From October 11, 2016 to January 24, 2018, a separate 10 percent rating for left knee instability is granted. Prior to September 5, 2012, a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. From May 31, 2011 to July 4, 2013, the Veteran's right knee arthritis and chondromalacia was manifested by limitation of extension to no worse than 15 degrees, even considering painful motion, flare-ups and other factors. 2. From July 5, 2013 to September 17, 2013, the Veteran's right knee arthritis and chondromalacia was manifested by limitation of extension to no worse than 20 degrees, even considering painful motion, flare-ups and other factors. 3. Prior to January 24, 2018, the Veteran's left knee arthritis and chondromalacia was manifested by limitation of flexion to no worse than 45 degrees, even considering painful motion, flare-ups and other factors. 4. Prior to September 17, 2013, the Veteran's right knee instability was manifested by no worse than slight instability. 5. From October 11, 2016 to January 24, 2018, the Veteran experienced slight left knee instability. 6. Prior to September 5, 2012, the Veteran was not prevented from securing and following substantially gainful employment as a result of her service-connected disabilities. CONCLUSIONS OF LAW 1. From May 31, 2011 to July 4, 2013, the criteria for a rating in excess of 20 percent for arthritis and chondromalacia of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5261. 2. From July 5, 2013 to September 17, 2013, the criteria for a rating in excess of 30 percent for arthritis and chondromalacia of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261. 3. Prior to January 24, 2018, the criteria for a rating in excess of 10 percent for arthritis and chondromalacia of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260. 4. Prior to September 17, 2013, the criteria for a rating in excess of 10 percent for instability of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.14, 4.71a, DC 5257. 5. From October 11, 2016 to January 24, 2018, the criteria for a separate 10 percent rating for slight instability of the left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, DC 5257. 6. Prior to September 5, 2012, the criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1982 to May 1991. The case is on appeal from an October 2011 rating decision. In January 2019, the Veteran testified at a Board hearing. Most recently, in a January 2021 decision, the Board adjudicated five rating claims and remanded the remaining claims for further development. While the case was in remand status, in a February 2021 rating decision pursuant to the Board's January 2021 decision, the RO increased the Veteran's right knee rating to 20 percent effective May 31, 2011. Thereafter, in an April 2021 rating decision, the RO increased the right knee rating to 30 percent effective July 5, 2013. Although higher ratings have been assigned for the right knee disorder, the increased rating matter remains in appellate status as the maximum ratings have not been assigned. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Additional evidence was received subsequent to the most recent supplemental statement of the case (SSOC) issued in May 2021. As the evidence is not pertinent to the claims on appeal, a remand for RO consideration of the evidence is not necessary. See 38 C.F.R. § 20.1305(c). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran, her representative and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating General Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). An effective date for an increased rating should not be assigned mechanically based on the date of a diagnosis. Rather, all of the facts should be examined to determine the date that the disability first manifested. Accordingly, the effective date for an increased rating-as well as for an initial rating or for staged ratings is predicated on when the increase in the level of disability can be ascertained. Swain v. McDonald, 27 Vet. App. 219, 224 (2015); DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). Effective February 7, 2021, VA published a final rule amending its regulations on the musculoskeletal system, to include amending DCs. See 85 Fed. Reg. 76453 (November 30, 2020). Claims pending prior to the February 2021 effective date will be considered under both old and new rating criteria and whichever criteria is more favorable to the Veteran will be applied. However, as the current musculoskeletal claims are all being reviewed for rating periods prior to February 7, 2021, only the old rating criteria will be applied. 1. From May 31, 2011 to July 4, 2013, a rating in excess of 20 percent for arthritis and chondromalacia of the right knee. 2. From July 5, 2013 to September 17, 2013, a rating in excess of 30 percent for arthritis and chondromalacia of the right knee. Specific Legal Criteria Prior to the Veteran's September 2013 total right knee replacement surgery, her right knee range of motion disability was rated under DC 5261, pertaining to limitation of extension of the knee. Under DC 5261, limitation of extension of a leg to 5 degrees warrants a zero percent rating. A 10 percent rating requires that extension be limited to 10 degrees. A 20 percent rating requires that extension be limited to 15 degrees. A 30 percent rating requires that extension be limited to 20 degrees. A 40 percent rating requires that extension be limited to 30 degrees. A 50 percent rating requires that extension be limited to 45 degrees. See 38 C.F.R. § 4.71a, DC 5261. Normal range of motion of the knee is zero to 140 degrees. See 38 C.F.R. § 4.71, Plate II. Facts Following the Veteran's May 2011 claim for an increased right knee rating, she was afforded an August 2011 VA examination. On examination, the examiner found abnormal movement, effusion and tenderness, with no edema, instability, weakness, deformity, guarding or malalignment. The examiner indicated there was crepitus with no ankylosis. Range of motion testing revealed flexion limited to 128 degrees with pain beginning at 128 degrees. Extension was limited to zero degrees with pain at zero degrees. After repetitive motion testing, there was no additional limitation in motion. The examiner reported the stability testing was all within normal limits. The Veteran's right knee pain was noted to increase with increased activities. The Veteran was afforded a July 2013 VA examination in which the examiner indicated a diagnosis of right knee degenerative joint disease with instability. Flare-ups were not found for the right knee. The examiner reported flexion was limited to 130 degrees with pain beginning at 100 degrees. Extension was limited to 5 degrees with pain beginning at 5 degrees. Following repetitive testing, the examiner indicated her flexion and extension were not further reduced. She stated the Veteran's symptoms include less movement than normal, excess fatigability, pain during movement, swelling, disturbance of locomotion and interference with sitting, standing and weight-bearing. With regard to instability, the examiner found mild right knee instability, including medial-lateral instability 1+ (0-5 millimeters). The examiner noted frequent episodes of joint pain, as well as residual signs and symptoms due to a meniscectomy. She reported the Veteran cannot stand for more than 15 minutes, walk further than one block without pain or lift greater than 20 pounds, and walking on the stairs is limited. She further indicated there is a loss in right knee range of motion of 10 degrees of flexion, during a flare-up or upon repetitive use due to pain and swelling. Thereafter, the Veteran underwent a September 2013 right total knee arthroplasty, as well as an April 2014 right knee patellar revision surgery. The Board notes the Veteran has received treatment for her right knee disorder through the VA Medical Center. An August 2012 VA treatment record indicated reports of chronic right knee pain and instability, as well as patellofemoral osteoarthritis. An October 2012 VA record noted constant right knee pain, an increase of pain at night and instability of the right knee. A January 2013 VA record included range of motion testing which showed flexion was limited to 125 degrees and a March 2015 record reported severe right knee pain. The claim came before the Board in June 2019 and was remanded for further development. Pursuant to the Board's June 2019 remand, the Veteran was afforded a VA examination in July 2020, as well as an addendum opinion in August 2020 to provide a retroactive opinion regarding the prior rating period on appeal. The August 2020 addendum opinion indicated a retroactive opinion as to the severity of the Veteran's right knee prior to September 2013 would be too speculative due to the length of time that has elapsed since the prior VA examinations in August 2011 and July 2013. In January 2021, the Board remanded the claim for another VA opinion. The Board directed the examiner to estimate the amount in degrees of range of motion lost due to right and left knee flare-ups experienced by the Veteran at the time of the VA examinations conducted in August 2011 and July 2013. A February 2021 VA opinion was provided in which the examiner opined based on the severity of the Veteran's right knee condition from the progression of the disorder to the total right knee replacement in September 2013 and revision surgery in March 2014, and without resorting to speculation, additional range of motion loss is indicated. Moreover, he indicated during the August 2011 VA examination, the Veteran's flexion was limited to 100 degrees and extension to zero degrees, with pain, fatigue, and lack of endurance causing functional loss. For the July 2013 VA examination, the examiner stated the Veteran's flexion was limited to 85 degrees with extension limited to 20 degrees, with pain, fatigue, weakness and lack of endurance causing functional loss. Analysis After a careful review of the evidence, the Board determines that increased ratings are not warranted for the Veteran's right knee arthritis. The Board finds from May 31, 2011 to July 4, 2013, the Veteran's right knee disorder approximated limitation of extension to no worse than 15 degrees and the current 20 percent rating is appropriate. Further, from July 5, 2013 to September 17, 2013, the right knee condition approximated limitation of extension to no worse than 20 degrees and the current 30 percent rating is supported. The evidence shows that the Veteran experienced significant right knee symptoms during the period on appeal, including effusion, tenderness and limited movement. Further symptoms noted in the medical evidence include excess fatigability, swelling, disturbance of locomotion and trouble standing more than 15 minutes and walking further than one block. Even with the noted limitations, the evidence does not reflect that the Veteran's right knee symptoms approximate a functional loss greater than what is already contemplated by the assigned 20 percent rating from May 31, 2011 to July 4, 2013, and the 30 percent rating thereafter. The Board takes note of the January 2021 Board remand and post-remand February 2021 VA opinion. The February 2021 examiner adequately responded to the remand questions and thoroughly addressed the prior August 2011 and July 2013 VA examination reports, to include with estimates as to the additional degrees of range of motion lost due to right knee flare-ups. As noted above, such opinion was the basis for the increased right knee rating to 30 percent effective July 5, 2013 by the RO. In sum, the Board finds that increased ratings prior to September 17, 2013 are not warranted for the Veteran's service-connected right knee arthritis and chondromalacia. From May 31, 2011 to July 4, 2013, a rating in excess of 20 percent is not warranted and from July 5, 2013 to September 17, 2013, a rating in excess of 30 percent is not supported. As such, the preponderance of the evidence is against the claims and increased ratings are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 3. Prior to January 24, 2018, a rating in excess of 10 percent for arthritis and chondromalacia of the left knee. Specific Legal Criteria Prior to the Veteran's January 2018 left knee replacement surgery, her left knee disorder was rated under DC 5260, pertaining to limitation of flexion of the knee. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. Normal range of motion of the knee is zero to 140 degrees. See 38 C.F.R. § 4.71, Plate II. Facts Following the Veteran's May 2011 claim for an increased rating, she was afforded an August 2011 VA examination. The examiner found the left knee showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, deformity, malalignment or guarding. The examiner did note the presence of pain and crepitus. Range of motion testing revealed flexion to 135 degrees with pain beginning at 135 degrees and extension to zero degrees with pain at zero degrees. Following repetitive testing, there was no additional limitation of motion. The examiner found stability testing for the left knee was within normal limits and there was no instability indicated. The Veteran was afforded a July 2013 VA examination in which no flare-ups were reported. Range of motion testing revealed flexion to 140 degrees with pain beginning at 130 degrees and no limitation in extension or objective evidence of painful motion. Following repetitive testing, there was no further limitation of flexion or extension. The examiner indicated the Veteran has pain and excess fatigability of the left knee with no instability found. The Veteran has received treatment for her left knee disorder through the VA Medical Center. A March 2016 VA treatment record indicated she reported pain and swelling of the left knee. An October 2016 VA record indicated the Veteran reported her left knee "gave out." She stated it was extremely painful to put any weight on it and she experienced chronic left knee pain. A September 2017 VA record indicated ongoing left knee pain. As noted, the Veteran underwent a January 2018 left knee replacement surgery. Following the Board's June 2019 remand, the Veteran was afforded a July 2020 VA examination, as well as an addendum opinion in August 2020 to provide a retroactive opinion regarding the prior rating period on appeal. The August 2020 addendum opinion indicated a retroactive opinion was not possible and would be too speculative due to the length of time that has elapsed since the prior VA examinations in August 2011 and July 2013. Following the Board's January 2021 remand, a February 2021 VA opinion was provided. The February 2021 examiner indicated after review of the evidence, there was only minimal additional limitation of motion related to the left knee disorder, prior to September 2013. He stated based on the severity of the Veteran's left knee disorder from the progression of the disability to the January 2018 total knee replacement, the additional range of motion loss for the August 2011 VA examination was flexion limited to 125 degrees and extension to zero degrees, with pain causing functional loss. For the July 2013 VA examination, the examiner reported the Veteran's flexion was limited to 130 degrees with extension limited to zero degrees, and with pain causing functional loss. Analysis The Board determines an increased rating for the Veteran's left knee disorder, prior to January 24, 2018, is not warranted. Her left knee arthritis and chondromalacia was manifested by limitation of flexion to no worse than 45 degrees, even with consideration of her pain and other symptoms. The evidence prior to the January 2018 left knee replacement surgery does not show that the Veteran's left knee disorder approximated limitation of flexion to 30 degrees, suggestive of a higher rating. The August 2011 VA examination report indicated flexion limited to 135 degrees with pain beginning at 135 degrees and extension to zero degrees with pain at zero degrees. Further, the July 2013 VA examination report noted flexion to 140 degrees with pain beginning at 130 degrees and no limitation in extension. The Board acknowledges the October 2016 VA record which indicated chronic left knee pain and that the Veteran reported her left knee "gave out." However, left knee instability, including a separate rating for instability is addressed below. Additionally, the Board notes the post-remand February 2021 VA opinion which indicated only minimal additional limitation of motion related to the left knee disorder, prior to January 2018. The examiner reported the August 2011 VA examination had additional limitation of flexion to 125 degrees and the July 2013 VA examination had additional limitation in flexion to 130 degrees. In sum, the Board finds that an increased rating for arthritis and chondromalacia of the left knee prior to January 24, 2018 is not warranted. The left knee arthritis and chondromalacia manifested limitation of flexion to no worse than 45 degrees. As such, the preponderance of the evidence is against the claim and an increased rating in excess of 10 percent is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 4. Prior to September 17, 2013, a rating in excess of 10 percent for instability of the right knee. 5. From October 11, 2016 to January 24, 2018, whether a separate 10 percent rating is warranted for slight left knee instability. Specific Legal Criteria DC 5257 provides for a 10 percent rating for either slight recurrent subluxation or slight lateral instability. Moderate recurrent subluxation or moderate lateral instability is rated 20 percent disabling. Severe recurrent subluxation or severe lateral instability is rated 30 percent disabling. Facts Following the May 2011 claim for an increased rating for right knee instability, the Veteran was afforded an August 2011 VA examination. The examiner found no right or left knee instability or weakness on examination. The Veteran was afforded a July 2013 VA examination in which the examiner indicated the presence of right knee instability. No left knee instability was found. She stated the Veteran's right knee showed mild instability, including medial-lateral instability 1+ (0-5 millimeters). The examiner noted frequent episodes of joint pain, as well as residual signs and symptoms due to a meniscectomy. As noted, no left knee instability was indicated by the examiner. With regard to the right knee, an August 2012 VA treatment record indicated reports of chronic right knee pain and instability, as well as patellofemoral osteoarthritis. An October 2012 VA record noted constant right pain, an increase of pain at night and instability of the knee. As addressed above, the Veteran underwent a September 2013 right total knee arthroplasty, as well as an April 2014 right knee patellar revision surgery. With regard to the left knee, an October 2016 VA record indicated the Veteran reported her left knee "gave out." The Veteran stated it was extremely painful to put any weight on her left knee. The record further indicated chronic left knee pain. Additionally, during the January 2019 Board hearing, the Veteran reported experiencing left knee instability. She reported she has trouble walking in a straight line without feeling that her left knee will give out. She stated she has overcompensated on her left side due to her right knee symptoms which has led to increased instability or "giving way" of the left knee. As noted, the Veteran underwent a January 2018 left knee replacement surgery. Analysis The Board determines that prior to September 17, 2013, a rating in excess of 10 percent for right knee instability is not warranted. However, a separate 10 percent rating due to slight left knee instability is supported, from October 11, 2016 to January 24, 2018. With regard to the right knee, the evidence of record does not support right knee instability greater than slight in severity, and therefore, a rating in excess of 10 percent is not warranted. Initially, the May 2011 VA examiner found no right knee instability. While the July 2013 examiner indicated instability was present, she determined such was mild, including medial-lateral instability 1+ (0-5 millimeters). Further, VA treatment records noted instability, but not to the level of moderate recurrent subluxation or moderate lateral instability, suggestive of a higher rating. Thus, prior to September 17, 2013, a rating in excess of 10 percent for right knee instability is not warranted. With regard to the left knee, the Board finds that the medical evidence of record, along with the Veteran's January 2019 hearing testimony, supports that she experienced slight left knee instability from October 11, 2016, indicative of a 10 percent rating under DC 5257. The Board notes the earliest evidence suggestive of left knee instability is the October 2016 VA treatment record in which the Veteran reported her left knee "gave out" and she had difficulty putting weight on it. Additionally, during the January 2019 Board hearing, the Veteran reported experiencing left knee instability, including overcompensating on her left side due to her right knee disorder which led to increased instability or "giving way." The Board notes that awarding the Veteran a separate 10 percent rating for left knee instability under DC 5257, from October 11, 2016 to January 24, 2018, does not constitute pyramiding. The Veteran has received a 10 percent rating from October 11, 2016 to January 24, 2018, under DC 5260; however, the symptoms for which the Veteran receives the 10 percent rating are separate and distinct from the instability rating under DC 5257. As the ratings are not based on the same manifestations of the disability, this does not constitute pyramiding. Moreover, the assignment of a particular DC is "completely dependent on the facts of a particular case" and the Board can choose the DC to apply so long as it is supported by reasons and bases as well as the evidence. Butts v. Brown, 5 Vet. App. 532, 538 (1993). In sum, after resolving reasonable doubt in the Veteran's favor, the evidence of record supports the presence of slight left knee instability from October 11, 2016 to January 24, 2018. Further, the Board determines a rating in excess of 10 percent for right knee instability, prior to September 17, 2013, is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 6. Prior to September 5, 2012, a TDIU. Legal Criteria Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran 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, such disability shall be ratable as 60 percent or more, and 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). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: The veteran's history, education, skill, and training; Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). For purposes of this decision, the Board uses the term "sedentary" to have the common meaning of a non-physical job, primarily involving sitting and usually performed in an indoor, office-type environment. See Withers v. Wilkie, 30 Vet. App. 139, 147-48 (2018). Facts The Veteran asserts that she is unable to work due to her service-connected disabilities. The Veteran's combined disability ratings were 100 percent from September 5, 2012, with several prior periods in which she was assigned temporary 100 percent ratings. The Board notes the Veteran is service connected for PTSD with a 70 percent rating from September 5, 2012. In her initial June 2011 TDIU application, the Veteran indicated she last worked full-time in November 2008 as a security guard. Thus, the period of review for entitlement to a TDIU is November 2008 to September 5, 2012. The June 2011 TDIU application also reported that the Veteran is a college graduate with additional education or training, including Social Worker Supervisor certification and Merchant Security Guard certification. Additionally, the Board notes she worked from March 2001 to January 2007 as a supervisor for the city and county of Denver, Department of Human Services. The Veteran was afforded a July 2008 VA examination for her musculoskeletal disabilities. The examiner indicated the Veteran has constant low back pain, which increases with any twisting or lifting, and additional symptoms of weakness and stiffness. However, she stated the Veteran is able to function in her usual occupation. The examiner noted the Veteran can walk for one to two hours and sit for 15 to 20 minutes. With regard to her bilateral knees, the examiner indicated the disabilities make walking difficult for the Veteran. However, she reported the Veteran had not missed any days in her usual occupation due to her knees. For the ankles, the examiner indicated the Veteran experiences pain and swelling, especially with walking. With regard to the bilateral hips, the examiner reported she has pain and stiffness, as well as a sense of instability where her hip "goes out." The Veteran was afforded an October 2010 VA examination in which the examiner indicated the Veteran is unable to work as a security guard, as she is unable to ambulate for more than a few minutes and cannot run due to ankle and knee pain. She stated the Veteran's left ankle disorder causes significant effects on her usual occupation, due to decreased mobility and pain. As noted, in the initial June 2011 TDIU application, the Veteran reported that she last worked as a Merchant Security Guard in November 2008. The Veteran was afforded an August 2011 VA examination for her musculoskeletal disabilities. For the left hip disorder, the Veteran reported difficulty with movement and pain, and difficulty standing and walking. However, the examiner stated she does not experience any overall functional impairment from the left hip disorder. With regard to the left knee and right ankle disorders, the examiner reported she does not experience any overall functional impairment from these disorders. For the left ankle condition, the examiner noted the Veteran has trouble with household chores, sitting, standing and walking. With regard to the back disorder, the examiner similarly indicated she experiences pain throughout her back, which limits her standing, sitting and walking. The August 2011 VA examiner opined the Veteran cannot perform tasks with prolonged standing, walking or carrying; however, she may perform sedentary work as long as she has the ability to change positions frequently. He indicated although the Veteran has back and knee pain, she can safely perform sedentary jobs which do not require heavy lifting, climbing or extensive walking or running. The Veteran was afforded a July 2013 VA spine examination in which the examiner concluded the Veteran cannot walk or stand for long periods, cannot lift 20 or more pounds and must sit for 30 minutes or less due to her back symptoms. With regard to the knee disorders, the examiner reported the Veteran is limited in standing to 15 minutes, walking to no more than one block, lifting to 20 pounds and with limited use of the stairs. During the Veteran's January 2019 Board hearing, she testified that her service-connected disabilities prevented all substantially gainful employment. Her representative stated that the Veteran worked with a security company and for Goodwill, both positions which were not sedentary in nature. He noted the ability to perform sedentary employment does not prevent entitlement to a TDIU. He further indicated the Veteran's physical disabilities alone prevented substantially gainful employment prior to September 5, 2012. Analysis After review of the medical and lay evidence of record, the Board finds the Veteran was not prevented from all substantially gainful employment due to her service-connected disabilities, prior to September 5, 2012. While the Veteran reported she stopped working as a Merchant Security Guard in November 2008, the evidence does not support that her service-connected musculoskeletal disabilities prevented all substantially gainful employment at that time. As noted, the Veteran is service-connected for PTSD with a 70 percent rating from September 5, 2012, the date in which she receives a combined 100 percent rating. The Board determines prior to September 5, 2012, and based solely on her musculoskeletal disorders, the Veteran has not been prevented from all employment. The Board determines the Veteran was capable of working in a sedentary-type occupation prior to September 5, 2012. As noted, the Board is using the term "sedentary employment" in its commonly held meaning of a non-physical, light-duty, office-type job which primarily involves sitting. See Withers, 30 Vet. App. at 139. As noted, the July 2008 VA examiner reported the Veteran has ongoing symptoms and limitations based on her musculoskeletal disorders, including pain, weakness, stiffness and limited standing and walking. However, the examiner opined the Veteran is able to function in her usual occupation based on her back, knees, ankle and hip disabilities. Thereafter, the Board acknowledges the October 2010 VA examination report which indicated the Veteran is unable to work as a security guard due to her decreased mobility. While the opinion suggests the Veteran could no longer work as a security guard, the examiner did not adequately discuss whether the Veteran was capable of performing any substantially gainful employment. Further, the subsequent August 2011 VA examination report found the Veteran does not have any overall functional impairment from the left hip, left knee and right ankle conditions. With regard to her left ankle and back conditions, the August 2011 examiner reported she has difficulty with prolonged sitting, standing and walking; however, the examiner stated the Veteran can perform sedentary work as long as she has the ability to change positions frequently and can avoid heavy lifting, climbing or extensive walking or running. The Board finds the medical evidence of record does not support that the Veteran is prevented from performing sedentary employment due to her service-connected disabilities, prior to September 5, 2012. The Board notes the Veteran is a college graduate with additional education or training, including Social Worker Supervisor certification and Merchant Security Guard certification. While she experienced impairment due to her service-connected musculoskeletal disabilities prior to September 2012, the evidence does not suggest the Veteran is prevented from all employment, including sedentary employment, due to her service-connected disabilities. (Continued on the next page) The Board is sympathetic to the Veteran's assertions regarding the impact her disabilities had on her ability to work prior to September 5, 2012, both professionally and personally. However, those problems are compensated by the schedular ratings assigned for such disabilities, including several previous periods in which the Veteran was assigned temporary 100 percent ratings from November 2008 to September 2012. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Moreover, while the Veteran's service-connected disabilities have caused some economic impairment, her assigned disability ratings have contemplated her level of occupational impairment. A TDIU claim is not purely a medical question. Here, the Board has considered both the relevant medical evidence, as well as the non-medical evidence such as work history, education level and additional training. As discussed above, the Veteran is a college graduate with additional training and prior to September 2012, she was capable of working in a sedentary or non-physical occupation performed in an office-type environment. Moreover, the Board notes she worked from March 2001 to January 2007 in a sedentary position, as a supervisor for the city and county of Denver, Department of Human Services. In sum, the preponderance of the evidence is against the claim and the Board finds the Veteran was not prevented from securing and following all substantially gainful employment as a result of her service-connected disabilities, prior to September 5, 2012. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, a TDIU is not warranted prior to September 5, 2012. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Isaacs, Brandon 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.