Citation Nr: 21005268 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 15-10 509 DATE: February 1, 2021 ORDER A rating higher than 30 percent for right knee degenerative joint disease is denied. A rating higher than 20 percent for lumbar spine degenerative disc and joint disease with spinal stenosis is denied. A rating higher than 20 percent for right leg distal tibia and fibula fracture with traumatic arthritis is denied. A compensable rating for right eye diabetic retinopathy is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The Veteran’s right knee degenerative joint disease manifests as painful motion limited to no less than 110 degrees flexion and no more than 20 degrees extension. 2. The Veteran’s lumbar spine degenerative disc and joint disease with spinal stenosis manifests as painful motion and limitation to no less than 45 degrees flexion. 3. The Veteran’s right leg distal tibia and fibula fracture with traumatic arthritis manifests as marked limitation of dorsiflexion, but not a marked ankle disability generally. 4. The Veteran’s right eye diabetic retinopathy does not manifest as visual impairment and did not result in any incapacitating episodes. 5. The Veteran’s service-connected disabilities have not rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 30 percent for right knee degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5262-5014. 2. The criteria for a rating higher than 20 percent for lumbar spine degenerative disc and joint disease with spinal stenosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5292. 3. The criteria for a rating higher than 20 percent for right leg distal tibia and fibula fracture with traumatic arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5271-5262. 4. The criteria for a compensable rating for right eye diabetic retinopathy have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79 Diagnostic Codes 6006-6606. 5. The criteria for TDIU have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 3.102, 3.340, 3.341, 4.3, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty, including from October 1978 to February 1993. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a February 2015 correspondence, the Veteran withdrew his claim for an increased rating for right hip extremity sciatica. In June 2018, the Board remanded this claim, including the issue of a TDIU that was raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), for further development. During the pendency of this appeal, in an April 2017 rating decision, the RO found clear and unmistakable error (CUE) in the October 2014 rating decision insofar as the effective date assigned for the grant of service connection for right hip sciatica, the disability evaluation assigned for right knee degenerative joint disease, and the disability rating assigned for lumbar spine degenerative disc and joint disease with spinal stenosis; found CUE in the March 2015 rating decision insofar as the effective date assigned for right hip mechanical strain; and found CUE in the February 2016 decision review officer (DRO) decision insofar as the effective date assigned for right leg discrepancy. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 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). Per Correia v. McDonald, 28 Vet. App. 158 (2016), 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.” The spine has no opposite 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. Hyphenated diagnostic codes are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number is “built up” with the first two digits being selected from that part of the schedule most closely identifying the part, and the last two digits being “99” for an unlisted condition. Id. 1. A rating higher than 30 percent for right knee degenerative joint disease The Veteran was originally granted service connection for right knee arthralgia in a March 2004 rating decision. At that time, this disability was assigned a 10 percent rating effective December 31, 2002. The Veteran filed a claim for an increased rating in February 2007 that was denied in a June 2007. This rating decision recharacterized the disability as right knee patellofemoral syndrome. The Veteran’s current claim for an increased rating was received on June 18, 2014. The October 2014 rating decision on appeal granted a 30 percent rating effective June 18, 2014. The Veteran has appealed that rating. During the pendency of the appeal, in an April 2017 rating decision, the RO found clear and unmistakable error in the October 2014 rating decision insofar as the disability evaluation assigned for right knee degenerative joint disease and proposed a reduction to 10 percent. This proposed reduction was not enacted. The Veteran’s right knee disability is rated under 38 C.F.R. § 4.71a, hyphenated Diagnostic Code 5003-5261. Diagnostic Code 5003 provides rating criteria for degenerative arthritis substantiated by x-ray findings, rated either on limitation of motion of the affected joint under the appropriate diagnostic code or, if only a noncompensable limitation of motion is found, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating is warranted if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is warranted if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Additionally, under DC 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Normal range of motion of the knee is zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71a, Plate II. If the criteria for a compensable rating under both DC 5260 and DC 5261 are met, separate ratings can be assigned. VAOPGCPREC 9-2004 (Sept. 17, 2004). Similarly, a claimant who has both arthritis and instability of the knee may be rated separately under DC 5010 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). A September 2014 VA knee conditions disability benefits questionnaire (DBQ) noted the Veteran’s complaints of knee pain. He denied swelling or redness. He occasionally had a “hot poker” sensation, but was frequently able to relieve this by getting up and stretching. He denied flare-ups that impacted the function of his knee or lower leg. A physical examination found active range of motion of the right knee from 20 degrees extension to 120 degrees flexion, which was increased to 125 degrees of flexion after three repetitions. There was no objective evidence of painful motion. Functionally, the Veteran’s right knee disability resulted in less movement than normal. He did not have localized tenderness of pain on palpation of the joints/soft tissue of either knee. He had full muscle strength, and joint stability testing results were normal. He did not have ankylosis of the knee. The Veteran did not currently or historically have “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. He had not had any meniscal condition or surgical procedures for a meniscal condition. He had not had a total knee joint replacement, arthroscopic, or other knee surgery. He did not have any associated scars. Right knee crepitation was noted on passive range of motion. He did not use an assistive device as a normal means of locomotion. This disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies did not show arthritis, patellar subluxation, or any other significant diagnostic findings or result. This disability did not impact his ability to work. The February 2015 VA knee and lower leg conditions DBQ found bilateral patellofemoral pain syndrome. He stated that his left knee did not bother him, but his right knee hurt along the inferior and superior patellar borders. It would hurt if he was on his feet for two hours. There was no locking, giving way, or swelling. Kneeling in his garden did not hurt his knees as the ground was soft, but he did have trouble standing from a kneeling position; he had to grab something to get up. Part of this was due to his right ankle’s difficulty with dorsiflexion. He did not report flare-ups or any functional loss/impairment. His range of motion was from 5 degrees extension to 125 degrees flexion in the right knee and from zero degrees extension to 130 degrees flexion in the left knee. The range of motion itself did not contribute to functional loss. No pain was noted on exam. There was no evidence of pain with weight bearing. There was objective evidence of right knee tenderness along the superior and lateral patellar borders and slight left knee tenderness along the superior patellar border. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss of limitation of range of motion. The Veteran was not examined immediately after repetitive use over time, and this examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, and incoordination did not limit functional ability with repetitive use over time. Again, the Veteran did not report flare-ups. There were no additional factors contributing to disability in either knee. He had full muscle strength bilaterally and no muscle atrophy. He did not have ankylosis of either knee. The Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion in either knee. Stability testing was performed, and no instability was found in either knee. The Veteran had a 2-centimeter leg length discrepancy, left leg longer than right leg, but this was attributed to right ankle fracture, not a knee condition. He had not had any meniscal condition or surgical procedures for a meniscal condition. He reported a history of arthroscopic surgery on his left knee, but could not recall the date or details. He did not have any associated scars. He did not use an assistive device as a normal means of locomotion. This disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. Imaging studies were performed, but did not find arthritis. This disability did not impact the Veteran’s ability to work, but the examiner did note that the other disabilities would preclude moderate or heavy physical activity. The March 2017 VA knee and lower leg conditions DBQ noted the Veteran’s complaints of generalized knee pain and occasional locking, especially when descending stairs. He reported flare-ups of right knee pain caused by kneeling, mowing lawn with push mower, walking on hard surfaces, stairs, and standing too long. His range of motion was from 5 degrees extension to 120 degrees flexion in the right knee and from 5 degrees extension to 135 degrees flexion in the left knee. The range of motion itself did not contribute to functional loss. Pain was noted in right knee flexion, but did not result in or cause functional loss. There was no evidence of pain with weight bearing. There was not objective evidence of localized tenderness or pain on palpation. There was objective evidence of crepitus in the right knee. The Veteran was able to perform repetitive use testing without additional functional loss of limitation of range of motion. There were no additional factors contributing to disability in either knee. He had full muscle strength bilaterally and no muscle atrophy. He did not have ankylosis of either knee. The Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion in either knee. Stability testing was performed, and no instability was found in either knee. The Veteran did not currently or historically have “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran did not have a current meniscal condition or a history of one, but did report a history of arthroscopic debridement with residual stiffness. He did not have any associated scars or any other pertinent physical findings, complications, conditions, signs, or symptoms associated with this disability. He did not use an assistive device as a normal means of locomotion. This disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were performed and confirmed bilateral knee arthritis. This disability would impact the Veteran’s ability to work, in that it would limit jobs that required kneeling, standing or walking on hard surface, and frequent use of stairs. Sedentary work was not precluded. A June 2018 VA treatment record notes that the Veteran was able to ambulate into the clinic without any alteration in his gait pattern. His right knee had no edema, erythema, or ecchymosis. He demonstrated good range of motion with full extension and flexion past 110 degrees. His muscle strength was 5/5 in flexion and extension, and he had no joint line tenderness to palpation. An October 2018 VA treatment record found no erythema, ecchymosis or edema on visual examination. Palpation around the patella elicited no pain. Patellar grind test was negative both medially and laterally, and palpation of the medial and lateral joint lines elicited mild pain only at the medial joint line. His range of active motion in right knee flexion and extension were within normal limits, but elicited pain. Knee joint was grossly stable in both varus and valgus. Provocative tests elicited no pain. The February 2019 VA knee and lower leg conditions DBQ notes the Veteran’s complaints of constant right knee pain along the medial/lateral joint line, occasional anterior and posterior pain, and daily giving out. He found himself rocking back and forth five to ten inches when standing. He denied limitations to sitting. He was unable to kneel at church. He needed to hold something to stand from a squatting position. Ascending stairs was worse than descending. He avoided hilly terrain. He reported a popping sound in his right knee. He tolerated his hobbies, including woodworking and golfing. He held on to railings at hold when needed. Otherwise, he was able to perform his activities of daily living without any assistance. He denied concerns when using a rider or snowblower. He reported daily flare-ups of increased knee pain, limping, and difficulty walking that lasted a few minutes. His range of motion was from 5 degrees extension to 130 degrees flexion in the right knee and from zero degrees extension to 135 degrees flexion in the left knee. The range of motion itself did not contribute to functional loss. Pain was noted in right knee flexion, but did not result in or cause functional loss. There was evidence of pain with weight bearing on the right only. There was objective evidence of pain on the lateral side of the right knee. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss of limitation of range of motion. The Veteran was not examined immediately after repetitive use over time, and this examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain weakness, fatigability, and incoordination did not limit functional ability with repetitive use over time. Similarly, the exam was not conducted during a flare-up, and this examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during a flare-up. Pain, weakness, fatigability, and incoordination did not limit functional ability during flare-ups. The additional contributing factors of disability were climbing and squatting. There were no additional factors contributing to disability in either knee. He had full muscle strength bilaterally and no muscle atrophy. He did not have ankylosis of either knee. The Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion in either knee. Stability testing was performed, and no instability was found in either knee. The Veteran had a history of stress fracture to the right lower leg that affected his range of motion of the right ankle and leg length discrepancy with the left leg .5 centimeters longer than the right that was attributed to his ankle disability. He reported a history of left meniscal surgery, but no current symptoms. He had undergone no other knee surgeries. The Veteran ambled with a steady gait and mild right-sided limp with or without ankle brace. He rose slowly from the exam room chair, holding on to the desk and chair seat for support related to his back. He had no calluses on his feet or unusual shoe wear pattern. His left knee scars were barely visible, and he had no right knee scars. There was no pain with non-weight bearing or passive range of motion in either knee. The Veteran constantly used a right ankle brace; regularly used a cane for his back and right knee, ankle, and leg; and occasionally used an air splint on his right ankle. This disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were performed and confirmed bilateral knee arthritis. This disability would impact the Veteran’s ability to work, in that it would limit standing for more than ten minutes or walking more than an hour and he had to avoid uneven terrain. VA treatment records from this period note repeated complaints of right knee pain and treatment, including injections. The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for right knee degenerative joint disease. This disability manifests as painful motion limited to no less than 110 degrees flexion and no more than 20 degrees extension. This is a noncompensable limitation of flexion, and the limitation of extension is consistent with the current 30 percent rating. See 38 C.F.R. § 4.71a, DCs 5260, 5261. A higher rating would require limitation of extension to no less than 30 degrees, which is not shown here. Instead, while the September 2014 DBQ showed limitation of extension to 20 degrees, the more recent records consistently show a much larger range of extension. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain with certain activities and/or prolonged use. However, even considering the Veteran’s lay reports of symptoms and functional loss, the degree of additional limitation reflected by the Veteran’s statements would not result in limitation of motion more nearly approximating extension limited to 30 degrees. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Here, the Veteran is already receiving a separate rating for malunion or nonunion of the tibia and fibula upon under DC 5262, and the question of a higher rating for that disability is addressed below. There was no finding of ankylosis, so a rating under DC 5256 is not warranted. Despite more recent subjective complaints of frequent giving way, objective stability testing was repeatedly normal, and the Veteran did not have recurrent patellar subluxation/dislocation of the right knee. Therefore, a separate compensable rating under DC 5257 is not warranted. While the Veteran has reported a history of left knee meniscal arthroscopic surgery, there is no evidence of a right knee meniscal condition that would warrant a compensable rating under DC 5258 or DC 5259. Finally, the record does not show genu recurvatum; thus, DC 5263 is not applicable. In March 2016, the Veteran’s representative asked that all claims be considered for extraschedular ratings. Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. In regard to the first element, comparison of the Veteran’s symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The record shows that he has complaints and findings of painful motion, limitation of motion, and limitation of activities, such as prolonged standing or walking on uneven terrain associated with this disability. Diagnostic Code 5261 does not specifically list all the Veteran’s symptoms. However, for all musculoskeletal disabilities, the Rating Schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the Rating Schedule specifically contemplates such factors as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Here, the Veteran has been rated based on the most severe limitation of motion documented in the medical evidence. The Board has considered whether these additional limitations due to flare-ups and repetitive use are the equivalent of additional limitation to range of motion, but the medical evidence does not establish this. Because the Rating Schedule was purposely designed to compensate for such functional effects of the Veteran’s disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the Rating Schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent for right knee degenerative joint disease. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. A rating higher than 20 percent for lumbar spine degenerative disc and joint disease with spinal stenosis The Veteran’s current claim for an increased rating was received June 18, 2014. The assigned 20 percent evaluation has been in effect since December 10, 2013. The Veteran’s lumbar spine degenerative disc and joint disease with spinal stenosis is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Ankylosis, however, has not been shown at any point during the pendency of this appeal. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. These criteria are accordingly inapplicable. Given the absence of ankylosis and physician-prescribed bedrest, the only basis for a higher evaluation would be flexion limited to 30 degrees, taking into account the DeLuca factors. A review of the Veteran’s VA examination reports (September 2014, February 2015, March 2017, and February 2019), however, does not show such a finding. The Veteran’s lumbar spine degenerative disc and joint disease with spinal stenosis manifests as limitation of flexion to no less than 45 degrees flexion, which is consistent with the current 20 percent rating. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, including pain during flare-ups, pain with specific activities, and pain with prolonged standing. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less, let alone ankylosis. The Veteran is currently receiving a separate 10 percent rating for right hip sciatica under DC 8799-8720, for mild neuralgia of the sciatic nerve. The Veteran previously withdrew an appeal of his right hip sciatica disability rating in February 2015. Finally, the lay and medical evidence of record is against a finding of any other chronic neurological abnormality associated with his spine disability. Again, the Veteran’s representative asked that all claims be considered for extraschedular ratings. In regard to the first Thun element, comparison of the Veteran’s symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. See 22 Vet. App. 111. The record shows that he has complaints and findings of painful motion, limitation of motion, and limitation of activities, such as prolonged standing, twisting, or walking on uneven terrain associated with this disability. While not specifically listed in Diagnostic Code 5242, the Rating Schedule does contemplate functional loss. 38 C.F.R. §§ 4.40, 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Here, the Veteran has been rated based on the most severe limitation of motion documented in the medical evidence, and consideration has been given to whether he suffered any incapacitating episodes that would entitle him to a higher rating based on IVDS. The Board has considered whether these additional limitations due to flare-ups and repetitive use are the equivalent of additional limitation to range of motion, but the medical evidence does not establish this. Because the Rating Schedule was purposely designed to compensate for such functional effects of the Veteran’s disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the Rating Schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. Based on the foregoing, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for lumbar spine degenerative disc and joint disease with spinal stenosis. In denying such a rating, the Board finds that the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107. 3. A rating higher than 20 percent for right leg distal tibia and fibula fracture with traumatic arthritis The Veteran was originally granted service connection for a fracture of the right distal tibia and fibula with traumatic arthritis in a May 1993 rating decision. At that time, this disability was assigned a 20 percent rating effective March 1, 1993. In a March 2004 rating decision, this rating was increased to 30 percent effective October 21, 2003. A June 2007 rating decision proposed a decreased in this rating to 10 percent. Ultimately, it was decreased to 20 percent effective September 21, 2007. See October 2007 rating decision. The Veteran’s current claim for an increased rating was received July 31, 2014. The Veteran’s fracture right distal tibia and fibula with traumatic arthritis is rated under hyphenated Diagnostic Code 5271-5262. See 38 C.F.R. § 4.71a. Under Diagnostic Code 5271, for limitation of motion of the ankle, a maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. As the Veteran is in receipt of the highest schedular rating for limited motion of the ankle, there is no basis to award a higher rating due to limitation of motion. Under Diagnostic Code 5262, for impairment of the tibia and fibula, a 10 percent rating is warranted for malunion of 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 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. According to MERRIAM WEBSTER’S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “slight” means small in amount. “Moderate” means limited in scope or effect. “Marked” means having a distinctive or emphasized character. VA treatment records for this period generally show complaints of ankle pain, limitation of motion, use of a right ankle air cast for stability, and treatment with injections. A September 2014 VA ankle conditions DBQ noted the Veteran’s complaints of regular stiffness, occasional swelling, crackling and crunching when descending stairs, and occasional used of a brace as his ankle twisted easily. He did not report flare-ups that impacted the function of his ankle. Physical examination found right ankle range of motion of 30 degrees plantar flexion and -5 degrees of dorsiflexion, which remained constant after repetitive use testing. There was no objective evidence of painful motion. Functionally, the Veteran’s right ankle disability resulted in less movement than normal. He did not have localized tenderness of pain on palpation of the joints/soft tissue of either ankle. He had full muscle strength and no laxity was found on joint stability testing. He did not have ankylosis of the ankle. The Veteran did not currently or historically have “shin splints,” stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talis (astragalus), of a talectomy (astragalectomy). He had not had a total ankle joint replacement, arthroscopic, or other ankle surgery. He did not have any associated scars. He did have slight swelling of the right ankle. He did not use an assistive device as a normal means of locomotion. This disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies confirmed right ankle arthritis. This disability did not impact his ability to work. A February 2015 VA ankle conditions DBQ noted the Veteran’s complaints of constant anterior and lateral right ankle pain with occasional radiation to the shins. Pain increased with use, when walking on concrete, and when descending stairs. He had a 1.5-centimeter leg length discrepancy, but did not use a lift. He reported occasional painful popping and swelling with prolonged use, weakness, and giving way on stairs, but did not describe any particular instability when walking un uneven terrain. He did not report flare-ups. He had full range of plantar flexion bilaterally, but his range of dorsiflexion was limited to 10 degrees in the left ankle and five degrees in the right ankle. The examiner found that 10 degrees of dorsiflexion was normal for the left ankle and likely due to limited flexibility due to age as the Veteran had no complaints of left ankle problems of any injury to that ankle. His difficulty with dorsiflexion caused difficulty rising from the floor or climbing stairs. Pain was noted on examination of the right ankle in both planes, but did not result in or cause functional loss. There was evidence of right ankle pain with weight bearing and moderate tenderness to palpation of the lateral malleolus and lateral ankle. The Veteran was able to perform repetitive use testing without any additional loss of function or range of motion. The Veteran was not examined immediately after repetitive use over time, but the examiner found that the examination supported the Veteran’s statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time. The Veteran was not examined during a flare-up, and the examiner found that the examination neither supported not contradicted the Veteran’s statements describing functional loss during flare-up. Pain, weakness, fatigability, and incoordination did not significantly limit functional ability during flare-ups. The Veteran walked with an antalgic limp on the right. He had full muscle strength bilaterally without atrophy. He did not have ankylosis of either ankle. No ankle instability or dislocation was suspected. The Veteran did not currently or historically have “shin splints,” stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talis (astragalus), of a talectomy (astragalectomy). The Veteran had mild chronic bony hypertrophic enlargement lateral malleolus consistent with posttraumatic arthritis. He was unable to walk on heels or do repeated toe raises due to decreased dorsiflexion. He had mild difficulty walking on toes and doing repeated heel raises. His right leg measured two centimeters shorted than the left. His shoes looked fairly new, but had slight increased wear on the posterior lateral aspect of left heel. He did not have any associated scars. He did not use an assistive device as a regular mode of locomotion, but did infrequently use a cane for his right ankle and wore a pneumatic stirrup splint. This disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies confirmed right ankle arthritis. There was no objective evidence of crepitus. This disability prevented him from working in jobs that required prolonged or repeated walking, stair climbing, standing and other weight bearing activities. He could walk no more than two hours at a time. His ankle limitations also prevented him from working in jobs that require him to get up and down from the floor repeatedly. A June 2018 VA treatment record noted that the Veteran was able to ambulate into the clinic without any alteration in his gait pattern. His right ankle had no edema, erythema, or ecchymosis. There were some large varicosities lower on his leg, but no gross signs of infection. He had pain with dorsiflexion of his foot, but appropriate range of motion. There was no tenderness to palpation over the medial or lateral malleolus and no gross instability on exam. A September 2018 VA treatment record noted that the Veteran was able to walk into the clinic without any alteration in his gait pattern. He worse an air cast for stability, but still walked briskly. He reported that wearing the air cast enabled him to walk and continue to play golf. His right ankle had no edema, erythema, or ecchymosis. His range of motion was severely limited to degenerative arthritis with dorsiflexion limited to 10 degrees and plantar flexion limited to about 45 degrees, but he still had full muscle strength in both flexion and extension. The February 2019 VA ankle conditions DBQ noted the Veteran’s reports of inability to stand for an unspecified prolonged period. He reported a popping sound when climbing stairs and preferred to walk on his heel when descending stairs. He limped but did not quantify specific limitation to walking. He stated that he was unable to carry heavy loads up and down stairs, but could tolerate a twenty-pound laundry basket. He wore an ankle brace while golfing and an air splint while woodworking. He did not need assistance with activities of daily living. He reported ankle stiffness when switching from gas to brake pedal and frequently used cruise control. He reported flare-ups of severe ankle pain occurring weekly, caused by stairclimbing, and lasting one hour. This was relieved with rest, sitting, and elevation. The Veteran had no range of dorsiflexion and full range of plantar flexion in the right ankle and full range of both in the left ankle. This range of motion itself did not contribute to a functional loss. No pain was noted on examination. There was evidence of pain with weight bearing in the right ankle. There was objective evidence of localized lateral tenderness or pain on palpation of the right ankle. There was no objective evidence of crepitus. He was able to perform repetitive use testing with at least three repetitions without additional loss of function or range of motion. The Veteran was not examined immediately after repetitive use over time, and this examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain weakness, fatigability, and incoordination did not limit functional ability with repetitive use over time. This examination was not performed during a flare-up, and this examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss during flare-ups. Pain weakness, fatigability, and incoordination did not limit functional ability during flare-ups. This right ankle disability resulted in difficulty standing and climbing. His right ankle muscle strength was reduced to 4/5 (active movement against some resistance) for both plantar flexion and dorsiflexion. His left ankle had full muscle strength. There was no atrophy. There was no ankylosis in either ankle. Right ankle instability was suspected, but no laxity was found on stability testing. The Veteran had a history of right lower leg stress fracture. The Veteran ambled with a steady gait and mild right-sided limp with or without ankle brace. He rose slowly from the exam room chair, holding on to the desk and chair seat for support related to his back. He had no calluses on his feet or unusual shoe wear pattern. There was noted difficulty walking on right tiptoes or heel. No pain was noted in either ankle with passive range of motion or non-weight bearing. The Veteran did not have any associated scars. The Veteran constantly used a right ankle brace; regularly used a cane for his back and right knee, ankle, and leg; and occasionally used an air splint on his right ankle. This disability did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies were performed and confirmed right ankle arthritis. Functionally, standing was limited to 10 minutes, walking was limited to one hour, and he avoided uneven terrain. This disability impacted the Veteran’s ability to work in that he was limited from employment requiring prolonged standing without repositioning, frequent moderate/heavy lifting involving squatting or crawling, frequent walking on uneven terrain, and stairclimbing, but not in light sedentary activity. A March 2019 VA treatment record showed 25 degrees of dorsiflexion of the foot and 25 degrees of extension. He had full muscle strength in all joints with no gross instability of his right lower extremity. A March 2020 VA treatment record showed a recent injury to the ankle that had caused increased pain for several weeks until it “popped” back into place. He was seeking a steroid injection for his ankle. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for right leg distal tibia and fibula fracture with traumatic arthritis. The Veteran’s right leg distal tibia and fibula fracture with traumatic arthritis manifests as marked limitation of dorsiflexion, but not a marked ankle disability. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain during flare-ups and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements would not result in symptoms more nearly approximating malunion of the tibia or fibula with marked knee or ankle disability. Specifically, the Board notes that, despite a mild limp, the Veteran is able to ambulate and, with use of assistive devices, even golf and woodwork for an hour or more. Thus, while there is significant limitation of motion of the right ankle, the record does not more nearly approximate malunion of the tibia or fibula with marked ankle disability. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). In this case, the Veteran is already receiving a separate rating for right knee disability that contemplates his right knee and leg symptoms. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. Indeed, only DC 5270 provides rating criteria for evaluations higher than the current 20 percent rating and those ratings are only available for ankylosis of the ankle, which is not shown here. Again, the Board has considered whether an extraschedular rating is warranted. In regard to the first element, comparison of the Veteran’s symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The record shows that he has complaints and findings of marked limitation of dorsiflexion, and additional functional loss due to pain during flare-ups and pain during repetitive use over time. The rating criteria under Diagnostic Code 5262 does not explicitly include particular symptoms, but instead describes impairment or severity level. As a result, Diagnostic Code 5262 contemplates the entire range of impairment resulting from a right leg distal tibia and fibula disability. For this reason, the Veteran’s specific symptoms and their severity are contemplated by the rating schedule. See, e.g., Spellers v. Wilkie, 30 Vet. App. 211, 219 (2018). Because the Rating Schedule was purposely designed to compensate for such functional effects of the Veteran’s disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the Rating Schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for right leg distal tibia and fibula fracture with traumatic arthritis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. A compensable rating for right eye diabetic retinopathy The Veteran was originally granted service connection for right eye diabetic retinopathy in an August 2011 rating decision. At that time, this disability was assigned a noncompensable (0 percent) rating effective December 15, 2010. The Veteran’s current claim for an increased rating was received June 18, 2014. The Veteran’s right eye diabetic retinopathy is currently rated under hyphenated diagnostic code 7913-6066. DC 7913 provides rating criteria for diabetes mellitus. See 38 C.F.R. § 4.119. The Veteran is currently rated 20 percent separately for this underlying disability. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15,316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Under the former criteria, retinopathy (DC 6006) is rated under the General Rating Formula for Diagnostic Codes 6000 through 6009. The General Rating Formula instructs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where incapacitating episodes have a total duration of at least 1 week, but less than 2 weeks, during the past 12 months, a 10 percent rating is warranted. Where incapacitating episodes have a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, a 20 percent rating is warranted. Where incapacitating episodes have a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months, a 40 percent rating is warranted. Where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months, a 60 percent rating is warranted. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Under the revised criteria, retinopathy (DC 6006) is rated under the General Rating Formula for Diseases of the Eye. The General Rating Formula instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. The criteria for visual impairment, including impairments of visual acuity, visual fields, and/or muscle function, have remained unchanged. Impaired visual acuity is rated under diagnostic codes 6061-6066 based on the best corrected distance vision. 38 C.F.R. §§ 4.76, 4.79. Impairment of visual fields are rated under DC 6080-6081 based on the average concentric contraction of the visual field of each eye; asymmetric impairments are converted to their visual acuity equivalents. 38 C.F.R. §§ 4.77, 4.79. Impaired muscle function is rated under DC 6090-6091 with an evaluation for diplopia being assigned to only one eye. 38 C.F.R. §§ 4.78, 4.79. When only one eye is service connected, the other eye considered 20/40 for rating purposes regardless of the actual level of impairment. 38 C.F.R. § 4.75 (c). At the time of his October 2014 VA eye conditions DBQ, the Veteran stated that he had seen several floaters over the prior year, worse since his cataracts had been removed. He had not had flashes of light in the eye for several months. He had been diagnosed with bilateral posterior vitreous detachment in April 2013, but this was a normal age-related process. He had undergone cataract surgery in both eyes with implants. He had a family history of glaucoma and was treating his suspected glaucoma with medicated eye drops. The Veteran’s uncorrected visual acuity was 20/40 or better in the right eye and 20/70 in the left eye. His uncorrected near vision was 20/50 in the right eye and 20/70 in the left eye. All were corrected to 20/40 or better. His pupils were round and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness in either eye. He did not have astigmatism or diplopia. Bilaterally, he had posterior chamber intraocular lenses, but otherwise normal external eyes. Internally, his cup-to-disc ratio was .6 bilaterally, and he had bilateral posterior vitreous detachment. He did not have a visual field defect. His confrontation field were full to finger count bilaterally. The Veteran’s post-operative cataracts resulted in bilateral replacement intraocular lenses, but not aphakia or dislocation of either crystalline lens, but not visual impairment as no visual impairment was shown. His suspected bilateral glaucoma required continuous medication for treatment, but did not result in visual impairment, as no visual impairment was shown. The Veteran did not have any other eye conditions, pertinent physical findings, complications, conditions, signs, and/or symptoms related to his eye conditions. He did not have scarring or disfigurement attributable to any eye condition. During the prior twelve months, the Veteran had not had any incapacitating episodes attributable to any eye condition. His eye conditions did not impact his ability to work. There were no signs of diabetic retinopathy in either eye or any increase in the severity of diabetic retinopathy. The February 2015 VA eye conditions DBQ diagnosed diabetes without mention of complications, unspecified glaucoma, pseudophakia, and posterior vitreous detachment. Historically, the Veteran had undergone several eye examinations since his diabetes diagnosis in 2007, and none of these examinations had shown signs of diabetic retinopathy in either eye. The Veteran was claiming that his glaucoma was due to his diabetes. He did have a family history of glaucoma. His uncorrected distance visual acuity was 20/50 in the right eye and 20/100 in the left, corrected to 20/40 or better bilaterally. His uncorrected and corrected near visual acuity was 20/40 or better bilaterally. His pupils were round and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness in either eye. He did not have astigmatism or diplopia. Bilaterally, he had posterior chamber intraocular lenses, but otherwise normal external eyes. Internally, his cup-to-disc ratio was .6 or more bilaterally, and he had bilateral posterior vitreous detachment. He did not have a visual field defect. The Veteran’s post-operative cataracts resulted in bilateral replacement intraocular lenses, but not aphakia or dislocation of either crystalline lens, but not visual impairment as no visual impairment was shown. His bilateral open-angle glaucoma required continuous medication for treatment, but did not result in visual impairment as no visual impairment was shown. This glaucoma did not cause scarring or disfigurement. The Veteran did not have any other eye conditions, pertinent physical findings, complications, conditions, signs, and/or symptoms related to his eye conditions. He did not have scarring or disfigurement attributable to any eye condition. During the prior twelve months, the Veteran had not had any incapacitating episodes attributable to any eye condition. His eye conditions did not impact his ability to work. This examiner found that the Veteran’s glaucoma was less likely than not related to his diabetes, noting that diabetic patients were not at a higher risk of developing glaucoma than non-diabetic patients and he had no history of damage to his eye from his diabetes. Instead, the Veteran’s glaucoma was more likely hereditary. The February 2019 VA eye conditions DBQ again diagnosed diabetes without mention of complications, unspecified glaucoma, pseudophakia, and posterior vitreous detachment. Historically, there was no record of diabetic retinopathy in either eye. The Veteran’s uncorrected distance visual acuity was 20/50 in the right eye and 20/100 in the left. His uncorrected near visual acuity was 20/70 in the right eye and 20/40 in the left eye. Both were corrected to 20/20 or better bilaterally. His pupils were round and reactive to light. No afferent pupillary defect was present. The Veteran did not have anatomical loss, light perception only, extremely poor vision, or blindness in either eye. He did not have astigmatism or diplopia. Bilaterally, he had posterior chamber intraocular lenses, but otherwise normal external eyes. Internally, his cup-to-disc ratio was .65 bilaterally. He did not have a documented visual field defect. The Veteran’s bilateral open-angle glaucoma required continuous medication for treatment, but did not result in visual impairment as no visual impairment was shown. His post-operative cataracts resulted in bilateral replacement intraocular lenses, but not aphakia or dislocation of either crystalline lens, but not visual impairment as no visual impairment was shown. He also had bilateral posterior vitreous detachment. The Veteran did not have scarring or disfigurement attributable to any eye condition. During the prior twelve months, the Veteran had not had any incapacitating episodes attributable to any eye condition. His eye conditions did not impact his ability to work. No diabetic retinopathy was found in either eye. The Veteran’s interocular pressure was stable. The visual filed machine was not working, but the examiner noted that the Veteran’s last visual field test in March 2018 had shown no right eye defects, and the scattered left eye defects were not a glaucomatous pattern. VA treatment records during the appeals period consistently note no diabetic retinopathy. Based on the above, the Veteran right eye diabetic retinopathy has not manifested by visual impairment or incapacitating episodes. No impairment of visual field or muscle function is noted, and, to the extent that there is impaired visual acuity, this is corrected to a noncompensable level. As such, there is no showing of right eye visual impairment. Similarly, there is no showing of any incapacitating episodes attributable to any eye condition, including right eye diabetic retinopathy. Indeed, the record does not show any symptoms attributable to right eye diabetic retinopathy and instead consistently notes no retinopathy is present. Again, the Veteran’s representative requested extraschedular consideration for all of the Veteran’s disabilities. In this case, however, no symptoms have been associated with right eye diabetic retinopathy. Therefore, there are no symptoms to consider for an extraschedular rating. As such, the evidence does not support a compensable rating and the Veteran’s appeal is denied. 5. TDIU Total disability ratings for compensation may be assigned, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Here, the Veteran’s is service connected for emphysema, bilateral knee disabilities, right leg distal tibia and fibula fracture with traumatic arthritis, diabetes mellitus, lumbar spine disability, right inguinal hernia scar, coronary artery disease, right hip sciatica, right hip chronic mechanical strain, sinusitis, hypertension, reflux esophagitis, right thigh scar, right eye diabetic retinopathy, and right leg length discrepancy, with a total combined rating of 90 percent. While no single disability is rated at 40 percent or more, the Veteran’s bilateral knee disabilities were granted secondary to right leg distal tibia and fibula fracture, which established a common etiology for these disabilities, resulting in a “single” rating of more than 40 percent. See id. This is sufficient to meet the schedular criteria for TDIU consideration. The issue becomes whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. The issue is whether the Veteran’s service-connected disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a “living wage”). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this case, the Veteran last worked in June 2009, when he retired from a position as a purchasing agent. The May 2015 medical opinion found that the symptoms reported by the Veteran, the objective findings on examination, the diagnostic imaging results, and the medical record documentation do not demonstrate an extraordinary level of employment impairment beyond what would be anticipated for the severity of the service-connected lumbar arthritis, fractured right distal tibia and fibula, and right knee patellofemoral syndrome. Moreover, as listed above, the individual medical examinations performed repeated noted limitations to physical labor, but not sedentary work. The February 2015 respiratory DBQ likewise noted that his emphysema limited physical labor, but not sedentary work. The February hip and thigh DBQ found limitations, due to his right hip disabilities, to jobs where the Veteran had to be on his feet repeatedly for prolonged periods. The Veteran’s most recent employment as a purchasing agent was not shown to entail physical labor. While the severity of his disabilities, as reflected by their ratings, has increased since he last worked, it is probative to note that his prior employer listed his only required concessions as disability parking and ramp that were provided to all disabled personnel. As such, it appears that this was a sedentary position, and the evidence does not show any reason why he would not be qualified to return to work in this field. While there are some noted limitations to sitting, these focus on avoidance of hard chairs and the ability to frequently reposition. These concerns could be addressed with reasonable accommodations including a more comfortable chair and the ability to reposition as necessary. As such, the Board does not find that at the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Thus, a total disability rating due to individual unemployability is denied. 38 C.F.R. §§ 4.3, 4.16(a). A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Houbeck 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.