Citation Nr: 21007063 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 15-42 990 DATE: February 8, 2021 ORDER A rating in excess of 10 percent for degenerative joint disease (DJD) of the left knee prior to December 18, 2018, is denied. A rating in excess of 10 percent for post-traumatic osteoarthritis of the right knee prior to December 18, 2018, is denied. Subject to the laws and regulations governing the award of monetary benefits, a rating of 10 percent, but no more, for symptomatic right meniscal tear prior to December 18, 2018, is granted. A rating in excess of 30 percent for left knee replacement residuals from February 1, 2020, is denied. A rating in excess of 30 percent for right knee replacement residuals from February 1, 2020, is denied. A rating in excess of 20 percent for degenerative disc disease (DDD) of the lumbar spine is denied. A rating in excess of 10 percent for DDD of the cervical spine is denied. A total disability rating due to individual unemployability based on service-connected disabilities (TDIU), to include on an extraschedular basis, is denied. FINDINGS OF FACT 1. Prior to December 18, 2018, at no point was flexion limited to 30 degrees in either knee, including upon clinical examination or as determined to result after repeated use over time or during flare-ups. 2. Prior to December 18, 2018, the Veteran’s right knee history of meniscal tear was symptomatic. 3. From February 1, 2020, the Veteran’s bilateral knees resulted in painful limitation of motion and mild weakness but did not result in ankylosis, extension limited to 30 degrees, or nonunion of the tibia and fibula with loose motion requiring a brace. 4. Throughout the appeal period, the Veteran’s lumbar spine did not result in forward flexion limited to 30 degrees, including upon clinical examination or as determined to result after repeated use over time or during flare-ups, nor did he have incapacitating episodes of at least 4 weeks over 12 months. 5. Throughout the appeal period, the Veteran’s cervical spine did not result in forward flexion limited to 30 degrees, including upon clinical examination or as determined to result after repeated use over time or during flare-ups; muscle spasm or guarding severe enough to result in abnormal gait or spinal contour; nor did he have incapacitating episodes of at least 2 weeks over 12 months. 6. Throughout the entire appeal period, the Veteran’s service-connected disabilities did not render him unable to obtain or maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for DJD of the left knee prior to December 18, 2018, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003-5260. 2. The criteria for rating in excess of 10 percent for post-traumatic osteoarthritis of the right knee prior to December 18, 2018, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003-5260. 3. The criteria for a 10 percent rating, but no more, for symptomatic right meniscal tear prior to December 18, 2018, have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5259. 4. The criteria for a rating in excess of 30 percent for left knee replacement residuals from February 1, 2020, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5055. 5. The criteria for a rating in excess of 30 percent for right knee replacement residuals from February 1, 2020, have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5055. 6. The criteria for a rating in excess of 20 percent for DDD of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5242. 7. The criteria for a rating in excess of 10 percent for DDD of the cervical spine have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5242. 8. The criteria for an award of a TDIU, to include on an extraschedular basis, have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. § § 3.158, 3.321, 3.340, 3.341, 4.15, 4.16, 4.19 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1975 to July 1978 and January 2003 to August 2004. By way of background, the Board notes that these issues on appeal stem from a September 13, 2013, claim seeking increased ratings for the bilateral knees, the lumbar spine, and the cervical spine. Thus, the Board will consider the severity of the issues on appeal from September 13, 2013, as well as whether there was any factually ascertainable increase in the severity of any of the claimed conditions within the year preceding the increased rating claim. See 38 C.F.R. § 3.400(o)(2). These matters were previously before the Board in September 2018 at which time they were remanded for further evidentiary development. Substantial compliance with the remand requests having been accomplished, the Board may proceed to consider the claims. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran claimed entitlement to TDIU following his bilateral knee replacement surgery which was denied in a December 2019 rating decision. The Veteran has not appealed the decision and has not provided any subsequent information suggesting that he is currently unemployed due to his service-connected disabilities. However, the Board finds that entitlement to TDIU has been raised by medical evidence subsequently added to the record and has taken jurisdiction of the matter herein. See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009); Harper v. Wilkie, 30 Vet. App. 356 (2018). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran 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 Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Court, in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Further, in evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. at 592. Additionally, the Court has stated that flare-ups must be factored into an examiner’s assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Bilateral Knees The Veteran was granted service connection for right knee post-traumatic osteoarthritis at 10 percent under 38 C.F.R. § 4.71a, DC 5003-5260, effective August 9, 2004. A 10 percent rating under DC 5003-5260 was also granted for left knee DJD, effective September 2, 2010. As noted in the introduction, this appeal stems from the Veteran’s claim filed in September 13, 2013, indicating his conditions had worsened. Thus, the Board will consider the severity of his knees from September 13, 2013, as well as whether there was a factually ascertainable increase in severity within the year preceding his increased rating claim. See 38 C.F.R. § 3.400(o)(2). For reasons outlined below, the Board finds an increased rating is not warranted for either knee at any time on appeal. During the pendency of his appeal, on December 18, 2018, the Veteran underwent bilateral total knee replacement surgery. His right and left knee ratings were thereafter recharacterized under 38 C.F.R. § 4.71a, DC 5055. He received 100 percent ratings for each knee from December 18, 2018, to February 1, 2020. From February 1, 2020, each knee is rated 30 percent under DC 5055. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating, with the first code representing the underlying condition and the second code representing the residuals. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic codes indicate that the bilateral knee disabilities are rated based on evidence of degenerative arthritis with painful flexion. Degenerative and/or traumatic arthritis as shown by x-ray studies are rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 5003, 2010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Under DC 5260, flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. Also relevant to any discussion of knee disabilities are the criteria under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Under DC 5256, favorable ankylosis of the knee, in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent disability rating; ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent disability rating; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent disability rating. Under DC 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling, moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. Under DC 5258, a claimant is entitled to a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5261, extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Under DC 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. Under DC 5263, a 10 percent rating is warranted for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Pursuant to DC 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to DC 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. The Board notes that the terms “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Although a medical examiner’s use of descriptive terminology such as “mild” is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Turning to the evidence of record, a VA medical opinion was obtained in September 18, 2012, a little less than one year prior to the Veteran’s increased rating claim. At that time, an examiner was asked to clarify findings from an older, August 2012 VA examination, of the left knee, where x-rays noted mild degenerative changes, but the Veteran did not have any current complaints and physical examination of the left knee was normal. The examiner, thus, clarified that the x-ray findings were “not clinically significant” since they did not correlate with any current complaints or physical examination findings. After the Veteran contended his conditions had worsened, he was afforded a new VA examination in December 2013. The Veteran described flare-ups of aggravated pain after ambulation up to 5 to 6 blocks and with running. Right knee flexion was to 95 degrees with pain and extension was to 0 degrees with no evidence of pain. Left knee flexion was to 95 degrees with pain and extension was to 0 degrees with no evidence of pain. The Veteran was able to perform repetitive use testing with flexion limited to 90 degrees bilaterally and no loss of extension. Additional functional loss was noted to be less movement than normal and pain on movement bilaterally and weakened movement and mild varus deformity in the right knee. Pain was observed on palpation bilaterally. Muscle strength testing was normal on flexion in both knees and normal on extension in the left knee. Muscle strength testing on extension in the right knee was reduced. Joint stability testing was normal bilaterally. There was no history of recurrent patellar subluxation or dislocation; no shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment; and no meniscal conditions. The Veteran reported occasional use of elastic knee braces. X-rays revealed that the bilateral osteoarthritis had progressed, with an osteochondral loose body in the right posterior knee. There was no functional impact from the bilateral knee disabilities. An addendum VA opinion was obtained in June 2014. The examiner stated that an opinion regarding whether pain, weakness, fatigability, or incoordination would significantly limit functional ability during flare-ups or with repeated use over time could not be provided without resorting to mere speculation because it was not documented whether the Veteran was undergoing a flare-up or had used the joints repeatedly over time at the prior examination. She would need to measure range of motion during a flare-up or after repeated use over time in order to provide an opinion. In a July 2016 VA treatment record, the Veteran reported left knee sharp pain for two weeks. Upon observation, the knee was swollen and warm with joint-line tenderness. There was no evidence of ligament or meniscus injury. Active flexion was from 0 to 90 degrees. An x-ray revealed increased arthritis changes and a small new joint effusion. There was no acute fracture. In August 2016, the Veteran described 7 out of 10 knee pain. His knee tightened when he drove a bus for work. Pain was worse at night and he had to loosen it upon awakening for 30 to 45 minutes. Pain worsened with movement. He stated that he had trouble going up and down stairs and he felt like his leg would give out. Upon observation, he had swelling in both knees, but no warmth, redness, erythema, or tenderness to palpation. He had full range of motion bilaterally. Effusions were observed, greater in the left knee than the right. Crepitus was present, as well. He received a Kenalog injection in his left knee. A September 2016 VA treatment record noted that the Veteran’s knees had full range of motion. There was no erythema, warmth, or tenderness to palpation. Mild effusion and crepitus were observed. He received a Kenalog injection in his right knee. VA treatment records from April 2017 reflected complaints of left knee pain and swelling for three weeks. The Veteran was advised to use a walker or cane to support the knee, avoid activities triggering the pain, and to use warm and cold compresses and elevate the knee. He later described bilateral knee pain, worse in the right knee. The pain was throbbing and 8 out of 10. Pain was worse with movement and sitting. He was limited to walking short distances. Upon observation, there was slight tenderness in both knees but no swelling or erythema. Active flexion and extension were intact bilaterally. The Veteran was ambulatory with a steady gait. Another treatment record reflected a report of chronic, throbbing pain to the left knee, worse the past month, at a 7 out of 10. There were no gross effusions. A VA treatment record from September 2017 noted that the Veteran’s bilateral knees had full range of motion, and no erythema, warmth, or tenderness to palpation. There was mild effusion and crepitus, worse on the right than the left. Clinicians stated that his moderately-severe osteoarthritis limited his ability to exercise and work. He received bilateral Kenalog injections. The Veteran received private medical treatment for his bilateral knees in November 2017. He described progressive pain in the past 6 to 7 months. He experienced severe pain with weight-bearing. Pain was a 5 out of 10, constant, sharp, and dull with episodes of clicking and swelling. Precipitating factors were noted to be going down stairs and moving from sitting to standing. An alleviating factor was rest. The left knee had full range of motion of 0 to 135 degrees and a mild effusion. There was no crepitus, medial pain, lateral pain, Lachman, pivot shift, and anterior or posterior drawer. The knee was stable with varus alignment. The right knee had full range of motion of 0 to 110 degrees and a mild effusion. There was no crepitus, medial pain, lateral pain, Lachman, pivot shift, and anterior or posterior drawer. The knee was stable. Valgus alignment was noted to be 1+ opening with valgus stress. X-rays revealed right knee diffuse degenerative arthritis, decreased lateral joint space, valgus alignment, and severe patellofemoral arthritis. The left knee demonstrated diffuse degenerative arthritis, decreased lateral joint space, varus alignment, and severe patellofemoral arthritis. At another private appointment in August 2018, the Veteran reported minimum pain in the knees of 3 out of 10 and maximum pain of 5 out of 10. He had increased limitations with his activities of daily living and noticed increased mechanical symptoms. The left knee had full range of motion of 0 to 120 degrees, a moderate effusion, moderate crepitus, and generalized pain nonspecific to the joint line. The knee was stable with varus alignment. The right knee had full range of motion of 0 to 120 degrees, moderate effusion, and moderate crepitus with no medial or lateral pain. The knee was stable with valgus alignment. X-rays revealed in the right knee diffuse degenerative arthritis, decreased lateral joint space, valgus alignment, moderate patellofemoral arthritis, and severe grade 4 changes. In the left knee was diffuse degenerative arthritis, decreased medial joint space, varus alignment, moderate patellofemoral arthritis, severe grade 4 changes, and sclerosis. A November 2018 private MRI of the right knee demonstrated that the ligaments and tendons were intact. There was a large joint effusion and full-thickness cartilage. The Veteran underwent another VA examination in April 2019. He described chronic pain of a 6 out of 10 persisting since his bilateral knee replacements in December 2018. He noted that he rarely had flare-ups but that they consisted of pain, swelling, and tingling. Flexion in the right knee was from 0 to 90 degrees and extension was from 90 to 0 degrees. Pain was noted on flexion but did not cause functional loss. There was also pain with passive motion testing. There was evidence of pain with weight-bearing but not with nonweight-bearing. There was tenderness localized to the joint line but no evidence of crepitus. Flexion in the left knee was from 0 to 80 degrees and extension was from 80 to 0 degrees. Pain was noted on flexion but did not cause functional loss. There was also pain with passive motion testing. There was evidence of pain with weight-bearing but not with nonweight-bearing. There was evidence of joint-line tenderness and crepitus. Repetitive use testing was conducted without additional loss of range of motion. The examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and during flare-ups and that pain, weakness, fatigability, or incoordination would not significantly limit functional ability. Muscle strength testing was 4 out of 5 bilaterally in flexion and 5 out of 5 bilaterally in extension. There was no muscle atrophy. There was no ankylosis in either knee. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing yielded normal results in both knees. The Veteran had a meniscus condition in the past but no current symptoms. Following the total bilateral knee replacement, the Veteran had residuals of intermediate degrees of residual weakness, pain, or limitation of motion in both knees. The Veteran reported constant use of a cane for his bilateral knee disabilities. Functional impact was determined to be that the Veteran could not walk great distances due to fatigue. Subsequent VA treatment records did not contain any reports of ongoing symptomology or complaints relative to the bilateral knees. The Board notes at the outset that the VA examinations of record, taken in conjunction with records of medical treatment, are an adequate basis upon which to determine the extent and severity of the Veteran’s left and right knee disabilities. Although whether there was pain with passive movement and nonweight-bearing was not elicited on every examination, the Veteran has indicated that he experienced increased pain and stiffness when sitting or upon waking which was relieved with motion, suggesting additional pain with passive and nonweight-bearing activities. He also described increased pain and functional limitation doing weight-bearing activities such as walking, running, driving, and going down stairs. Although the December 2013/June 2014 examiners could not determine additional loss of range of motion or whether pain, weakness, fatigability, or incoordination would significantly limit functional ability during flare-ups or with repeated use over time without resorting to mere speculation, the Veteran himself has provided statements regarding the limitation of his activities from which to extrapolate the extent and severity of his knee disabilities during flare-ups and after repeated use. In fact, he sought VA treatment during such flare-ups noting recent sharp pain and increased effects on his ability to drive the bus and manage stairs. Further, the April 2019 examiner determined there would be no loss of motion with repeated use over time and during flare-ups. Given the totality of the information, including the Veteran’s own descriptions of his limitations, the Board finds that the requirements of DeLuca, Sharp, and Correia have been adequately addressed. DeLuca v. Brown, 8 Vet. App. At 202; Sharp v. Shulkin, 29 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158. (a.) A rating in excess of 10 percent for DJD of the left knee prior to December 18, 2018, is denied. (b.) A rating in excess of 10 percent for post-traumatic osteoarthritis of the right knee prior to December 18, 2018, is denied. Based on the foregoing, the Board finds that a rating in excess of 10 percent for left knee DJD and right knee post-traumatic osteoarthritis prior to December 18, 2018, is not warranted. At no point was flexion limited to 30 degrees in either knee, including upon clinical examination or as determined to result after repeated use over time or during flare-ups, thereby warranting a 20 percent rating under the criteria of DC 5260. The Veteran continues to have evidence of arthritis with painful flexion in both knees, warranting a 10 percent rating for each knee under the criteria of DC 5003-5260. See 38 C.F.R. § 4.59; Mitchell v. Shinseki, 25 Vet. App. at 32. There is no evidence of incapacitating exacerbations meriting a 20 percent rating under the criteria of DC 5003. Accordingly, a rating in excess of 10 percent for left knee DJD and in excess of 10 percent for right knee post-traumatic osteoarthritis under DC 5003-5260 is not established. (c.) A rating of 10 percent for symptomatic right meniscal tear prior to December 18, 2018, is granted. The Board has considered whether rating the bilateral knee disabilities under additional or alternative diagnostic codes pertaining to the knees would be more appropriate or advantageous to the Veteran. Additional 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. at 261-62; 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). Rating either knee disability under DC 5256 is not indicated as there is no evidence of ankylosis. The record does not demonstrate recurrent subluxation or lateral instability in either knee warranting evaluation under DC 5257. Extension has not been limited to 5 degrees such that additional rating might be available under DC 5261. Further, there is no malunion or nonunion of the tibia and fibula and no genu recurvatum indicating rating under DC 5262 and DC 5263. The Veteran’s right knee disability was based on an in-service meniscal injury which advanced to osteoarthritis. As such, rating the disability under either DC 5258 or 5259 is implicated. There is evidence of frequent episodes of pain and effusion in the right knee joint. However, locking has not been demonstrated at any point. As such, rating under DC 5258 is not warranted. The criteria of DC 5259 require that the removal of semilunar cartilage or meniscus is symptomatic. Here, along with demonstrated painful limitation of flexion, which is compensated under DC 5003-5260, the Veteran has meniscal symptoms including recurring effusions. As such, an additional rating under DC 5259 would not violate the rule against pyramiding. See Lyles v. Shulkin, 29 Vet. App. at 107 (holding that ratings under DC 5257, 5260, and 5261 do not necessarily preclude ratings under DC 5258 and 5259). Therefore, an additional 10 percent maximum rating for the Veteran’s right knee symptomatic meniscus tear is warranted under DC 5259 prior to December 18, 2018. Although the Veteran has demonstrated frequent episodes of effusion and pain in the left knee, there was no underlying meniscal condition and no episodes of locking. As such, rating the left knee disability under DC 5258 or 5259 is not warranted. (d.) A rating in excess of 30 percent for left knee replacement residuals from February 1, 2020, is denied. (e.) A rating in excess of 30 percent for right knee replacement residuals from February 1, 2020, is denied. The Board finds that ratings in excess of 30 percent for the bilateral knees following the total replacement surgeries are not warranted. There is no evidence throughout the appeal period of ankylosis, limitation of extension to 30 degrees or more, nor of nonunion of the tibia and fibula with loose motion requiring a brace or analogous symptomology in either knee. As such, a rating in excess of 30 percent rated by analogy under DC 5256, DC 5261, or DC 5262 is not established. Further, the Veteran’s symptom presentation does not rise to the level of severe painful motion or weakness. Although the April 2019 examination demonstrated continued painful limitation of motion and mild weakness upon muscle strength testing, the examiner determined that the Veteran’s bilateral knees did not have chronic residuals of severe painful motion or weakness. Pain was noted on flexion, but it did not result in functional impairment. Muscle strength was only slightly reduced and there was no muscle atrophy to suggest chronic severe weakness. VA treatment records did not reflect any ongoing symptomology in the knees, as well. The Board has considered whether additional ratings may be indicated for the bilateral knee disabilities. However, the Veteran’s symptoms of painful limitation of motion and mild weakness are contemplated under DC 5055. As such, additional ratings under diagnostic codes encompassing such symptomology would constitute pyramiding. Accordingly, a rating in excess of 30 percent for left knee replacement residuals and in excess of 30 percent for right knee replacement residuals from February 1, 2020, is not warranted. 2. Lumbar and Cervical Spine The Veteran was granted a 10 percent rating for lumbar spine DDD under 38 C.F.R. § 4.71a, DC 5242, effective August 9, 2004. The rating was increased to 20 percent based on a clear and unmistakable error, effective August 9, 2004. The Veteran in in receipt of a 10 percent rating for cervical spine DDD under 38 C.F.R. § 4.71a, DC 5242, effective August 9, 2004. As noted in the introduction, this appeal stems from the Veteran’s claim for increase filed on September 13, 2013, indicating his conditions had worsened. Thus, the Board will consider the severity of his lumbar and cervical spine disabilities from September 13, 2013, as well as whether there was a factually ascertainable increase in severity within the year preceding his increased rating claim. See 38 C.F.R. § 3.400(o)(2). For reasons outlined below, the Board finds an increased rating is not warranted for either the lumbar spine disability or cervical spine disability at any time during the appeal. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula provides for assignment of a 10 percent rating where forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; forward flexion of the cervical spine is greater than 30 degrees but not greater than 40 degrees; or a combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or combined range of motion of the cervical spine is greater than 170 degrees but not greater than 335 degrees; or there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or there is vertebral fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or the combined range of motion of the cervical spine is not greater than 170 degrees; or muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or forward flexion of the thoracolumbar spine 30 degrees or less; or ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion is zero to 30 degrees, and left and right lateral rotation is zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine at Note (2); see also 38 C.F.R. § 4.71a, Plate V (2017). Alternatively, disability involving disc disease may be rated under the Formula for Rating IVDS Based on Incapacitating Episodes. That formula provides a 10 percent disability rating for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent disability rating for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). (a.) Lumbar Spine Turning to the evidence of record, the Veteran underwent a VA examination in December 2013. He described flare-ups of aggravated pain after prolonged sitting, standing, or ambulation. It was noted that he was in bed frequently. Forward flexion was to 40 degrees with pain; extension was to 30 degrees or greater; right and left lateral flexion was to 30 degrees or greater with pain; and right and left lateral rotation was to 30 degrees or greater. He was able to perform repetitive use testing with similar range of motion except in extension which was to 25 degrees. Additional functional loss was noted to be less movement than normal, weakened movement, and pain on movement. There was localized tenderness at the bilateral thoraco-lumbar paraspinals. The Veteran had muscle spasm severe enough to result in abnormal gait (slow, antalgic gait) and abnormal spinal contour (exaggerated lumbar lordosis) but no guarding. Muscle strength testing was normal bilaterally except was reduced in the right knee. There was no muscle atrophy. Deep tendon reflexes were normal. A sensory examination yielded normal results. There was no radicular pain or signs or symptoms of radiculopathy. There were no other neurologic abnormalities or findings. He had IVDS but incapacitating episodes lasted less than one week. The Veteran did not use assistive devices. X-rays revealed straightening of the lordosis; DDD at the T11 to T12 and T12 to L1 levels with mild T11 to T12 anterolisthesis. The examiner determined that there was no functional impact. An addendum VA opinion was obtained in June 2014. The examiner stated that an opinion regarding whether pain, weakness, fatigability, or incoordination would significantly limit functional ability during flare-ups or with repeated use over time could not be provided without resorting to mere speculation because it was not documented whether the Veteran was undergoing a flare-up or had used the spine repeatedly over time at the prior examination. She would need to measure range of motion during a flare-up or after repeated use over time in order to provide an opinion. In an August 2016 VA treatment record, it was noted that the Veteran’s back had full range of motion and no tenderness to palpation. In April 2017, he reported no back pain. In a November 2017 private treatment record, a clinician stated that the Veteran’s lumbar spine appeared normal, moved freely, and was nontender. In February 2018, he described pain in his lower back at a 4 out of 10 pain level to VA clinicians. In an August 2018 private treatment record, it was noted that his lumbar spine appeared normal, moved freely, and was nontender. Another VA examination was conducted in April 2019. The Veteran endorsed flare-ups of more pain and decreased mobility. He described functional loss as less flexibility with flare-ups and difficulty bending. Forward flexion was to 70 degrees, extension was to 30 degrees, right lateral flexion was to 10 degrees, left lateral flexion was to 20 degrees, and right and left lateral rotation were to 30 degrees. Pain was noted on forward flexion and right lateral flexion but did not result in functional loss. There was evidence of pain with passive range of motion testing and with weight-bearing but not with nonweight-bearing. There was mid-lumbar tenderness. The Veteran was able to perform repetitive use testing without additional loss of function or range of motion. The examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and during flare-ups. Pain would result in difficulty bending. The Veteran had guarding and muscle spasm not resulting in abnormal gait or abnormal spinal contour. Muscle strength testing was normal and there was no muscle atrophy. Deep tendon reflexes were hypoactive at the ankle and normal at the knee. A sensory examination was normal at the upper anterior thigh, lower leg/ankle, and foot/toes, but decreased at the thigh/knee. There was no evidence of radicular pain or other signs or symptoms due to radiculopathy, no other neurologic abnormalities or findings, no ankylosis, and no IVDS. The Veteran reported constant use of a cane, but it was noted that it was mainly used for his knee pain. X-rays revealed some mild changes of chronic DDD seen at T12 to L1; posterior spinous processes, transverse processes, and pedicles intact; and slight chronic degenerative change seen at the lower lumbar posterior facet joints. The functional impact was determined to be that the back stiffened if sitting for a long time and the Veteran was a bus driver. Also, his pain increased at night, affecting sleep. The Board notes at the outset that although the December 2013/June 2014 examiners did not discuss the additional requirements outlined in Correia or provide limitation of motion after repeated use over time or during flare-ups in terms of degrees of motion, the Veteran himself has provided statements regarding the limitation of his activities from which to extrapolate the extent and severity of his lumbar spine disability. His own depictions of the symptomology and practical effects of his condition provide an adequate basis upon which to evaluate the disability. For instance, he has stated that he experiences increased pain with prolonged sitting, standing, or ambulation and evaluations have revealed pain on movement, suggesting that weight-bearing activities cause more functional impairment than nonweight-bearing activities. As such, testing active motion with weight-bearing is more likely to represent the most severe limitation of motion caused by the disability. Additionally, the April 2019 examiner specifically concluded that pain did not result from nonweight-bearing activities. Further, although the April 2019 examiner did not determine additional impairment in terms of degrees of range of motion after repeated use over time and with flare-ups, the examiner found that pain would result in difficulty bending only and he used the Veteran’s own description of his limitations to describe the functional impact. Given the totality of the information, including the Veteran’s own descriptions of his limitations, the Board finds that the requirements of DeLuca, Sharp, and Correia have been adequately addressed. DeLuca v. Brown, 8 Vet. App. At 202; Sharp v. Shulkin, 29 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158. 1. A rating in excess of 20 percent for DDD of the lumbar spine is denied. Based on the foregoing, the Board finds that a rating in excess of 20 percent is not warranted at any point during the appeal period. The December 2013 examination demonstrated forward flexion limited to 40 degrees and muscle spasm severe enough to result in abnormal gait and spinal contour, warranting a 20 percent rating. Range of motion was improved throughout the rest of the appeal period and muscle spasm and guarding did not result in abnormal gait or spinal contour; however, the Board finds that a 20 percent rating is warranted throughout the entire appeal period. At no point was forward flexion limited to 30 degrees nor was there favorable ankylosis of the entire thoracolumbar spine. Further, there is no evidence that IVDS resulted in incapacitating episodes of at least 4 weeks in a 12-month period. As such, a rating in excess of 20 percent is not warranted. The Board also notes that there is no evidence of radiculopathy or other neurological abnormalities resulting from the Veteran’s lumbar spine disability demonstrated throughout the record. Although there was decreased sensation at the thigh/knee, the Veteran has separately service-connected knee disabilities and there was no evidence of involvement of the lumbar spine warranting a separate evaluation for radiculopathy/neuropathy. The Board recognizes the Veteran’s belief that his lumbar spine disability merits a higher rating. However, an application of the relevant diagnostic codes and consideration of the DeLuca factors indicates that a higher evaluation is not warranted based on the evidence of record. (b.) Cervical Spine Turning to the evidence of record, the Veteran underwent a VA examination in December 2013. He described flare-ups of pain aggravated by prolonged sitting, standing, and ambulation. Forward flexion was to 45 degrees or greater with no evidence of painful motion; extension was to 45 degrees or greater with no evidence of painful motion; right lateral flexion was to 35 degrees with pain; left lateral flexion was to 40 degrees with pain; right lateral rotation was to 45 degrees with pain; and left lateral rotation was to 45 degrees with pain. The Veteran was able to perform repetitive use testing with no loss of motion other than in left lateral flexion which was to 35 degrees. Additional functional loss was noted to be less movement than normal and pain on movement. There was no localized tenderness or pain on palpation. The Veteran had guarding or muscle spasm not resulting in abnormal gait or contour. Muscle strength testing was normal with no atrophy. A reflex examination and sensory examination yielded normal results. There was no radicular pain or any other signs or symptoms due to radiculopathy and no other neurologic abnormalities. The Veteran did have IVDS but had no incapacitating episodes over the past 12 months due to IVDS. The most recent x-rays revealed DDD at the C3-C4 through C6-C7 levels. He did not require assistive devices. The examiner determined that there was no functional impact caused by the cervical spine disability. An addendum VA opinion was obtained in June 2014. The examiner stated that an opinion regarding whether pain, weakness, fatigability, or incoordination would significantly limit functional ability during flare-ups or with repeated use over time could not be provided without resorting to mere speculation because it was not documented whether the Veteran was undergoing a flare-up or had used the spine repeatedly over time at the prior examination. She would need to measure range of motion during a flare-up or after repeated use over time in order to provide an opinion. In an August 2016 VA treatment record, the Veteran noted that he occasionally had neck pain. His neck demonstrated full range of motion and no tenderness to palpation. Private treatment records in November 2017 and August 2018 stated that the Veteran’s cervical spine appeared normal, moved freely, and was nontender. Another VA examination was conducted in April 2019. The Veteran described steady pain in his neck at 5 to 6 out of 10. He treated his symptoms with ice or heat and rare Motrin use. There was no radiation or weakness. His pain was worse if he tried lifting but he denied flare-ups. Forward flexion was to 45 degrees, extension was to 30 degrees, right and left lateral flexion were to 45 degrees, and right and left lateral rotation were to 80 degrees. Pain was noted on extension but did not result in functional loss. There was pain with passive range of motion testing but no evidence of pain with weight-bearing or nonweight-bearing. There was no localized tenderness or pain on palpation. The Veteran was able to perform repetitive use testing without additional loss of function or range of motion. The examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and concluded that pain, weakness, fatigability, or incoordination would not significantly limit functional ability with repeated use over time. There was no guarding or muscle spasm of the cervical spine and no additional factors contributing to disability. Muscle strength testing was normal and there was no atrophy. Deep tendon reflexes were hypoactive. A sensory examination was normal. The Veteran did not have radicular pain or any other signs or symptoms of radiculopathy, no other neurologic abnormalities, no ankylosis, and no IVDS. The Veteran did not use assistive devices. The most recent x-ray revealed mild scoliosis convexity ot the right cervical spine with no fractures, no prevertebral soft tissue swelling, and degenerative changes with narrowing of the C3-C4, C4-C5, C5-C6, and C6-C7 disc spaces with osteophyte area. The functional impact of the disability was determined to be that the Veteran could not lift or carry heavy objects as it exacerbated his pain. He knew to avoid this, so he rarely experienced flare-ups. The Board notes at the outset that although the December 2013/June 2014 examiners did not discuss the additional requirements outlined in Correia or provide limitation of motion after repeated use over time or during flare-ups in terms of degrees of motion, the Veteran himself has provided statements regarding the limitation of his activities from which to extrapolate the extent and severity of his cervical spine disability. His own depictions of the symptomology and practical effects of his condition provide an adequate basis upon which to evaluate the disability. For instance, he has stated that he experiences increased pain with prolonged sitting, standing, or ambulation and evaluations have revealed pain on movement, suggesting that weight-bearing activities cause more functional impairment than nonweight-bearing activities. As such, testing active motion with weight-bearing is more likely to represent the most severe limitation of motion caused by the disability. Additionally, the April 2019 examiner specifically concluded that pain did not result from nonweight-bearing activities and the Veteran described increased pain with lifting and carrying. Further, although the April 2019 examiner did not determine additional impairment in terms of degrees of range of motion after repeated use over time, the examiner found that pain, weakness, fatigability, or incoordination would not significantly limit functional ability with repeated use over time and he used the Veteran’s own description of his limitations to describe the functional impact. Given the totality of the information, including the Veteran’s own descriptions of his limitations, the Board finds that the requirements of DeLuca, Sharp, and Correia have been adequately addressed. DeLuca v. Brown, 8 Vet. App. At 202; Sharp v. Shulkin, 29 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158. 1. A rating in excess of 10 percent for DDD of the cervical spine is denied. Based on the foregoing, the Board finds that a rating in excess of 10 percent is not warranted at any point during the appeal period. At no point was forward flexion limited to 30 degrees. Although there was scoliosis demonstrated upon x-ray at the April 2019 examination, the examiner determined that it was not caused by guarding or muscle spasm. Further, there is no evidence that IVDS resulted in incapacitating episodes of at least 2 weeks in a 12-month period. As such, a rating in excess of 10 percent is not warranted. The Board also notes that there is no evidence of radiculopathy or other neurological abnormalities resulting from the Veteran’s cervical spine disability demonstrated throughout the record warranting a separate evaluation for radiculopathy/neuropathy. The Board recognizes the Veteran’s belief that his cervical spine disability merits a higher rating. However, an application of the relevant diagnostic codes and consideration of the DeLuca factors indicates that a higher evaluation is not warranted based on the evidence of record. 3. TDIU As noted above, the increased ratings appeal period stems from a September 13, 2013, claim. During the appeal period, the Veteran was granted 100 percent ratings for his left and right knee replacements from December 18, 2018, to February 1, 2020. The Board notes that the presence of a schedular 100 percent disability rating does not necessarily render the issue of TDIU moot. See Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008) (holding that 100 percent evaluation does not render a TDIU claim moot where there is a possibility that TDIU will impact entitlement to special monthly compensation (SMC) based on receipt of service connection for a disability with a 100 percent rating and another with a separate 60 percent rating). Although the total disability requirement must be met by a single disability, the 60 percent requirement may be met by applying the combined rating of the veteran’s remaining disabilities. Id., (noting that combined ratings satisfy the second requirement but not the first). As such, the Board will consider entitlement to TDIU based on the entirety of the Veteran’s service-connected disabilities prior to December 18, 2018; entitlement to TDIU based on his service-connected disabilities other than the left and right knee replacements from December 18, 2018, to February 1, 2020; and entitlement to TDIU based on all service-connected disabilities from February 1, 2020. A total disability rating for compensation purposes may be assigned where the schedular rating is less than total and where it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Consideration may be given to the Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). To meet the requirement of “one 60 percent disability” or “one 40 percent disability,” the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment may also be held to exist, on a facts-found basis (including, but not limited to, employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16. The term “substantially gainful occupation” is not defined in the rating schedule. Rather, the Court in Ray v. Wilkie, found the phrase has two components: an economic one and a noneconomic one. 31 Vet. App. 58 (2019). In assessing the veteran’s ability to secure and follow a substantially gainful occupation, the Board is to consider the veteran’s history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Id. Such specific physical ability factors include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. Id. Specific mental ability factors include memory, concentration, ability to adapt to change, handle workplace stress, getting along with coworkers, and demonstrating reliability and productivity. Id. In Withers v. Wilkie, the Court noted that VA has not explicitly defined the meaning of “sedentary employment.” 30 Vet. App. 139 (2018). Until VA provides such a definition, “the meaning and relevance of the term will have to be discerned on a case-by-case basis from the medical and lay evidence presented and in light of each veteran’s education, training, and work history.” Id. at 149-150. Prior to December 18, 2018, the Veteran’s service-connected disabilities included lumbar spine DDD at 20 percent, left knee DJD at 10 percent, right knee post-traumatic osteoarthritis at 10 percent, symptomatic right meniscal tear at 10 percent, and cervical spine DDD at 10 percent, for a combined evaluation of 50 percent. Thus, prior to December 18, 2018, the Veteran did not meet the initial eligibility requirements to receive TDIU benefits. 38 C.F.R. § 4.16(a). From December 18, 2018, to February 1, 2020, the Veteran’s service-connected disabilities other than his left and right knee replacements included lumbar spine DDD at 20 percent and cervical spine DDD at 10 percent, for a combined evaluation of 30 percent. As such, From December 18, 2018, to February 1, 2020, the Veteran was not in receipt of a 100 percent rating along with separately rated disabilities at 60 percent. See Bradley v. Peake, 22 Vet. App. at 293-94. From February 1, 2020, the Veteran’s service-connected disabilities included left knee replacement at 30 percent, right knee replacement at 30 percent, lumbar spine DDD at 20 percent, and cervical spine DDD at 10 percent, for a combined evaluation of 70 percent. The Board notes that the Veteran was service-connected for his left knee disability as secondary to his right knee disability. As such, they result from one common etiology and together meet the 40 percent threshold criteria for TDIU. Concerning the economic component, the Veteran has a high school education along with two years of college education. He also has additional training in photography. His military occupational specialty was watercraft operator. On a VA form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, submitted in March 2019, he indicated that he worked as a bus driver full-time with no time lost from illness from December 2001 to the present, but that he became too disabled to work December 14, 2018. Multiple attempts were made to contact the Veteran’s employer to verify his employment, however no response was received. September and October 2018 VA treatment records noted that the Veteran’s current occupation was plumber. He indicated to an August 2019 VA examiner that he stopped working due to his bilateral knee replacement surgery in December 2018. As such, from an economic perspective, the Veteran had the education, skills, work history, and training to perform work including bus driver or vehicle operator, watercraft operator, and possibly plumbing work. Concerning the noneconomic component, the Veteran underwent several VA examinations to determine the extent and severity of his service-connected disabilities. December 2013 examinations regarding his bilateral knee, lumbar spine, and cervical spine disabilities noted that there was no impact to his ability to work. The examiner remarked that the Veteran was a bus driver but did not report any aggravation of his disabilities due to his work. An April 2019 examiner determined that the Veteran’s bilateral knee disabilities meant that he could not walk great distances due to fatigue. His lumbar spine disability impacted his functional ability in that his back stiffened if sitting for a long time. Also, pain increased at night, affecting his sleep. His cervical spine disability resulted in an inability to lift or carry heavy objects as it exacerbated his pain. An addendum VA opinion was obtained in August 2019 regarding the impact of the Veteran’s service-connected disabilities on employment. The clinician stated that the Veteran had chronic knee pains which persisted even after his bilateral knee replacements. The knee pain worsened with walking, precluding active occupations requiring mobility. He had neck pains that limited lifting or carrying heavy objects with his hands. He also had back pains which were worse when sitting for prolonged periods, such as when driving the bus, and those made it difficult for him to return to working as a bus driver. The clinician determined that the Veteran could do sedentary work such as office work with opportunities to stand and stretch. He also could drive short distances, as a personal livery driver for instance, if he had opportunities to rest and stretch. The clinician concluded that although the Veteran’s disabilities extended to many tasks, they did not render him completely unemployable. (a.) Entitlement to TDIU is denied. As noted above, prior to December 18, 2018, the Veteran’s service-connected disabilities did not meet the schedular threshold for a TDIU. If a claimant does not meet the threshold criteria, a TDIU may still be assigned but on a different basis. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 38 C.F.R. §4.16(b). The rating boards are required to submit all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards, to the Director of Compensation Service for extraschedular consideration. Id. The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rather, the Board’s sole inquiry is whether referral for extraschedular consideration is warranted in light of the evidence showing the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. In this case, the Board finds no basis to refer the matter for extraschedular consideration as the evidence does not show the Veteran’s service-connected disabilities prevented substantially gainful employment prior to December 18, 2018. Prior to December 18, 2018, the Veteran worked full-time as a bus driver. VA examiners determined that there was no functional impact of his bilateral knee, lumbar spine, and cervical spine disabilities. It was noted at the December 2013 examinations that his work did not aggravate his disabilities. The Board considered the physical ability factors noted in Ray, to include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. See Ray v. Wilkie, 31 Vet. App. at 58. VA examiners did not find that the Veteran would be limited in being able to engage in any of the physical ability factors. The Board also considered the mental ability factors noted in Ray, to include memory, concentration, ability to adapt to change, handle workplace stress, getting along with coworkers, and demonstrating reliability and productivity. Id. The Veteran was not service-connected for any disabilities affecting his mental ability factors and there were no noted mental acuity effects of his service-connected disabilities. Accordingly, based on the Veteran’s successful full-time employment and the limited impact of his service-connected disabilities on his ability to perform work for which he has the education, skills, work history, and training, the evidence does not show that his service-connected disabilities prevented substantially gainful employment prior to December 18, 2018. As such, the Board finds no basis to refer the matter for extraschedular consideration. From December 18, 2018, to February 1, 2020, there is no indication that his service-connected disabilities other than the bilateral knee replacements rendered the Veteran unemployable. He indicated that the only reason he ceased working was because of the knee surgery and convalescence. As outlined above, there was no increase in severity of the Veteran’s lumbar spine and cervical spine disabilities during this period. As such, the Board finds that the Veteran was not rendered unable to obtain or maintain substantially gainful employment due to his lumbar spine and cervical spine disabilities alone. Further, the spine disabilities combined to a 30 percent evaluation only. As such, entitlement to TDIU and SMC are not warranted from December 18, 2018, to February 1, 2020. From February 1, 2020, the Board finds that the Veteran was not rendered unemployable by his service-connected disabilities. The Board considered the physical ability factors noted in Ray, to include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. The VA examiners found that the Veteran could not engage in prolonged walking or sitting and could not lift or carry heavy objects. As such, he could not return to his previous work as a bus driver, as it requires prolonged sitting. However, he could engage in sedentary work such as office work or personal livery driver if he had the opportunity to rest and stretch. The Board notes that although a complete employment history was not provided by the Veteran, it does not appear as though he has the skills and work history to perform office work. He does however have the skills and work history to engage in different forms of vehicle operation. The VA clinician determined that the Veteran could continue to engage in work comprised of vehicle operation which does not require constant sitting, and which provided the ability to rest and stretch, such as with personal livery work. The Board also considered the mental ability factors noted in Ray, to include memory, concentration, ability to adapt to change, handle workplace stress, getting along with coworkers, and demonstrating reliability and productivity. The April 2019 examiner found that the Veteran’s back pain was worse at night, affecting his sleep. However, there is no medical evidence in the record of daytime somnolence or other symptoms affecting mental ability factors. Based on the foregoing, the Board finds that the Veteran has not been rendered unable to obtain or maintain substantially gainful employment based on his service-connected disabilities from February 1, 2020. The Board does not doubt that the Veteran’s service-connected disabilities cause impairing symptomatology. This impairment of function is recognized by the ratings assigned to each of his service-connected disabilities. The evidence does not support that these disabilities preclude substantially gainful employment, specifically to include sedentary employment as outlined above. (Continued on the next page)   In light of the Veteran’s past work history, training, and skills and in light of the medical evidence in this case, the Board finds the Veteran was capable of substantially gainful work throughout the appeal period. Accordingly, entitlement to a TDIU is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.