Citation Nr: 21010380 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 12-26 250 DATE: February 24, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome of the left knee (left knee disability) is denied. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome of the right knee (right knee disability) is denied. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance and/or housebound status is denied. FINDINGS OF FACT 1. During the entire appellate period, the Veteran’s left knee disability has manifested by flexion limited to 120 degrees and extension limited to 0 degrees, to include when considering functional limitation. 2. During the entire appellate period, the Veteran’s right knee disability has manifested by flexion limited to 120 degrees and extension limited to 0 degrees, to include when considering functional limitation. 3. The preponderance of the evidence reveals that the rating criteria reasonably describes the Veteran’s bilateral knee disability symptomatology and that his disability picture is adequately contemplated by the rating criteria. 4. The Veteran’s service-connected disabilities do not cause incapacity which requires regular aid and attendance or render him housebound. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome of the left knee (left knee disability) have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5099-5014. 2. The criteria for entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome of the right knee (right knee disability) have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5099-5014. 3. The criteria for entitlement to SMC based on the need for regular aid and attendance and/or housebound status have not been met. 38 U.S.C. §§ 1114(l), 1114(s); 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1986 to May 1986. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2010 and July 2011 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in May 2013, January 2015, March 2016, May 2017 and January 2019 for further development by the RO. The case has been returned to the Board for further appellate action. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 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 their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as ‘staged ratings.’ Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. In determining the adequacy of assigned disability ratings, consideration is also given to factors affecting functional loss. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Such factors include a lack of normal endurance and functional loss due to pain and pain on use, specifically limitation of motion due to pain on use, including that experienced during flare ups. 38 C.F.R. § 4.40. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 4243 (2011) (holding that pain alone does not constitute functional loss and is just one fact to be considered when evaluating functional impairment). That said, 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. The Veteran’s bilateral knee disability is rated under Diagnostic Codes (DCs) 5099-5014, which pertains to an unlisted disability that will be rated as if it were residuals of osteomalacia. 38 C.F.R. § 4.71a; see also 38 C.F.R. § 4.27 (explaining and setting forth the procedure for assigning diagnostic criteria to unlisted disabilities, including the use of hyphenated ratings). Under DC 5014, residuals of osteomalacia shall be evaluated under diagnostic codes 5013 through 5024 as degenerative arthritis, based on limitation of motion of affected parts. 38 C.F.R. § 4.71a, Note to DCs 5013 to 5024. Under DC 5003, degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, DC 5003. In the absence of limitation of motion, with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is assigned; with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, a 10 percent rating is assigned. The diagnostic codes pertaining to limited motion of the knee are DCs 5260 and 5261. Limited flexion of the knee is rated under DC 5260, which assigns a noncompensable rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and, a 30 percent rating when limited to 15 degrees. Id., DC 5260. Limited extension of the knee is rated under DC 5261, which assigns a noncompensable rating when extension is limited to 5 degrees; a 10 percent rating when limited to 10 degrees; a 20 percent rating when limited to 15 degrees; a 30 percent rating when limited to 20 degrees; a 40 percent rating when limited to 30 degrees; and a 50 percent rating when limited to 45 degrees. Id., DC 5261. VA’s General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). 1. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome of the left knee (left knee disability) 2. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome of the right knee (right knee disability) The Veteran underwent a VA examination in August 2011 for individual unemployability. The examiner noted that the bilateral knee disability did not change since the last exam in February 2010. The Veteran continued to have chronic bilateral knee pain and stiffness. He can stand or walk for only 20 minutes due to pain. He has chosen to wear full leg braces since June 2009, as his physician prescribed only ankle braces. The Board notes that the Veteran is service connected for bilateral ankle disabilities. Exposure to cold weather causes pain and stiffness. He denied flare-ups. The examiner noted mild crepitus, no instability upon testing, and no atrophy. Non-weightbearing bilateral knee flexion is to 130 degrees; extension to zero degrees. He performed three bilateral non-weightbearing repetitions with pain throughout, but no change in range of motion. He declined to attempt weightbearing squats due to concerns over losing his balance. The Veteran underwent a VA examination for his knee condition in September 2013. The Veteran reported that the condition had worsened. The Veteran reported flare-ups consisting of constant pain. Initial range of motion measurements noted right knee flexion to 80 degrees with objective evidence of painful motion; extension was noted to zero degrees with objective evidence of painful motion noted at 40 degrees. Initial range of motion measurements noted left knee flexion to 80 degrees with objective evidence of painful motion; extension was noted to zero degrees with objective evidence of painful motion noted at 20 degrees. No additional limitation in range of motion was noted on repetitive use testing; however, functional loss was noted. In particular, less movement than normal and pain on movement were noted. The examiner was unable to perform any joint stability tests. No patellar subluxation or dislocation were noted. No “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment were noted. No meniscal conditions were noted. No knee replacement or surgeries were noted. No other pertinent physical findings, complications, conditions, signs and/or symptoms were noted. Regular use of a brace and walker were noted; constant use of a cane was noted. The examiner noted that there are contributing factors of pain, weakness, fatigability and/or incoordination but no additional limitation of functional ability of the knee joint during flare-ups or repeated use over time. An October 2013 VA treatment record noted full passive range of motion of knees and greater than 90 degrees active range of motion for the knees. The clinician noted that the examination was somewhat compromised due to embellishment. She advised the Veteran that his leg braces are counterproductive, though she noted that he likely does not wear them all the time as there was no evidence of muscle atrophy. A November 2013 VA treatment record noted no swelling and full range of active and passive motion bilaterally. The clinician noted that not using the braces would help with his conditions; she also recommended pain psychology. The Veteran underwent a third VA examination in March 2014. The Veteran reported painful knees and stiffness in cold weather; being able to walk to only 150 feet due to his knee and leg conditions; standing for only 15 minutes; and sitting for only 30 minutes. The Veteran noted no flare-ups. Initial range of motion measurements noted bilateral flexion to 130 degrees and extension to 0 degrees. No change was noted upon repetitive use testing. As for functional loss, the examiner noted less movement than normal, pain on movement and interference with sitting, standing and weight-bearing. Bilateral tenderness or pain on palpation were noted. Joint stability testing was normal. No evidence or history of recurrent patellar subluxation or dislocation were noted. No “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment were noted. No meniscus (semilunar cartilage) condition was noted. No other pertinent physical findings, complications, conditions, signs, or symptoms were noted. The examiner noted that no additional functional loss or change in range of motion is anticipated due to flares, pain or repetitive use or time. The examiner noted regular use of both a cane and brace. An April 2014 VA treatment record noted that the Veteran reported a fall after his knee giving out. The clinician noted an unimpressive exam with no acute problems. The examination revealed no swelling or effusion, a full range of motion, negative anterior and posterior drawer tests, and a negative McMurry test. The basis of the chronic knee pain and weakness is unclear. He did not appear to have any arthritis, degenerative joint disease, or joint space narrowing on X-rays. No atrophy of his thigh or calf muscles was noted; the ligaments were intact. No inflammatory or infectious causes were noted. The examiner could not exclude malingering, Munchausen’s or conversion disorder. The examination was repeated by another clinician who confirmed the findings, finding full flexion, no effusion, and no ligamentous laxity. The Veteran had no pain while palpating through the joint lines and no cause of knee pain could be determined. The Veteran underwent a fourth VA examination in July 2015. The Veteran reported having had physical therapy, but no corticosteroid injections, no visco-supplementation injections or surgeries and wearing knee braces intermittently. He was not wearing braces at the time of the examination and at the time was not undergoing physical therapy. He reported difficulty walking and climbing stairs. The Veteran reported no flare-ups or any functional loss including but not limited to repeated use over time. Initial range of motion measurements noted knee flexion to 120 degrees and extension to zero degrees; pain was noted and contributed to functional loss bilaterally. There was no evidence with pain on weight-bearing, tenderness or pain on palpation, or crepitus bilaterally. There was no additional functional loss or range of motion upon repetitive use testing. As for repeated use over time, the examiner was unable to say whether functional ability was further limited without mere speculation as there is no empiric bases for doing so without direct observation. There were no other factors contributing to the disability. The examiner noted no atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Testing revealed no joint instability; all results were normal. The examiner noted no recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. No meniscus (semilunar cartilage) condition was noted. No other pertinent physical findings, complications, conditions, signs, or symptoms were noted. Occasional use of a brace was noted; namely, when the Veteran leaves his home. An imaging report noted normal anatomy of the knees bilaterally. As for functional impact, the examiner noted that the Veteran cannot climb more than 2 flights of stairs, sit for more than 45 minutes or squat. The Veteran reported trouble with activities such as cooking and entering and exiting a bathtub, but his routine also includes leaving his home and socializing at adult daycare, reading, computer work, and watching television. The Veteran underwent a fifth VA examination in May 2016. The Veteran reported pain with cold weather and prolonged walking. The Veteran reported no flare-ups or functional loss including but not limited to repeated use over time. Initial range of motion measurements bilaterally were flexion to 130 degrees and extension to zero degrees; pain was noted but did not cause functional loss. There was no evidence with pain on weight-bearing, tenderness or pain on palpation bilaterally; there was evidence of crepitus. There was no additional functional loss or range of motion upon repetitive use testing. As for repeated use over time, the examiner noted that functional ability was not limited. No additional factors contributed to the disability. No atrophy or ankylosis were noted. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Testing revealed no joint instability; all results were normal. The examiner noted no recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. No meniscus (semilunar cartilage) condition was noted. No other pertinent physical findings, complications, conditions, signs, or symptoms were noted. Regular use of a cane was noted. As for functional impact, the examiner noted the Veteran cannot climb or do any prolonged walking or standing. The examiner also noted that there was some peripatellar crepitus with flexion and extension, but no pain with palpation, effusion or instability. A March 2017 VA treatment record noted meloxicam and gabapentin for knee pain. An August 2017 VA treatment record noted that the Veteran reported weak knees that give out, and that braces help with this. A September 2017 VA treatment record noted that full length braces are not prescribed; only ankle/foot orthoses. A November 2017 VA treatment record noted that the Veteran reported approximately four falls in the past three months due to his right knee giving out. The Veteran underwent a sixth VA examination in April 2018. The Veteran reported undergoing water therapy for his conditions. The examiner noted the Veteran did not undergo direct care such as injections for his knees. The examiner also noted a 2009 evaluation indicating imbalance of both lower extremities with extremely tight bilateral hamstrings and occasional infrapatellar swelling in the bursae with no effusion. The Veteran reported his knees locking out and he attributed occasional falls to his knee pain. The only orthotic prescription noted was braces for his ankle instability. The Veteran reported no flare-ups. As for functional loss, the Veteran reported he cannot squat due to his knee and foot conditions. Initial range of motion measurements noted right knee flexion to 125 degrees and extension to zero degrees; pain was noted on extension but did not cause functional loss. There was infrapatellar tenderness or pain on palpation; crepitus was also noted. Initial range of motion measurements noted left knee flexion to 135 degrees and extension to zero degrees; pain was noted on extension but did not cause functional loss. Tenderness or pain on palpation were noted; in particular, at the lateral joint line and ITB insertion. Crepitus was also noted. There was no additional functional loss or range of motion upon repetitive use testing bilaterally. As for repeated use over time, the examiner was unable to say whether functional ability was further limited without mere speculation as the Veteran does not repetitively use his knees due to his back and foot conditions. There were no other factors contributing to the disability. The examiner noted no atrophy due to the knee condition or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Testing revealed no joint instability; all results were normal. The examiner noted no recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. No meniscus (semilunar cartilage) condition was noted. As for other pertinent physical findings, passive flexion bilaterally was to 135 degrees; bilateral extension was to 0 degrees. Pain was noted for the right knee at 120 degrees of flexion and at 130 degrees for the left knee. Bilateral knee pain was noted at extension from 90 to 45 degrees. Such pain was noted not to cause functional loss. The examiner was unable to obtain weight-bearing measurements because of the Veteran’s braces and back and foot pain limiting such activity. The Veteran approached 30 degrees of flexion without the braces, but this was not estimated to be his maximum. The examiner also noted occasional use of braces and regular use of a cane; the braces are for the ankle and foot. The examiner also noted no radiographic evidence of evolution of arthritis over the past 8 years. As for functional impact, the Veteran noted squatting, which is also limited by back and foot conditions. The examiner also noted that Veteran’s pain can affect his moving from sitting to standing, squatting, returning from a squat, and stair navigation. The Veteran underwent a seventh examination in November 2019. The examiner noted that the braces are not for the knee condition. The examiner noted significant extra-articular swelling that did not involve the knee joints but made it difficult to see his patellae and the anterior knee at the time. The Veteran reported no flare-ups. As for functional loss, the Veteran reported being unable to walk or stand for any length of time or distance. He also cannot squat. Initial range of motion measurements bilaterally were flexion to 75 degrees and extension to zero degrees; pain was noted on flexion and caused functional loss. There was no crepitus bilaterally. There was bilateral evidence with pain on weight-bearing and tenderness on palpation over the patellofemoral joints. There was additional functional loss or range of motion upon repetitive use testing; flexion was reduced to 70 degrees bilaterally. As for repeated use over time, the examiner noted that functional ability was not limited bilaterally. No additional factors contributed to the disability. No atrophy or ankylosis were noted. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Testing revealed no joint instability; all results were normal. The examiner noted no recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. No meniscus (semilunar cartilage) condition was noted. No other pertinent physical findings, complications, conditions, signs, or symptoms were noted. Constant use of a cane for his knee disability was noted. As for functional impact, the examiner noted the Veteran cannot perform physical labor, whether light or heavy. Pain on passive range of motion was noted at 75 degrees bilaterally. The examiner was unable to perform weight-bearing testing as there was no available method to do so with specificity. An April 2020 VA treatment record noted five out of five on knee flexion and extension. On review of the record, the Board finds that the evidence weighs against a rating in excess of the currently assigned 10 percent rating. Throughout the appeal period, the Veteran has consistently reported difficulty with or an inability to perform certain activities for a prolonged length of time, to include standing, walking, sitting, climbing stairs, and squatting. However, the medical evidence indicates that the Veteran’s right and left knee flexion was most often recorded as between 120 to 135 degrees, to include when considering functional limitation, when considering the multiple VA examinations and treatment records as noted above. The Board notes that, at worse, the Veteran manifested flexion of 80 degrees at the September 2013 VA examination and 70 degrees in the November 2019 VA examination. These two reports alone are not necessarily representative of the overall disability picture, as flexion was more often reported between 120 to 135 degrees. Readings subsequent to these examinations noted full ranges of motion. See November 2013, April 2014 and April 2020 VA treatment records. Moreover, the flexion values reported therein are still insufficient to warrant a higher rating. A higher evaluation of 20 percent under DC 5260 is not warranted for limitation of flexion of the knee unless the evidence shows limitation of flexion of 30 degrees or less. As for extension, the medical evidence indicates that the Veteran’s right and left knee extension was most often recorded as zero degrees, to include when considering functional limitation. The Board notes that the September 2013 VA examination noted right knee extension to 40 degrees and left knee extension limited to 20 degrees, as pain caused functional loss of less movement. The Board also notes that the April 2018 VA examination noted passive bilateral extension from 45 to 90 degrees; this pain was noted not to cause functional loss. These two reports alone are not representative of the entire disability picture when considering the multiple VA examinations and treatment records that record higher values, as noted above. Readings subsequent to these examinations noted full ranges of motion. See November 2013, April 2014, and April 2020 VA treatment records; November 2019 VA examination (noting that pain caused functional loss only on flexion). The evidence has more often showed extension to zero degrees. Therefore, the disability picture is best approximated by the most frequently recorded extension values. The Board has considered and finds that the 20 percent rating criteria do not apply based on the Veteran’s overall disability picture. As such, higher disability ratings for limitation of flexion or extension of the right and left knee under DCs 5260 and 5261 are not warranted. Furthermore, a higher evaluation of 20 percent under DC 5003 is not warranted without X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, in absence of limitation of motion. Thus, the Board does not find that a higher disability rating is warranted. The Board has considered whether the Veteran is entitled to a higher disability rating or an additional separate rating under alternative diagnostic codes. However, the evidence of record does not support higher or additional ratings. In this regard, his VA examinations showed no recurrent subluxation or lateral instability and the Veteran has not been diagnosed with ankylosis, genu recurvatum, impairment of the tibia and fibula or dislocated semilunar cartilage. Considering the record as a whole, to include the medical and lay evidence, the Board finds that there are not separate manifestations of the knee disabilities not compensated by the current ratings assigned for limitation of motion in flexion. Therefore, the Board finds that DCs 5256, 5257, 5258, 5259, 5262, and 5263 are not applicable. 38 C.F.R. § 4.71a. The Board notes that the current versions of DCs 5257 and 5262 were amended effective February 7, 2021, the month of this decision. See 85 Fed. Reg. 76453 (Nov. 30, 2020). The current versions of DCs 5256 and 5257 may not be applied prior to the effective date of February 7, 2021. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003 (Nov. 19, 2003). However, as the Board is not prohibited from applying a prior regulation in effect during the pendency of a claim to the period on or after the effective date of the new version of the regulation, it may still apply the prior version of DCs 5256 and 5257 to the entire period on appeal if this would afford a more favorable outcome. The Board notes that the outcome would be the same under the new version as his VA examinations showed no recurrent subluxation, lateral instability, or impairment of the tibia and fibula. In assessing the severity of the Veteran’s bilateral knee patellofemoral pain syndrome, the Board has considered the Veteran’s assertions regarding his symptoms, which he is certainly competent to provide. See Layno v. Brown, 6 Vet. App. 465 (1994); 38 C.F.R. § 3.159(a)(2). However, the criteria needed to support higher ratings requires medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of a higher rating for the Veteran’s bilateral knee patellofemoral pain syndrome at any point pertinent to this appeal. The Veteran has made a number of contentions regarding his symptoms. In a March 2013 Statement in support of claim, the Veteran stated that he has very limited extension and flexion while wearing braces. However, multiple VA treatment records note that the use of full-leg braces is elective and not constant. The Veteran’s multiple VA examiners took note of his braces during their evaluations. Next, in a May 2014 Form 9, the Veteran argued that his symptoms are better represented by a 20 percent rating as his tight hamstrings cause instability and he has locking knees. Considering all the evidence of record, to include both medical and lay evidence, the Board finds that the Veteran does not have a separate manifestation of knee disability represented by instability of the knees, and therefore a separate rating under DC 5257 is not warranted. The Board acknowledges the reports of falls in VA treatment records. However, instability was tested and found to be normal in the VA examinations of August 2011, March 2014, July 2015, May 2016, and November 2019. An April 2014 VA treatment record of an examination following a fall due to reported knee giving out noted no remarkable results, to include negative anterior and posterior drawer tests, and the clinician could not rule out malingering, Munchausen’s or conversion disorder. Although the Veteran has attributed falls to his bilateral knee disability, he is not competent to make such a determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Furthermore, the November 2019 SMC examination notes that the Veteran’s back and foot conditions contribute to his instability. Lastly, in a November 2018 Statement in support of claim, the Veteran contended that the VA examinations did not fully take into account the effects of medication, to include meloxicam and gabapentin. He also noted that his range of motion cannot be normal as he is incapable of squatting. The Board acknowledges that the Veteran has reported taking medications. However, there is no medical evidence to indicate that the Veteran’s flexion or extension would be worse, or how much worse it would be, without such medication. See Jones v. Shinseki, 26 Vet. App. 56 (2012). Neither the Veteran nor his representative has presented or identified any medical treatments or medical opinion evidence that supports the finding of limited flexion or extension to the degrees contemplated by the next higher ratings under DC 5260 or 5261. The Board also notes that the multiple VA examinations have all noted the Veteran’s abnormal, limited range of motion. Furthermore, it is not clear that his inability to squat is due solely or predominately to his knee disability. The Board notes that he is service connected for multiple orthopedic disabilities. The April 2018 VA examiner opined that his back disability impairs any squatting. In sum, the Board finds that a disability rating in excess of 10 percent for the Veteran’s bilateral knee patellofemoral pain syndrome is not warranted. To the extent that the Veteran contends entitlement to a higher rating, the preponderance of the evidence is against the claim; there is no reasonable doubt to be resolved; and any further increased rating is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular consideration The present appeal includes the matter of whether a higher evaluation on an extraschedular basis is warranted. The Veteran argued in a May 2014 Form 9 that he may be entitled to extraschedular consideration as he wears a full leg brace that impacts his bilateral knee flexion and extension. An extraschedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization render the application of the regular schedular standards impracticable. 38 C.F.R. § 3.321(b)(1). Ordinarily, there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Second, if the schedular rating does not contemplate the veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran’s disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” Third, if the rating schedule is inadequate to evaluate a veteran’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran’s disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Turning to the first step of the extraschedular analysis, the Board notes the Veteran’s argument that his leg braces impact his bilateral knee flexion and extension. However, limited flexion and extension are explicitly contemplated by the rating criteria. Moreover, the Veteran has not argued, and the record does not otherwise show, that his braces result in any symptoms other than limitation of motion when worn. Further, the Board notes that these braces are worn regularly or occasionally rather than constantly, and they were not prescribed for his knee condition. VA treatment records from October 2013 and November 2013 indicate that the braces may be counterproductive. The Veteran is not entitled to additional separate disability ratings where the symptoms for the conditions in question overlap or are duplicative. See 38 C.F.R. §§ 4.14 (prohibiting evaluation of the same manifestation under various diagnoses). In conclusion, the Board finds that the available schedular evaluation is adequate to fully compensate the Veteran. In the absence of this threshold finding, there is no need to consider whether there are “related factors” such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19. Therefore, extraschedular consideration is not warranted. 3. Entitlement to SMC based on the need for regular aid and attendance and/or housebound status SMC is payable at the “l” rate if a veteran, as the result of service-connected disability, is in need of regular aid and attendance. Need for aid and attendance means helplessness or is so nearly helpless as to require the regular aid and attendance of another person. A veteran will be considered to be in need of regular aid and attendance if he or she is blind or is so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; if the veteran is a patient in a nursing home because of mental or physical incapacity; or if the evidence establishes a factual need for aid and attendance or “permanently bedridden” status under the criteria set forth in 38 C.F.R. § 3.352(a). See 38 U.S.C. § 1114(l); 38 C.F.R. § 3.351(b), (c). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. “Bedridden” will be a proper basis for the determination. 38 C.F.R. § 3.352(a). For the purpose of this paragraph “bedridden” will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. Id. It is not required that all of the conditions enumerated in the provisions of 38 C.F.R. § 3.352(a) be found to exist in order to establish entitlement to aid and assistance, but that at least one of the enumerated factors must be present. Id.; see also Turco v. Brown, 9 Vet. App. 222, 224 (1996). The particular function a veteran is unable to perform must be considered in connection with his or her condition as a whole; it is only necessary to establish that a veteran is in need of regular aid and attendance, not that there be a constant need. Id. Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant’s condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. Id. The Board initially notes that the Veteran has not contended or demonstrated that he has a visual impairment to the extent that he was blind or nearly blind or that he is or was a patient in a nursing home, and the evidence of record does not so suggest. As such, the foregoing analysis will focus on whether there is a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). See 38 U.S.C. § 1114(l); 38 C.F.R. § 3.351(b). An October 2013 VA treatment record notes that the Veteran’s wife assists him with driving around but that he can bathe unassisted. He can also prepare microwave meals. He cannot drive, but rather uses the access-a-ride service. A May 2014 VA treatment record notes that the Veteran requested assistance taking his pants on and off and reported that his wife assists him with dressing at home. The clinician noted that he was able to do so at the time with minimal assistance. The Veteran underwent an aid and attendance or housebound examination in April 2016. The examiner opined that the Veteran was not bedridden. He was able to dress, undress, keep clean and presentable, use the toilet, feed himself, keep safe from hazards and fully manage financial affairs. Although pain limited the duration of ambulation, he was fully capable of traveling beyond the home and immediate premises. The examiner noted that the Veteran can perform all functions and can leave the home without restrictions. In the April 2018 VA examination for his knee conditions, the Veteran reported that he can dress himself but for occasionally requesting assistance for his lower extremities due to back pain. He prepared his own microwave food and managed his medications on his own. He reported feeling housebound due to his fear of encountering marijuana, to which he is severely allergic, outside the home. The Veteran underwent another aid and attendance or housebound examination in November 2019. The examiner noted that the Veteran is not permanently bedridden or hospitalized. The Veteran can also travel beyond his current domicile. As for his daily activities, the Veteran’s wife assists him with dressing and putting on his braces. He is able to bathe but needs grab bars to enter and exit the bathtub or shower. His wife washes his feet and back as he cannot reach these. The examiner determined that the Veteran is unable to dress, undress or bathe. The Veteran remains at home but for medical treatments to which his wife drives him. She also prepares all his meals. She retired from her job to be his full-time caretaker in 2014. As for his ability to protect himself from daily hazards, the examiner noted that the Veteran’s back and foot pain contribute to his lack of balance and instability. Moreover, the Veteran’s functional impairments are permanent. Upon consideration of the evidence, the Board finds that the Veteran’s service-connected disabilities have not rendered him so helpless as to need regular aid and attendance. Although the evidence shows that the Veteran requires certain assistance, he is not helpless due to his service-connected disabilities. SMC based on the need for aid and attendance requires a finding that the service-connected disabilities cause very specific types of limitations; the evidence of record indicates that the Veteran does not have these specific limitations. The Board notes that the November 2019 VA examiner determined that the Veteran cannot dress, undress or bathe himself. However, the examiner also indicated that the Veteran does retain some function in these areas; this is supported by the VA treatment records noted above. While the Board is sympathetic to the Veteran’s claim, these limitations alone are insufficient to support an award of SMC. The overall disability picture shows that the Veteran is not so helpless as to be in need of regular aid and attendance. The Board finds that the preponderance of the evidence is against finding that the Veteran was permanently bedridden or otherwise so helpless as to be in need of regular aid and attendance due to his service-connected disabilities. As the preponderance of the evidence is against this claim, reasonable doubt may not be resolved in the Veteran’s favor. 38 U.S.C. § 5107(b); Gilbert v. Derwinksi, 1 Vet. App. 49, 53-56 (1990). The Board has also considered entitlement to SMC pursuant to 38 U.S.C. § 1114(s); however, the criteria have not been met. SMC is payable at the “s” rate (also referred to as the “housebound rate”) where the Veteran has a single service-connected disability rated as 100-percent disabling and, in addition: (1) has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). A “single service-connected disability rated as total” under 38 U.S.C. § 1114(s) is not limited to cases where a 100 percent rating has been assigned via the application of one or more diagnostic codes in the rating schedule; rather, entitlement to a total disability rating based on individual unemployability (TDIU) may serve as the “total” rating for the purposes of SMC at the “s” rate if the TDIU is predicated upon a single disability. Bradley v. Peake, 22 Vet. App. 280 (2009). Thus, an award of TDIU, if it based upon a single service-connected disability, is sufficient to satisfy § 1114(s) requirement of a service-connected disability rated as 100 percent disabling. Bradley v. Peake, 22 Vet. App. 280, 293 (2008); see also Buie v. Shinseki, 24 Vet. App. 242, 250 (2010); however, a TDIU rating that is based on multiple underlying disabilities cannot satisfy the § 1114(s) requirement of “a service-connected disability” because that requirement must be met by a single disability. Id. Here, the Veteran is service connected for right lower extremity sciatica, lumbar intervertebral disc syndrome with low back pain, bilateral patellofemoral pain syndrome, right ankle degenerative joint disease, left ankle tendonitis, left lower extremity radiculopathy, and bilateral pes planus. See July 2020 rating decision code sheet. The Board granted an award of TDIU as of September 2013 based on the Veteran’s multiple service-connected orthopedic disabilities. See January 2019 Board decision. Therefore, the Board finds that TDIU was not awarded based on a single disability. Furthermore, the Veteran does not have a separate service-connected disability independently rated as 60 percent disabling. Therefore, he does not meet the legal criteria for payment of compensation at the housebound rate. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350. Moreover, as detailed above, the medical evidence does not show that the Veteran was housebound due to service-connected disabilities. Thus, the Veteran does not qualify for SMC by reason of being housebound due to a service-connected disability. As the preponderance of the evidence is against this claim, reasonable doubt may not be resolved in the Veteran’s favor. 38 U.S.C. § 5107(b); Gilbert v. Derwinksi, 1 Vet. App. 49, 53-56 (1990).   In sum, the Board finds that the Veteran is not, as the result of service-connected disabilities, with such significant disabilities as to be in need of regular aid and attendance and is not, by reason of service-connected disabilities, permanently housebound. As such, the Board concludes that the criteria for SMC based on the need for aid and attendance or housebound status have not been met. 38 U.S.C. §§ 1114 (l), (s), 5121; 38 C.F.R. §§ 3.350, 3.352, 3.1000. Accordingly, entitlement to SMC based on the need for aid and attendance or housebound status is denied. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Minaya, 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.