Citation Nr: 21010611 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 11-13 920 DATE: February 25, 2021 ORDER Prior to April 14, 2017, entitlement to a disability rating in excess of 10 percent for right knee osteoarthritis is denied. After April 14, 2017, entitlement to a separate 20 percent rating for limitation of extension of the right knee is granted. Entitlement to a total disability rating based on individual unemployability (TDIU), to include on an extraschedular basis, due to the Veteran's service-connected disabilities is denied. FINDINGS OF FACT 1. Prior to April 14, 2017, the Veteran’s right knee disability was manifest by osteoarthritis only. 2. After April 14, 2017, the Veteran’s right knee is manifest by limitation of flexion and extension of 15 degrees; recurrent subluxation and instability are not demonstrated. 3. The Veteran’s service-connected disabilities do not preclude him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to April 14, 2017, the criteria for entitlement to a disability rating in excess of 10 percent for right knee osteoarthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003. 2. After April 14, 2017, the criteria for a separate rating of 20 percent, but no higher, for limitation of extension of the right knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 3. The criteria for entitlement to a total disability rating due to individual unemployability (TDIU) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1977 to September 1980 and from July 1981 to May 1984. This appeal comes before the Board of Veterans’ Appeals (Board) from a July 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2011, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is available in the record. This matter was previously remanded in December 2017 for further development, to include requesting the Agency of Original Jurisdiction (AOJ) to obtain a VA medical opinion. The VA medical opinion was obtained, and therefore, the Board finds that its remand instructions were substantially complied with. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation 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. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.) Where entitlement to compensation has already been established, as is the case here, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), Diagnostic Code 5258 (cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion), and Diagnostic Code 5260 (limitation of flexion). Notably, during the appeal period, changes were made to 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5257, 5262. Effective February 7, 2021, VA amended its regulations governing the schedule of rating musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5257, 5262). Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under the old rating criteria for Diagnostic Code 5257, an evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability, an evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Under the new rating criteria for DC 5257 and effective February 7, 2021, a 10 percent rating is assigned for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is assigned for one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es) walker) or bracing for ambulation. A 30 percent rating is assigned for an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es) walker) and bracing for ambulation. The new rating criteria for DC 5257 also indicates that for patellar instability, a 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patella femoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (1) indicates for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) indicates a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Diagnostic Code 5260 pertains to limited flexion of the knee. Flexion limited to 60 degrees is noncompensable. A 10 percent rating applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees. A 30 percent rating applies when flexion is limited to 15 degrees. Diagnostic Code 5261 pertains to limited extension. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. Under the old rating criteria for Diagnostic Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating when there is malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating for malunion of the tibia and fibula with marked knee or ankle disability; and a maximum rating of 40 percent for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a. Under the new rating criteria for Diagnostic Code 5262, a 40 percent rating is assigned when there is nonunion of the tibia and fibula with loose motion, requiring a brace. If there is malunion of the tibia and fibula, such should be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Diagnostic Code 5258 provides that a 20 percent rating is assigned for dislocation of the semilunar or meniscal cartilage of the knee, with frequent episodes of “locking,” pain, and effusion into the joint. Additionally, the VA General Counsel has held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 (which provides for a 10 percent rating for a noncompensable limitation of motion or painful motion of an affected joint) and 5257, provided that a separate rating must be based upon additional disability. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Also, separate ratings may be assigned for limitation of flexion, limitation of extension, and subluxation of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion, compensable subluxation, and a compensable limitation of extension of the same knee, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). 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. 1. Prior to April 14, 2017, entitlement to a disability rating in excess of 10 percent for right knee osteoarthritis is denied. 2. After April 14, 2017, entitlement to a rating in excess of 30 percent is granted as a separate rating of 20 percent, but no higher, for limitation of extension of the right knee is warranted Prior to April 14, 2017, the Veteran’s right knee was rated as10 percent disabling under Diagnostic Code (DC) 5003 for osteoarthritis. After April 14, 2017, the Veteran’s knee was rated as 30 percent disabling under DC 5260 for limitation of flexion. The Veteran contends he is entitled to higher rating for his right knee, specifically for instability. Summary of the Evidence The Veteran underwent a VA examination in April 2010. The Veteran reported to the VA examiner that he suffered from weakness, stiffness, intermittent swelling, pain, giving away, lack of endurance, locking, fatigability, and tenderness. The Veteran’s range of motion was normal, and was not limited by repetitive use, pain, fatigue, weakness, endurance, or incoordination. The Veteran reported he experienced flare-ups that could last up to two weeks. No additional limitation of range of motion caused by flare-ups could be determined by the VA examiner. The Veteran also underwent a VA examination in April 2012. The Veteran reported instability and that knee locking had caused him to fall in the past month going up the stairs. The Veteran reported flare-ups of the knee that resulted in him staying in bed for a week due to pain. However, the Veteran also reported he did not experience loss of range of motion during flare-ups. The Veteran’s right knee flexion and extension were measured as 140 degrees or greater. Joint stability testing was performed and was normal. No subluxation or dislocation was noted. The examiner did note that the Veteran had a wobble to his gait when attempting the heel to toe walk. The Veteran underwent another VA examination in 2017. The Veteran reported he experienced flare-ups of the knee with very intense pain that would last for long periods of time. The Veteran reported having functional loss as he was unable to kneel or walk without 2 canes for stability. He also reported he was unable to run. The Veteran’s flexion and extension was measured at 70 degrees. The examiner indicated the abnormal range of motion did not contribute to functional loss. The Veteran was however, limited by pain, fatigue, and weakness during flare-ups to 15 degrees flexion and extension. No ankylosis or history of recurrent subluxation or lateral instability was noted. Joint testing for stability was performed and was found to be normal. The VA examiner specifically stated that although the Veteran reported he feels as though his knee is going to give out, the stability testing did not show any instability and his knee was sound. A clarifying VA medical opinion was obtained in June 2020. The VA examiner stated that after a review of the Veteran’s records, his reported symptoms, to include his knee giving out and falling, are due to recurrent subluxation or lateral instability of the right knee. Another VA medical opinion was obtained in September 2020. The VA examiner opined it was less likely than not that the Veteran’s reported symptomatology, to include “giving out” and falling, is not akin to or analogous with recurrent subluxation or lateral instability in the right knee. He further indicated the VA examinations from 1984, 2005, 2010, 2012, and 2017 and post service treatment records have not demonstrated lateral instability or subluxation since exiting service in 1984. The examiner concluded that the June 2020 medical opinion is not supported by the weight of the evidence as it only considers the Veteran’s asserted symptomatology and not the objective VA examinations and treatment records. Chondromalacia patella, Osgood-Schlatter’s and osteoarthritis of the knee are not associated with knee instability or recurrent subluxation. The Veteran also testified at his September 2011 Board hearing that he experienced constant knee pain and clicking. He was unable to do prolonged standing. Getting up or sitting down was difficult for him if the angle was under 45 degrees. He further reported that sometimes when he would walk, his legs seemed to keep walking, which caused him to fall over on the right-hand side. Walking or standing for long periods of time caused him a lot of pain. The Veteran also testified he experienced swelling once or twice a month and he was not able to walk until it went down. He reported his knee would lock up two to three times a month and that would cause him to fall two to four times a month. Analysis First, the Board acknowledges that the April 2010 and April 2012 VA knee examinations do not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The VA examiners did not address the impact of flare-ups on the Veteran’s functional impairment and possible additional limitation of motion, despite the Veteran’s reported medical history of flare-ups. However, the Veteran stated to the April 2012 VA examiner that he did not experience loss of range of motion during flare-ups. Thus, no estimates regarding additional limitation of range of motion during flare-ups would be possible based on the Veteran’s descriptions of his flare-ups. For these reasons, the April 2010 and April 2012 VA examinations are not rendered inadequate due to the examiners’ failure to provide an estimate as to additional range of motion loss due to flare-ups of pain based on the Veteran’s lay reports of flare-ups. In addition, the April 2017 VA examination of record addressed the requirements of Sharp and adequately described the functional impairment experienced by the Veteran with flare-ups. As such, the Board may consider the increased rating claim. Second, to the extent any portion of the VA examination reports is not fully compliant with the most recent Court decisions relating to orthopedic examinations, any error in this regard is harmless. See Shinseki v. Sanders, 556 U.S. 396, 409-10 (2009); Cf. Correia v. McDonald, 28 Vet. App. 158 (2016). In this regard, the Veteran has demonstrated range of motion significantly greater than next higher rating criteria and additional motion loss was not found upon repetitive range of motion testing. The Veteran’s functional impairment reports mainly concern generalized joint pain as opposed to additional motion loss. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of 38 C.F.R. § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). The record does not include any indication that any passive motion or comparison studies would assist in the substantiation any of these claims. Passive movement (i.e. assisted motion) would inherently reflect greater mobility than active movement. The Veteran does not identify any specific problem with passive motion or assert a comparison study is needed for any claimed joint. See Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Consequently, the Board finds that the Veteran is not prejudiced by any VA opinion inadequacy with respect to orthopedic functional impairment and that another remand for additional orthopedic examinations would not benefit the Veteran. See Lamb v. Principi, 22 Vet. App. 227, 234 (2008) (remand not required when it would serve no useful purpose); Winters v. West, 12 Vet. App. 203, 208 (1999) (en banc) (“[A] remand is not required in those situations where doing so would result in the imposition of unnecessary burdens on the [Board] without the possibility of any benefits flowing to the appellant.”); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (noting that “[a] veteran’s interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution”). Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), Diagnostic Code 5258 (cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion), and Diagnostic Code 5260 (limitation of flexion). As stated above, during the appeal period, changes were made to 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5257, 5262. Effective February 7, 2021, VA amended its regulations governing the schedule of rating musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5257, 5262). Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran has a diagnosis of osteoarthritis of the right knee and not a sprain, incomplete ligament tear, complete ligament tear (repaired, unrepaired, or failed repair) or patellofemoral complex as required by the new rating criteria, the Board will use the old rating criteria prior to February 7, 2021, as it will be more advantageous to the Veteran. Id. Under the old rating criteria for Diagnostic Code 5257, an evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability, an evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Based on the evidence of record, the Board finds the Veteran is not entitled to a separate rating for recurrent subluxation or lateral instability of the right knee. The Veteran is competent to report the occurrence of lay-observable events such as symptoms of instability. 38 U.S.C. § 1153(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The record reflects the Veteran credibly and competently describing symptoms of instability. However, the Veteran’s lay statements are outweighed by the competent medical evidence of record. While the June 2020 VA examiner gave a positive opinion, she did not provide any rationale for her opinion or explain how she came to this conclusion despite the joint stability testing in the VA examinations showing normal with no instability. As such the Board finds this opinion is not adequate for adjudicatory purposes and is not probative. Barr v. Nicholson, 2 Vet. App. 303, 311-12 (2007). In contrast, the September 2020 VA examiner considered the Veteran’s lay statements, all the evidence of record, to include the April 2012 VA examiner’s statement that the Veteran had a wobble to his gait when performing the heel to toe walk, and opined it was less likely than not that the Veteran’s reported symptomatology, was a result of such, is akin to, or analogous with recurrent subluxation or lateral instability in the right knee. Further, joint testing was performed at the April 2012 and April 2017 VA examinations and came back normal and showing no joint instability. As such, the Board finds the preponderance of the evidence is against a separate rating for recurrent subluxation or lateral instability of the right knee. The Board has also considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5261 for limitation of extension. Diagnostic Code 5261 pertains to limitation of extension. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. At the April 2017 VA examination, the VA examiner noted the Veteran was limited by pain, fatigue, and weakness during flare-ups to 15 degrees on extension. As such, a separate rating of 20 percent, but no higher, is warranted. A higher rating is not warranted as the evidence of record does not show the Veteran experiencing limitation of extension to 20 degrees. As such a separate rating of 20 percent, but no higher, for limitation of extension is warranted. The Board also has considered whether the Veteran is entitled to higher rating under DC 5260 for limitation of flexion and finds it is not warranted. In a May 2017 rating decision, the RO increased the Veteran’s rating for his right knee to 30 percent disabling, effective April 14, 2017 due to limitation of flexion of 15 degrees during flare-ups. This is the highest rating allowed under DC 5260; however, the Board must consider whether such rating was warranted prior to April 14, 2017. Diagnostic Code 5260 pertains to limited flexion of the knee. Flexion limited to 60 degrees is noncompensable. A 10 percent rating applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees. A 30 percent rating applies when flexion is limited to 15 degrees. At both the April 2010 and April 2012 VA examinations the Veteran’s range of motion was found to be normal (140 degrees or greater). The Veteran also reported that he did not lose range of motion during flare-ups. The Board acknowledges the Veteran’s Board testimony that sitting or standing up from an angle less than 45 degrees was difficult for him; however, he did not state he was unable to sit or stand past 45 degrees or limited in flexion to 45 degrees. As such, the Board finds the Veteran is not entitled to an earlier rating for limitation of flexion. The Board has also considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5262 for impairment of the tibia and fibula, Diagnostic Code 5258 for dislocated cartilage, with frequent episodes of locking, pain, and effusion, Diagnostic Code 5259 for removal of the cartilage, and Diagnostic Code 5256 for ankylosis, but finds there is no evidence of any impairment to the tibia or fibula, dislocated cartilage, removed cartilage, or ankylosis in the record. As such, a separate rating under these diagnostic codes is not warranted. Extraschedular Rating Finally, the Board has considered the contention by the Veteran through his representative that he is entitled to extraschedular consideration for his right knee disability. See January 2021 Appellate Brief. Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran’s circumstances but would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111 (2008). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321. Because the Rating Schedule was purposely designed to compensate for such functional effects of the Veteran’s disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the Rating Schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. There is a three-step inquiry for determining whether a claimant is entitled to an extraschedular rating. Thun, supra. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare the level of severity and symptomatology of the claimant’s service-connected disability with the established criteria found in the rating schedule for that disability. If the rating criteria reasonably describe the claimant’s disability level and symptomatology, then the claimant’s disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Second, if the schedular evaluation is found to be 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 claimant’s disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant’s disability picture requires the assignment of an extraschedular rating. The first Thun element is not satisfied here. The Veteran’s service-connected right knee disability is manifested primarily by complaints of pain, limitation of motion, and functional impairment. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by decreased or abnormal excursion, speed, coordination, or endurance. 38 C.F.R. § 4.40 (2017); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as pain on movement. 38 C.F.R. §§ 4.45, 4.59; Mitchell, supra; DeLuca, supra. In summary, the schedular criteria for musculoskeletal disabilities contemplates a wide variety of manifestations of functional loss. The Board has addressed the Veteran’s symptoms, both the ones contained in the objective medical records and those proffered by the Veteran in his lay statements. The Board finds that the schedular criteria address his symptoms and his functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran’s disability picture relative to his right knee. In summary, entitlement to a disability rating in excess of 10 percent prior to April 14, 2017 for right knee osteoarthritis is denied. After April 14, 2017, entitlement to a separate rating of 20 percent, but no higher, for limitation of extension of the right knee is granted. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) due to the Veteran's service-connected disabilities is denied. The Veteran has argued entitlement to a TDIU. TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single 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. For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; disabilities resulting from a common etiology or a single accident; disabilities affecting a single body system; multiple injuries incurred in action; or multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16 (a). In determining whether the Veteran is entitled to TDIU, neither the Veteran’s non-service-connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993); 38 C.F.R. § 3.341 (a). The Veteran does not meet the schedular criteria for entitlement to TDIU. He is currently rated at 30 percent for his anxiety disorder, 30 percent for right knee limitation of flexion, and 20 percent for limitation of extension of the right knee. The Veteran’s overall combined evaluation is 60 percent. As he does not have a single service-connected disability rated at 60 percent or more, or more than one service-connected disability resulting in a combined rating of at least 70 percent, the schedular criteria have not been met. Accordingly, the claim for TDIU on a schedular basis must be denied. When the percentage requirements for a schedular TDIU rating under 38 C.F.R. § 4.16 (a) are not met, a total rating on an extraschedular basis may nonetheless be granted in exceptional cases when a veteran is unable to secure and follow a substantially gainful occupation due to service-connected disabilities. 38 C.F.R. § 4.16 (b). The Court of Appeals for Veterans Claims held that the phrase “unable to secure and follow a substantially gainful occupation” in § 4.16(b) has economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component is the claimant’s ability to secure or follow substantially gainful occupation employment. Id. In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to the veteran’s history, education, skill, and training. Id. Additionally, attention must be given whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations. Id. Further, attention should be given whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Id. The case was referred to the Director of Compensation Service for consideration of entitlement to TDIU on an extra-schedular basis. In a July 2017 advisory opinion, the Director of Compensation Service determined the overall evidence fails to support the contention that any of the service-connected disabilities or a combination of the effects of those disabilities prevent gainful employment. The Director noted that the Veteran reported that he uses two canes and a brace to ambulate due to his right knee osteoarthritis, however outpatient evidence indicates that the Veteran utilizes the canes due to the severe non-service-connected peripheral neuropathy of both lower extremities. In addition, the April 2017 VA examination findings do not support a significant restriction of walking and standing due solely to the Veteran’s right knee arthritis. Further, the evidence documents that the Veteran’s anxiety disorder is mild and causes minimal functional restrictions. As a result, the claims file contains no evidence from previous employers showing interference with employment due to any service-connected disabilities, and contains no medical opinions indicating that the Veteran cannot perform any type of employment due to his service-connected disabilities. Therefore, the Director denied TDIU on an extra-schedular basis. Having reviewed the record, the Board the finds that the present case is not so exceptional that entitlement to TDIU on an extra-schedular basis is warranted. The record indicates that the Veteran is not currently engaged in any employment. He is in receipt of social security disability benefits. The primary disability for which he receives Social Security Administration (SSA) benefits is non-service-connected peripheral neuropathy in both his feet and right hand. The secondary diagnosis listed is his service-connected anxiety disorder. The Veteran did not report to the SSA that his service-connected right knee disability precludes him from working. SSA determinations are not binding on the Board. The inquiry now turns to whether the Veteran can follow a substantially gainful occupation due to service-connected disabilities. The Board has considered the Veteran’s employment history and education. With respect to the Veteran’s employment history, the Veteran participated in VA’s Vocational Rehabilitation program from October 11, 2005 to June 11, 2011. Prior to that, the Veteran worked from 1987 to 2000 in dietary management for a care center, in 2003 for 8 to 9 months in dietary management for a different care center, and for 6 months in 2005 making sections of furniture. He made between $8.00 and $8.50 an hour at each of those jobs. See SSA records. In addition, Veteran completed high school and attended one or two years of college. He also has training as an auto mechanic. The April 2012 VA knee examiner opined the Veteran can work in a safe environment with non-slip surfaces and hand railings. He will need to take rest breaks as needed and change positions as needed. Given his physical disabilities with his right knee that limits his standing, walking, lifting, and carrying, he would not be able to work in a setting that demanded physical manual labor with standing or walking or prolonged periods of time. However, he is not limited in grasping, gripping, reaching over his head, using a keyboard, writing, or hearing over the phone. Therefore, his service-connected osteoarthritis in and of itself would not render the Veteran unable to secure or maintain substantially gainful employment with his education and employment experiences. The April 2012 and March 2015 VA mental disorder examiners indicated the Veteran experiences occupational and social impairment due to mild transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. A June 2015 VA Memo from a rehabilitation counselor indicates that while the Veteran’s disabilities can cause impairment in his ability to maintain employment, the impairment is not significant and the Veteran should be able to maintain suitable employment as long as he continues to receive treatment for his disabilities. Based on a review of the evidence, and taking into consideration the Veteran’s level of education, work experience, and resulting physical and mental impairment from service-connected disabilities, the Board finds that the evidence is against a finding of entitlement to TDIU. Here, the record establishes that the Veteran experiences physical limitations and some mental limitations as a result of his service-connected disabilities. However, none of the VA examiners or vocational rehabilitation counselor have found the Veteran to be totally unable to obtain or maintain employment due to his service-connected disabilities. In addition, the April 2012 VA examiner indicated the Veteran is not limited in grasping, gripping, reaching over his head, using a keyboard, writing, or hearing over the phone. Further, the SSA records reflect the Veteran has several physical limitations due to a non-service-connected condition of neuropathy, such as only occasionally lifting 20 pounds maximum, frequently lifting 10 pounds maximum, standing and/or walking at least 2 hours during the workday, is medically required to have a hand-held assistive device for ambulation, and sitting about 6 hours of the workday. The Board may only consider service-connected disabilities regarding whether TDIU is warranted. In sum, the Veteran’s service-connected disabilities may result in some occupational impairment due to physical limitations, but the weight of the evidence does not demonstrate that the Veteran’s service-connected disabilities alone are of sufficient severity to preclude him from obtaining and maintaining all forms of substantially gainful employment. For these reasons, the Board finds that the criteria for a TDIU have not been met or more nearly approximated. The evidence is not in equipoise and, as such, the benefit of the doubt rule is inapplicable in this case. The appeal for a TDIU, to include on an extra-schedular basis, is denied. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Holcombe, 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.