Citation Nr: 21011092 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 16-28 700 DATE: February 26, 2021 ORDER Entitlement to service connection for peripheral neuropathy, on the basis of substitution, is denied. Entitlement to a rating in excess of 10 percent for left knee subluxation, on the basis of substitution, is denied. Entitlement to a rating in excess of 10 percent for left knee pain, on the basis of substitution, is denied. Entitlement to a rating in excess of 10 percent for a left ankle disability, on the basis of substitution, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU), on the basis of substitution, is granted. FINDINGS OF FACT 1. The weight of the evidence is against finding that peripheral neuropathy began during active service, and it is not shown to be related to the Veteran’s presumed herbicide agent exposure. 2. The Veteran’s left knee subluxation did not result in moderate recurrent subluxation or lateral instability. 3. The Veteran’s left knee disability was productive of flexion functionally limited to no less than 80 degrees, with full extension. 4. The Veteran’s left ankle disability did not result in any ankylosis, malunion, astragalectomy, or marked limitation of motion. 5. The evidence of record makes is at least in equipoise as to whether the Veteran’s service-connected disabilities were of sufficient severity to preclude him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral neuropathy have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304, 3.309. 2. The criteria for a rating in excess of 10 percent for left knee subluxation have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-63. 3. The criteria for a rating in excess of 10 percent for left knee pain have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-63. 4. The criteria for a rating in excess of 10 percent for a left ankle disability have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5270-74. 5. The criteria for a total disability rating based on individual unemployability (TDIU) have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1966 to August 1968, to include service in the Republic of Vietnam. The Veteran died in March 2019. The appellant is the Veteran’s widow. These matters come before the Board of Veterans’ Appeals (Board) on appeal from December 2013 and February 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Board remanded the appeal for further development. The RO recognized the appellant as a valid substitute claimant in place of the Veteran for the issues on appeal. Accordingly, the appellant has been substituted as the claimant for the purposes of all claims that were pending on the date of his death. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection may be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, including early onset peripheral neuropathy, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C. § 1113; 38 C.F.R. §§ 3.307, 3.309. The Veteran’s service record shows he had service in the Republic of Vietnam. As such, he was presumed to have been exposed to herbicide agents. The Veteran filed a request to reopen his service connection claim for peripheral neuropathy in February 2013, which was denied by a December 2013 rating decision. In a September 2018 Board decision, the Board granted reopening the Veteran’s service connection claim and remanded the claim for additional development. The Veteran and the appellant asserted that the Veteran’s peripheral neuropathy was due to his presumed herbicide agent exposure. The Veteran’s STRs show that at an August 1967 physical and an August 1968 separation physical, he did not report any peripheral neuropathy symptoms and had normal examinations of his upper and lower extremities. His STRs do not show any complaints, treatment, or diagnosis for peripheral neuropathy during his active service. The Veteran’s medical records show that the Veteran was diagnosed with slight bilateral foot neuropathy in March 2000, over three decades after his presumed herbicide agent exposure and his separation from active service. In June 2014, a private physician completed a Peripheral Nerves Condition Disability Benefits Questionnaire (DBQ). The physician noted a diagnosis of peripheral neuropathy before March 2012, indicating that symptoms pre-dated the diagnosis. The examiner stated that all other identifiable causes of his peripheral neuropathy have been ruled out, leaving known dioxin exposure as most likely etiological agent. In November 2015, the Veteran was afforded a VA examination. He reported that he started to have tingling in his arms and legs after his active service and that he was diagnosed with neuropathy in the mid-1980s. After reviewing the Veteran’s claims file, interviewing the Veteran, and conducting an examination, the examiner opined that the Veteran’s peripheral neuropathy was less likely than not due to diabetes, as the Veteran was not diagnosed with diabetes. In November 2020, a VA examiner reviewed the Veteran’s claims file and opined that the Veteran’s peripheral neuropathy was less likely than not due to the Veteran’s presumed herbicide agent exposure. The examiner noted that the claims file did not show a continuous finding of peripheral neuropathy within the years immediately after his active service. The examiner also noted that the etiology of the Veteran’s peripheral neuropathy was not known according to the Veteran’s physicians. The examiner stated that the conclusion that the Veteran’s peripheral neuropathy was more likely than not due to herbicide agent exposure was erroneous logic. Here, several medical opinions are of record, all of which were provided by medical professionals who are presumed to have the training and expertise to opine on a neurological condition. As such, each opinion is considered to constitute both competent and credible evidence, which is deemed to be probative. However, the Board must determine which evidence is the most probative. After weighing all the evidence, the Board finds the greatest probative value in the November 2020 VA examiner’s opinion, which considered the elements necessary to substantiate a service connection claim involving presumed herbicide agent exposure. The Veteran’s physician provided no rationale for his opinion, nor did he refer to any medical evidence within the Veteran’s claims file that supported his conclusion. Indeed, he examiner failed to note that the Veteran’s STRs and medical records contained no objective medical evidence of peripheral neuropathy until at least March 2000, which is over three decades after the Veteran’s separation from active service. As such, the Board finds that the opinion from the Veteran’s physician was not based on any objective medical evidence or medical studies and instead based on the absence of etiology for the Veteran’s peripheral neuropathy, which undermines the probative value of the opinion. Conversely, the November 2020 VA examiner concluded that the Veteran’s peripheral neuropathy was less likely than not due to his active service, to include his presumed herbicide agent exposure, and specifically explained why. The November 2020 VA examiner is shown to have reviewed and considered the pertinent evidence of record, referred to medical studies, and to have provided adequate rationale for the opinion. The Veteran’s reported history was adequately considered. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Board appreciates the opinion of the Veteran’s physician. However, ultimately, the November 2020 VA examiner’s opinion is given greater weight. The opinion by the November 2020 VA examiner was fully grounded in the medical evidence and medical literature. The November 2020 VA examiner was fully apprised of the Veteran’s presumed herbicide agent exposure. The November 2020 VA examiner clearly explained why the Veteran’s peripheral neuropathy was not due to any herbicide agent exposure. Here, the support provided by the November 2020 VA examiner for his opinion is found to be superior to the opinion of the Veteran’s physician, which found that the Veteran’s peripheral neuropathy was not due to any other cause and therefore was at least as likely as not due to herbicide agent exposure. Given its grounding in the medical evidence in this case and the medical literature, the opinion of the November 2020 VA examiner is found to be the most probative evidence in this case, and therefore are afforded the greatest weight. Consideration has been given to the assertions of the Veteran and the appellant that the Veteran’ peripheral neuropathy was due to his active service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, namely the etiology of peripheral neuropathy, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Neurological disorders are not the type of conditions that are readily amenable to mere lay diagnosis or probative comment regarding etiology, as the evidence shows that physical examinations that include objective medical tests, such as nerve conduction studies, are needed to properly assess and diagnose the disorders. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1377; Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that the Veteran and the appellant were competent to report neuropathy symptoms, such as numbness, to the extent they are identifiable by observation, neither is shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that either received any special training or acquired any medical expertise in evaluating neurological disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. In support of his claim, the Veteran submitted Board decisions decided for other Veterans, who had also claimed service connection for peripheral neuropathy, as being directly applicable to his claim. Previously issued Board decisions are not precedent. 38 C.F.R. § 20.1303 states, “Although the Board strives for consistency in issuing its decisions, previously issued Board decisions will be considered binding only with regard to the specific case decided.” Instead, “each case presented to the Board will be decided on the basis of the individual facts of the case in light of applicable procedure and substantive law.” Id. Accordingly, the prior VA Board decisions submitted by the Veteran do not lend any probative value as to the etiology of his peripheral neuropathy. The record does not contain evidence of a diagnosis of continuously ongoing peripheral neuropathy symptoms from the Veteran’s active service to his death, as the first objective medical evidence of peripheral neuropathy is not until March 2000, which is over three decades after his active service. In addition, at physicals during his active service, he had normal examinations of his upper and lower extremities. As such, the Board does not find that the evidence of record shows continuous foot symptomatology. The Board also notes that the Veteran was not entitled to presumptive service connection for his peripheral neuropathy. Presumptive service connection due to herbicide agent exposure would be granted if the Veteran was diagnosed with early-onset peripheral neuropathy. The record contains no objective medical diagnosis of early-onset peripheral neuropathy. The Veteran has been diagnosed with peripheral neuropathy. Therefore, the presumption of service connection for exposure to herbicide agents has not been triggered. Accordingly, the criteria for service connection have not been met for peripheral neuropathy. That is, the evidence does not show peripheral neuropathy was diagnosed during his active service or within a year of separation from active service, the weight of the evidence is against a finding that peripheral neuropathy had existed continuously since active service, and the weight of the evidence is against a finding that the Veteran’s peripheral neuropathy was due to his active service, to include his presumed herbicide agent exposure. As such, the claim is denied. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Left Knee Disability Historically, a February 2017 rating decision continued the assigned 10 percent rating for the Veteran’s left knee pain and assigned a separate 10 percent rating for his left knee subluxation effective November 15, 2016, the date his increased rating claim was received by VA. The Veteran and the appellant have asserted entitlement to higher ratings. The Veteran is assigned a 10 percent rating under Diagnostic Code (DC) 5257 for recurrent subluxation or lateral instability, as well as a 10 percent rating under DC 5260 for limitation of flexion. Under DC 5257, ratings of 10, 20, and 30 percent are assigned where recurrent subluxation or lateral instability is slight, moderate, or severe, respectively. The words “slight,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. Under DC 5260, ratings of 10, 20, and 30 percent are assigned where flexion is limited to 45, 30, or 15 degrees, respectively. Under DC 5261 for limitation of knee extension, a noncompensable rating is assigned for extension limited to 5 degrees. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Of note, separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. Specifically, when a veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. See VAOPGCPREC 09-04. 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. DC 5256 evaluates ankylosis of the knee, DC 5258 and 5259 evaluate impairments of the semilunar cartilage, DC 5262 evaluates impairment of the tibia and fibula, and DC 5263 evaluates genu recurvatum. The medical record does not document any of these conditions. Therefore, these DC are not applicable and will not be discussed further. The Veteran’s medical records show treatment for his left knee symptoms, but his medical records do not show findings consistent with higher ratings. In December 2016, a private physician completed a Knee and Lower Leg DBQ. The Veteran reported flare-ups that impacted the function of the knee and/or lower leg. He reported recurrent effusions, pain, and sense of giving way. He treated his pain with asprin and steroid injections. His symptoms were worse in the left knee. The Veteran described functional loss as difficulty using stairs, squatting, kneeling and walking. The physician indicated that the Veteran had left knee flexion to 105 degrees and normal extension to 0 degrees. The Veteran had functional loss of less movement than normal, excess fatigability, pain on movement, swelling, and atrophy of disuse. The physician indicated that the Veteran’s functional loss did not result in any additional limitation of motion. The Veteran retained normal 5/5 left knee flexion strength and reduced 4/5 left knee extension strength with quadricep muscle atrophy. The Veteran’s left knee had tenderness to palpation and crepitus. The Veteran did not have recurrent subluxation or lateral instability and had normal joint stability tests. The examiner indicated a history of moderate left patellar dislocation, noting a complete patellar dislocation of the left knee in 1966. The Veteran did not have a history of a meniscus condition. The Board finds that the criteria to assign ratings in excess of 10 percent for the Veteran’s left knee subluxation and limitation of flexion are not warranted. Regarding left knee subluxation, stability testing in December 2016 did not reveal any joint instability or subluxation. Moreover, treatment records during the appellate period did not reflect moderate left knee joint instability or subluxation. Thus, the Veteran did not meet the criteria for a 20 percent rating under DC 5257. Regarding limitation of flexion, the Veteran’s physician indicated that the Veteran demonstrated, at worse, left knee flexion to 105 degrees, which exceeds the 60 degree limitation equivalent to a noncompensable rating. Accordingly, the Veteran did not meet the criteria for a rating in excess of 10 percent under DC 5260. Turning to limitation of extension, the Veteran’s physician indicated that the Veteran retained normal left knee extension to 0 degrees, which exceeds the 5 degree limitation equivalent to a noncompensable rating. Accordingly, the Veteran does not meet the criteria for a compensable rating under DC 5261, which requires extension to be limited to 5 degrees. The Board has considered whether higher disability evaluations are warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 for either knee. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Veteran’s physician indicated that there was no additional limitation of motion due to pain, weakness, fatigability, or incoordination. The Veteran’s treatment records do not document flexion or extension equivalent to even noncompensable ratings. As such, the evidence simply does not support the conclusion that the Veteran’s left knee disability resulted in findings consistent with compensable ratings. Thus, a greater rating for limitation of flexion or extension is not warranted under DeLuca. While the Veteran was shown to experience left knee pain, the United States Court of Appeals for Veterans Claims has held that even if range of motion was slightly limited by pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. Here, the Veteran consistently retained flexion and extension in excess of compensable ratings. As such, there is no basis for higher ratings under DC 5260 or 5261. To the extent that it is argued that the Veteran’s range of motion was painful and therefore would merit a separate compensable rating under 38 C.F.R. § 4.59, that provision states that it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. However, here, the Veteran was assigned the minimum compensable rating and was in receipt of a 10 percent rating under DC 5260 for his left knee pain. A rating in excess of 10 percent based on pain alone was not warranted. Accordingly, a schedular rating in excess of 10 percent for the Veteran’s left knee subluxation and a schedular rating in excess of 10 percent for the Veteran’s left knee pain have not been met, and the claims are denied. As the Veteran's representative previously raised the issue, the Board has also considered whether referral for consideration of an extraschedular rating is warranted. Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321 (b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation Service for consideration of an extraschedular rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. That is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, the assigned schedular rating is adequate, and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds the Veteran's left knee disability did not present an exceptional or unusual disability picture such that the application of the regular schedular standards would be inapplicable. 38 C.F.R. § 3.321 (b). Specifically, the knee disability was manifested primarily by reports of pain, reduced range of motion, effusions, difficulty using stairs, squatting, kneeling and walking. While those impairments certainly impeded many aspects of the Veteran's daily life, those manifestations and related impairment are contemplated by criteria for the schedular rating currently assigned. An examination of the rating criteria as outlined above shows that the applicable schedular rating criteria not only contemplate decreased in range of motion, but also pain, weakness, and instability, or even ankylosis. Therefore, the Board finds that there is nothing exceptional or unusual about the left knee disability, and referral for extraschedular consideration is not warranted. Thun, 22 Vet. App. at 111. Left Ankle Disability The Veteran filed an increased rating claim for his left ankle disability in November 2016. A February 2017 rating decision continued the Veteran’s assigned 10 percent rating under DCs 5003-5271. DC 5271 evaluates range of motion in the ankle. A 10 percent rating is assigned for moderate limitation of motion and a 20 percent rating, the maximum rating, is assigned for marked limitation of motion. Ankle dorsiflexion is measured from 0 degrees to 20 degrees; plantar flexion is measured from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The Board notes that words such as moderate and marked are not defined in the Rating Schedule. Because the rating schedule offers no further guidance on the issue, the Board will rely on Webster’s definitions of the terms used. “Marked” means noticeable. Webster’s II New College Dictionary, 670 (1995). “Moderate” means of average or medium quantity. Id. at 704. In December 2016, the Veteran’s physician completed an Ankle Conditions DBQ. The physician noted that the Veteran had plantar flexion limited to 20 degrees and dorsiflexion limited to 20 degrees. Repetitive use testing did not result in any further limitation. The physician noted pain with weight bearing. The physician found that the Veteran’s left ankle pain resulted in less movement than normal, pain on movement, swelling, disturbance of locomotion, and interference with standing, which would further limit his plantar flexion to 15 degrees and his dorsiflexion to 15 degrees. Muscle strength testing revealed normal strength (5/5) in plantar flexion and active movement against some resistance (4/5) in dorsiflexion. However, the examiner noted that the Veteran’s peripheral neuropathy contributed to the reduced strength. There was no objective evidence of crepitus. Having reviewed the evidence of record, the Board concludes that the Veteran’s left ankle findings were consistent with “moderate” limitation of motion as dorsiflexion was limited to, at most, 15 degrees, which was more than half of normal range of motion, and plantar flexion was limited to, at most, 15 degrees, which is one third of normal range of motion. Based on the Veteran’s range of motion, noticeable limitation of motion was not shown as the Veteran retained total range of motion of approximately 46 percent. Accordingly, the Veteran’s left ankle disability resulted in a moderate limitation of motion, consistent with a 10 percent rating. The Board has considered whether a higher disability evaluation was warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca, 8 Vet. App. 202. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, the Veteran’s physician indicated that the Veteran had functional loss that further limited the Veteran’s plantar flexion and dorsiflexion to 15 degrees each. However, even considering these limitations, the Veteran nevertheless retained range of motion in excess of moderate limitation of motion, which is equivalent to a 10 percent rating. As such, the evidence simply does not support the conclusion that the Veteran’s left ankle disability resulted in findings consistent with a higher rating. Thus, a greater rating for marked limitation of motion was not warranted under DeLuca. While the Veteran was shown to experience left ankle pain, the Court has held that even if range of motion was slightly limited by pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell, 25 Vet. App. 32, 36-38. Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Id. at 43; see 38 C.F.R. § 4.40. Here, the Veteran consistently retained range of motion in excess of moderate limitations. As such, there is no basis for a higher rating under DC 5271. To the extent that it is argued that the Veteran’s range of motion was painful and therefore would merit a separate compensable rating under 38 C.F.R. § 4.59, that provision states that it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. However, here, the Veteran was assigned the minimum compensable rating for moderate limitation of motion, and as such, a rating in excess of 10 percent based on pain alone is not warranted. Accordingly, the criteria for a schedular rating in excess of 10 percent for the Veteran’s left ankle disability have not been met, and the claim is denied. As a final matter, the Board finds the Veteran's left ankle disability did not present an exceptional or unusual disability picture such that the application of the regular schedular standards would be inapplicable. 38 C.F.R. § 3.321 (b). Specifically, the ankle disability was manifested primarily by reports of pain, reduced range of motion, swelling, disturbance of locomotion, and interference with standing. While those impairments certainly impeded many aspects of the Veteran's daily life, those manifestations and related impairment are contemplated by criteria for the schedular rating currently assigned. An examination of the rating criteria as outlined above shows that the applicable schedular rating criteria not only contemplate functional impairment that contributes to decreased range of motion. Therefore, the Board finds that there is nothing exceptional or unusual about the left ankle disability, and referral for extraschedular consideration is not warranted. Thun, 22 Vet. App. at 111. TDIU A TDIU may be assigned where the schedular rating is less than total when the disabled person is, in the judgment of the Board, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, this shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent disability or more. 38 C.F.R. § 4.16(a). Marginal employment shall not be considered substantially gainful employment. Moreover, the existence or degree of nonservice-connected disabilities or previous unemployability status will be disregarded where the percentages referred to in this paragraph for the service connected disability or disabilities are met and in the judgment of the rating agency such service-connected disabilities render the veteran unemployable. The Veteran met the schedular requirements for a TDIU since December 1, 2016, as his posttraumatic stress disorder (PTSD) was assigned a 50 percent rating in addition to other service-connected disabilities resulting in a combined disability rating of 80 percent. In November 2016 and February 2018 applications for TDIU, the Veteran asserted that his PTSD, left knee disability, and left ankle disability prevented him from securing or following any substantially gainful occupation. He reported that he last worked in September 2014 as a police officer. The Veteran explained that, due to his nightmares, he cannot sleep and consequently cannot function during the day. He also could not work in the road due to cars backfiring and having flashbacks of gunfire in Vietnam. Finally, he stated that he could not be on his feet due to his ankle and knee pain. At a February 2016 VA PTSD examination, the examiner indicated that the Veteran’s PTSD symptoms included difficulty in establishing and maintaining effective work relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. In November 2016, the Veteran’s physician reported that the Veteran was totally and permanently 100 percent disabled due to his service-connected disabilities. His physician reported that the Veteran was permanently unemployable. In December 2016, the Veteran’s physician reported that the Veteran’s left knee and left ankle disabilities resulted in difficulty with prolonged standing, stairs, walking, and lifting. In December 2017, the Veteran’s physician again reported that the Veteran was totally and permanently 100 percent disabled due to his service-connected disabilities and was permanently unemployable. In March 2018, the Veteran’s psychiatrist indicated that the Veteran’s PTSD resulted in total occupational impairment. In light of the foregoing, the Board concludes that the evidence for and against TDIU is at least in equipoise. Given this conclusion, the Board will resolve any reasonable doubt in the Veteran’s behalf, and hold that TDIU is granted effective December 1, 2016, the date he met the schedular criteria for a TDIU. Roya Bahrami Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berryman, 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.