Citation Nr: 21012078 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 16-51 684 DATE: March 3, 2021 ORDER Entitlement to a rating in excess of 10 percent for the ischemic heart disease from September 15, 2015, to February 27, 2020, is denied. Entitlement to a rating in excess of 60 percent for ischemic heart disease since February 27, 2020, is denied. Entitlement to a rating in excess of 10 percent for hypertension is denied. Entitlement to a rating in excess of 10 percent for residuals, fracture, left knee with traumatic arthritis from September 15, 2015, to September 4, 2020, is denied. Entitlement to a separate rating of 10 percent, but not higher, for instability of the left knee from September 9, 2017, is granted. Entitlement to a rating in excess of 30 percent of residuals, fracture, left knee with traumatic arthritis since September 4, 2020, is denied. Entitlement to a rating in excess of 10 percent for residuals, fracture left clavicle with traumatic arthritis from September 15, 2015, to February 27, 2020, is denied. Entitlement to a rating in excess of 30 percent for residuals, fracture left clavicle with traumatic arthritis since February 27, 2020, is denied. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) prior to February 27, 2020, is granted, subject to the law and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. From September 15, 2015 to February 27, 2020, the Veteran’s ischemic heart disease did not result in of cardiac hypertrophy, cardiac dilation, or congestive heart failure. 2. From February 27, 2020 the Veteran’s heart disability did not result in chronic congestive heart failure. 3. The Veteran does not have history of a diastolic blood pressure elevation of predominantly 100 or more. 4. From September 15, 2015, to February 27, 2020, the Veteran’s left knee exhibited flexion 0 to 120 degrees and extension 120 to 0 degrees. 5. On September 9, 2017, a medical evaluation confirmed the presence of left knee instability. 6. Since February 27, 2020, the Veteran’s left knee exhibited extension of the leg limited to 20 degrees. 7. Prior to February 27, 2020, the Veteran’s left clavicle disability exhibited malunion of the scapula. 8. From February 27, 2020, the Veteran’s left clavicle disability exhibited limitation of motion to 25 degrees from side. 9. The Veteran’s service-connected disabilities prevents him from maintaining gainful employment prior to February 27, 2020. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for ischemic heart disease from September 15, 2015, to February 27, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for entitlement to an evaluation higher than 60 percent for ischemic heart disease from February 27, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, Diagnostic Code 7005. 3. The criteria for entitlement to a rating in excess of 10 percent for hypertension. have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101. 4. The criteria for entitlement to a rating in excess of 10 percent for residuals, fracture, left knee with traumatic arthritis from September 15, 2015, to September 4, 2020, have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.71a Diagnostic Code 5010-5256. 5. The criteria for a separate 10 percent rating, but not higher, for left knee instability have been met from September 9, 2017. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.71a Diagnostic Code 5257. 6. The criteria for entitlement to an evaluation higher than 30 percent of residuals, fracture, left knee with traumatic arthritis from September 4, 2020, have not been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.71a Diagnostic Code 5010-5256. 7. The criteria for entitlement to an evaluation higher than 10 percent for residuals, fracture left clavicle with traumatic arthritis from September 15, 2015, to February 27, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.951, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5201 ,5203. 8. The criteria for entitlement to an evaluation higher than 30 percent for residuals, fracture left clavicle with traumatic arthritis from February 27, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.951, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5201, 5203. 9. The criteria for entitlement to individual unemployability prior to February 27, 2020, have been met. 38 U.S.C. §§ 1155, 5110(a), (b)(2); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1961 to October 1977. The Veteran’s service included service in the Republic of Vietnam. The Veteran was awarded the Combat Infantryman Badge and the Bronze Star with V Device. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. In June 2019, the case came before the Board. The Board denied entitlement to an effective date prior to September 15, 2015, for the award of service connection for PTSD. The Board also denied entitlement to a rating in excess of 10 percent for degenerative disc disease of the lumbar spine prior to September 20,2017. In addition, the Board granted entitlement to a rating of 20 percent, but not higher, for degenerative disc disease from September 20, 2017. Moreover, the Board awarded entitlement to an initial rating of 50 percent, but not higher, for post-traumatic stress disorder (PTSD). Furthermore, the Board remanded the Veteran’s claims for increased ratings for a left clavicle disability, a left knee disability, hypertension, and ischemic heart disease in order for the Veteran to attend additional examinations. Lastly, the Board remanded the Veteran’s claim for TDIU because it was inextricably intertwined with the Veteran’s remaining claims. In September 2020, the RO issued a rating decision that increased the Veteran’s ischemic heart disease to 60 percent disabling effective from February 27, 2020. The RO also increased the Veteran’s left clavicle with traumatic arthritis to 30 percent disabling effective from February 27, 2020. Moreover, the RO increased the Veteran’s left knee with traumatic arthritis to 30 percent disabling effective from September 4, 2020. Increased Rating The Veteran contends that his disabilities warrant increased ratings throughout the course of the appeal. 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 evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in such cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, in Mitchell, the Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, and less or more movement than is considered normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board observes that the words “slight,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as “mild” by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in the process of arriving at a decision regarding an increased rating. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. In considering the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to an evaluation higher than 10 percent for the ischemic heart disease prior to February 27, 2020 VA received the Veteran’s claim for an increased rating on September 15, 2015. The Veteran’s disability was rated as 10 percent disabling according to Diagnostic Code 7005. Coronary artery disease is evaluated under Diagnostic Code 7005 of the Rating Schedule. 38 C.F.R. § 4.104. Under Diagnostic Code 7005, a 10 percent rating is warranted for a workload of greater than 7 METs, but not greater than 10 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or continuous medication is required. A 30 percent rating is warranted for a workload of greater than 5 METs, but not greater than 7 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or with evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the past year; or workload of greater than 3 METs, but not greater than 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent to 50 percent. Finally, a 100 percent rating is warranted for chronic congestive heart failure; or workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. One metabolic equivalent (MET) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Id. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as coronary artery disease. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in December 2015. The examiner indicated that the Veteran reported no significant problems with ischemic heart disease. Upon examination, the examiner indicated that the Veteran’s disability did not result in cardiac hypertrophy, cardiac dilation, or congestive heart failure. It was further noted that exercise stress testing was not required as part of the Veteran’s current treatment plan. The examiner conducted an interview-based METs test. The examiner indicated that the Veteran reported no significant problems with ischemic heart disease, and that his activity is limited due to joint pain and stiffness. The Veteran denied any dyspnea and angina at the current level of activities. The Board has also reviewed the Veteran’s medical records during this period of the appeal. After a review of the Veteran’s records, the Board finds that the Veteran’s records do not show symptoms that are more severe than what was reported at his VA examination. In sum, the Board finds that the Veteran’s disability has remained consistent during this period of the appeal and an increased rating is not warranted. After a review of the record, the Board finds that the Veteran’s disability does not meet the criteria for a rating in excess of 10 percent. Specifically, the Veteran’s VA examination and his medical treatment records do not show evidence of cardiac hypertrophy, cardiac dilation, or congestive heart failure. The evidence of record also does not show that the Veteran is unable to perform a workload of less than 7 METs. While no specific METs level was indicated, the Veteran’s report of no dyspnea or angina with activities would not, by itself, be consistent with a rating in excess of 10 percent as such a rating would at least require some report of such symptoms with activity. In addition, the evidence of record, does not show that the Veteran exhibits left ventricular dysfunction with an ejection fraction of less than 30 percent to 50 percent. The Board has considered the Veteran’s contention that his disability warrants an increased rating; however, the Veteran’s contentions are outweighed by the medical evidence of record that did not show that the Veteran met the criteria for an increased rating. Moreover, the Board notes that the Veteran’s own lay statements show that he attributed his inability to perform physical activities was limited due to joint pain and stiffness and not his service-connected heart disability. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 10 percent for ischemic heart disease from September 15, 2015, to February 27, 2020, must be denied. 2. Entitlement to an evaluation higher than 60 percent for ischemic heart disease from February 27, 2020. The Board was rated as 60 percent disabling during this period of the appeal according to Diagnostic Code 7005. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as coronary artery disease. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in February 2020, at which time the examiner noted that the Veteran did not exhibit congestive heart failure. An interview-based METs test was conducted. The Veteran was able to perform a workload of 3-5 METs. The examiner indicated that this level was due solely to the cardiac condition. The examiner opined that “part of METs limitation is non-cardiac musculoskeletal and Veteran on last echo had normal ejection fraction however with severe coronary calcifications and age cardiac function likely limited to 3-5 METs.” The Board has also reviewed the Veteran’s medical records during this period of the appeal. After a review of the Veteran’s records, the Board finds that the Veteran’s records do not show symptoms that are more severe than what was reported at his VA examination. Initially, the Board finds that the February 2020 VA examination was the first instance that the medical evidence of record demonstrated that the Veteran’s heart disability had increased in severity. The Board acknowledges that the February 2020 VA examination report shows that the examiner cited to a February 2019 interview based METs test; however, this appears to be a typographical error as the interview was conducted on the same date as the VA examination and the Veteran’s VA treatment records do not contain an interview based METs test in February 2019. Thus, the Board finds that the February 2020 VA examination report is the first piece of medical evidence that demonstrated that the Veteran’s heart had increased in severity. In sum, the Board finds that the Veteran’s disability has remained consistent during this period of the appeal and an increased rating is not warranted. After a review of the record the Board finds that the Veteran’s disability does not meet the criteria for a 100 percent rating. Specifically, the Veteran’s VA examination and his medical treatment records do not show evidence that the Veteran’s heart disability exhibits chronic congestive heart failure; or a workload of 3 METs or less that results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. The Board has considered the Veteran’s contention that his disability warrants an increased rating; however, the Veteran’s contentions are outweighed by the medical evidence of record that did not show that the Veteran met the criteria for an increased rating. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 60 percent for ischemic heart disease from February 27, 2020, must be denied. 3. Entitlement to an evaluation higher than 10 percent for hypertension. VA received the Veteran’s claim for an increased rating on September 15, 2015. The Veteran’s disability was evaluated as 10 percent disabling according to Diagnostic Code 7101. Under Diagnostic Code 7101, a 10 percent rating is warranted when diastolic pressure is predominantly 100 or more or when systolic pressure is predominantly 160 or more, or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control; a 20 percent rating is warranted when diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more; a 40 percent rating is warranted when diastolic pressure is predominantly 120 or more; and a 60 percent rating is warranted when diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, DC 7101. The term “predominant” is not defined in the rating criteria. Merriam-Webster defines predominant to mean “being most frequent or common.” See, e.g., “predominant,” Merriam-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as hypertension. In December 2015, the Veteran attended a VA examination for this issue. The examiner indicated that the Veteran’s treatment plan included taking continuous medication for hypertension. The examiner indicated that the Veteran’s blood pressure was 149/84. The examiner also found that the Veteran did not have history of a diastolic Blood Pressure elevation to predominantly 100 or more. In December 2015, the Veteran attended a VA examination for this issue. The examiner indicated that the Veteran’s treatment plan included taking continuous medication for hypertension. The examiner indicated that the Veteran’s blood pressure readings were as follows: 138/96, 135/97, and 136/ 95. The examiner also found that the Veteran did not have history of a diastolic blood pressure elevation to predominantly 100 or more. The Board has also reviewed the Veteran’s medical treatment records. After a review of these records, the Board finds that the Veteran’s blood pressure readings that were recorded during the course of the appeal do not show that the Veteran’s disability met the criteria for an increased rating. In sum, the Board finds that the Veteran’s disability has remained consistent and that an increased rating is not warranted. After a review of the record, the Board finds that the most probative evidence of record is the Veteran’s VA treatment records and his medical treatment records. This evidence did not show that the Veteran’s diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. The evidence also did not show that the Veteran’s diastolic pressure is predominantly 120 or more. Lastly, the evidence did not show that the Veteran’s diastolic pressure is predominantly 130 or more. The Board acknowledges that the Veteran believes that his hypertension has been more severe than the assigned disability rating reflects. However, the Veteran’s contentions are outweighed by the medical evidence in this case and the opinions of the medical examiners who have evaluated the Veteran. The Board has reached this conclusion because the medical professionals in this case have the training and experience to measure the Veteran’s blood pressure and provide an opinion regarding the severity of his disability while the Veteran does not. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 10 percent for hypertension, must be denied. 4. Entitlement to an evaluation higher than 10 percent for residuals, fracture, left knee with traumatic arthritis from September 15, 2015, to September 4, 2020. 5. Entitlement to a separate compensable rating for left knee instability. VA received the Veteran’s claim for an increased rating on September 15, 2015. The Veteran’s disability was rated as 10 percent disabling according to Diagnostic Code 5010-5260. 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 rating assigned. The additional code is shown after the hyphen. For purposes of this decision, the Board notes that the average normal range of motion of the knee is flexion from 0 to 140 degrees and extension from 140 to 0 degrees. 38 C.F.R. § 4.71. 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. Diagnostic Code 5010 provides that arthritis due to trauma that is substantiated by X-ray findings is to be rated as degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Disabilities of the knee are rated under Diagnostic Code 5256 through Diagnostic Code 5263. A knee disorder can receive separate ratings, based on symptoms related to arthritis, stability, flexion, and extension. Where a Veteran has degenerative joint disease, which is evaluated under Diagnostic Code 5003, a separate, compensable evaluation may be assigned under Diagnostic Code 5257 or 5258 if there are concomitant symptoms, such as knee instability or subluxation. See VAOPGCPREC 23-97. When a Veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. See VAOPGCPREC 9-98. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees is rated 30 percent disabling; in flexion between 10 degrees and 20 degrees is rated 40 percent disabling; in flexion between 20 degrees and 45 degrees is rated 50 percent disabling; and extremely unfavorable, in flexion at an angle of 45 degrees or more is rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent disability rating for cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for symptomatic residuals of removal of a semilunar cartilage. Ratings under DC 5259 require consideration of 38 C.F.R. §§ 4.40 and 4.45 because removal of a semilunar cartilage may result in complications producing loss of motion. VAOGCPREC 9-98. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated at 0 percent disabling, flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated 0 percent disabling, extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5262 provides ratings for impairment of the tibia and fibula. A 10 percent rating is warranted for malunion with slight knee or ankle disability. A 20 percent rating is warranted for malunion with moderate knee or ankle disability. A 30 percent rating is warranted for malunion with marked knee or ankle disability. A 40 percent rating is warranted for nonunion with loose motion and requiring a brace. 38 C.F.R. § 4.71a. Diagnostic Code 5263 is the rating code for genu recurvatum, providing a 10 percent rating for the disability. During the course of the appeal, VA revised the portion of the rating schedule that addresses the musculoskeletal system. Diagnostic Code 5257, which is pertinent to the Veteran’s appeal, was revised effective from February 7, 2021. Diagnostic Code 5257 now reads as follows: As to recurrent subluxation or instability: A 30 percent rating is warranted for 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. A 20 percent rating is warranted 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. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent is warranted for 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. As to patellar instability: A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral 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. A 20 percent rating is warranted 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 10 percent rating is warranted 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. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): 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). The Board will evaluate the Veteran’s claim with the Diagnostic Code that is most favorable to the Veteran. Initially, the Board notes that the medical evidence of record does not show signs of ankylosis, cartilage conditions, impairment of the tibia or fibula, or genu recurvatum. Thus, the Board finds that consideration of these Diagnostic Codes is not applicable to the Veteran’s claim. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as left knee arthritis. As to the Veteran’s lay statements, the Board acknowledges that the Veteran has reported left knee pain. The Veteran also reported left knee instability which caused him to fall and injure himself. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in December 2015. The examiner reported that the Veteran currently limps while walking which causes pain in left knee. The examiner reported that the Veteran said he is unable to walk for a long period of time. The Veteran reported that kneeling aggravates pain. The Veteran reported no flareups. Upon examination, the examiner indicated that the Veteran exhibited Flexion 0 to 120 degrees and extension 120 to 0 degrees. The examiner indicated that the Veteran had no additional functional loss or range of motion after three repetitions. The examiner indicated that the Veteran did not have any signs of ankylosis, subluxation, instability, or a meniscus condition. The Board has also reviewed the Veteran’s medical treatment records. The Board acknowledges that the Veteran receives treatment for left knee pain. The Board further acknowledges that, the Veteran’s private doctor stated in September 2017 that “the Veteran’s left knee has significant crepitus in ROM, has laxity in anterior drawer test and thus has a loose ACL ligament. He has swelling over the lateral collateral ligament.” The doctor also that the “I believe that for the reasons listed herein that the above condition(s) are more likely than not worsening.” In sum, the Board finds that the Veteran’s disability has remained consistent during this period of the appeal and an increased rating is not warranted. Specifically, the Board notes that the evidence of record does not demonstrate that the Veteran’s knee exhibits lost range of motion which warrants a rating in excess of 10 percent. The Board has considered the Veteran’s reports of pain; however, the Board does not find that the Veteran’s symptomatology, even when considering pain on motion, demonstrates that his disability results in lost range of motion which warrants a rating in excess of 10 percent. Specifically, the Board notes that the Veteran did not have any additional functional loss or range of motion after repetitive testing. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 10 percent for left knee arthritis, must be denied. While a rating in excess of 10 percent is not warranted for left knee arthritis, giving the Veteran the benefit of the doubt, the Board finds that a separate 10 percent rating is warranted for the Veteran’s slight instability of the left knee. After a review of the medical evidence of record and the Veteran’s lay statements, the Board finds that the evidence of record supports a finding that the Veteran’s left knee exhibits slight instability as of September 9, 2017. Specifically, the Board notes that the September 2017 private examination noted laxity in anterior drawer test and a loose ACL ligament as of September 9, 2017. The Board has considered a rating in excess of 10 percent; however, the Veteran’s VA examinations and medical treatment records of records throughout the course of the appeal do not show that the Veteran exhibits moderate or severe left knee instability. The Board has also considered an increased rating under the revised Diagnostic Code; however, the evidence of record does not show evidence of persistent instability, and a medical provider prescribing a brace and/or assistive device for ambulation. Thus, for the above stated reasons, the Board finds that a separate rating of 10 percent, but not higher, for left knee instability is warranted effective from September 9, 2017. 6. Entitlement to an evaluation higher than 30 percent of residuals, fracture, left knee traumatic arthritis since September 4, 2020 The Veteran’s disability was rated as 30 percent disabling during this period of the appeal according to Diagnostic Code 5010-5261. As to a current diagnosis, the Board notes that the Veteran’s left knee disability has been diagnosed as left knee arthritis. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in September 2020. The Veteran reported pain in his knee and flareups when he tries to garden. The Veteran reported that he had trouble walking due to the knee pain. Upon examination, the examiner indicated that the Veteran exhibited flexion 20 to 95 degrees and extension 95 to 20 degrees. The examiner indicated that the Veteran did not have any additional lost range of motion after three repetitions. The examiner indicated that the Veteran’s knee flareups flexion was 20 to 95 and extension was 95 to 20. Lastly, the examiner indicated that the Veteran did not exhibit ankylosis, subluxation, or instability. The Board has also reviewed the Veteran’s medical treatment records. The Veteran’s records do not show evidence of lost range of motion that was greater than what was reported at his VA examination. In sum, the Board finds that the Veteran’s disability has remained consistent during this period of the appeal and that an increased rating is not warranted. Specifically, the Board notes that the evidence of record does not demonstrate that the Veteran’s knee exhibits lost range of motion which warrants a rating in excess of 30 percent. The Board has considered the Veteran’s reports of pain; however, the Board does not find that the Veteran’s symptomatology, even when considering pain on motion, demonstrates that his disability results in lost range of motion which warrants a rating in excess of 30 percent. Specifically, the Board notes that the Veteran did not have any additional functional loss or range of motion after repetitive testing or during a flareup. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 30 percent for left knee arthritis since September 9, 2020, must be denied. 7. Entitlement to an evaluation higher than 10 percent for residuals, fracture left clavicle with traumatic arthritis from September 15, 2015, to February 27, 2020. VA received the Veteran’s increased rating claim on September 15, 2015. The Veteran’s claim was rated as 10 percent disabling according to Diagnostic Code 5003-5203. 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 rating assigned. The additional code is shown after the hyphen. The Board notes that the Veteran is right hand dominant. Normal range of motion in the shoulder is from zero to 180 degrees of forward elevation (flexion) and zero to 180 degrees of shoulder abduction. See 38 C.F.R. § 4.71a, Plate I Diagnostic Code 5200 provides evaluations for ankylosis of the scapulohumeral articulation and Diagnostic Code 5202 provides evaluations for impairment of the humerus. As there is no evidence of record supporting ankylosis or impairment of the humerus, the Veteran is not entitled to a rating under either diagnostic code. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). During the course of the appeal, VA revised the portion of the rating schedule that addresses the musculoskeletal system. Diagnostic Code 5201, which is pertinent to the Veteran’s appeal, was revised effective from February 7, 2021. Diagnostic Code 5201 now reads as follows: flexion and/or abduction limited to 25 degrees from side warrants a 40 percent rating for the major extremity and a 30 percent rating for the minor extremity. Limitation of motion of midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 30 percent rating for the major extremity and 20 percent for the minor extremity. Limitation of motion at shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for the major and minor extremity. Under Diagnostic Code 5203, malunion of the clavicle or scapula warrants a 10 percent rating in both the major and minor extremity. Nonunion of the clavicle or scapula without loose movement warrants a 10 percent rating in both the major and minor extremity. Nonunion of the clavicle or scapula with loose movement warrants a 20 percent rating in both the major and minor extremity. Dislocation of the clavicle or scapula warrants a maximum 20 percent rating in both the major and minor extremity. Or rate on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, Diagnostic Code 5203. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as residuals of a fractured left clavicle with traumatic arthritis. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in December 2015. The Veteran reported intermittent pain in left shoulder. The Veteran stated that he cannot push, pull or lift heavy weight. The Veteran reported problems doing overhead activities. Upon examination, the examiner indicated that the Veteran exhibited flexion: 0 to 150 degrees, abduction 0 to 130 degrees, external rotation: 0 to 70 degrees, and internal rotation: 0 to 90 degrees. The examiner indicated that the Veteran did not have instability, dislocation, or labral pathology. The examiner indicated that the Veteran did not have a clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint condition. The examiner indicated that the Veteran does not have ankylosis, flail shoulder, false flail shoulder, or fibrous union of the humerus. The examiner indicated that no pain was noted on examination and no functional loss or range of motion after three repetitions. The Board has also reviewed the Veteran’s medical treatment records. After a review of the Veteran’s treatment history, the Board finds that the Veteran’s records do not show that the Veteran’s clavicle disability resulted in an arm disorder. The Board further finds that the Veterans’ records do not show evidence that the Veteran has exhibited lost range of motion that is greater than what was reported at his VA examination. Lastly, the Board acknowledges that in September 2017, the Veteran’s doctor indicated that the Veteran’s clavicle is getting worse but, he did not provide any range of motion estimates. Thus, the Board is unable to place any probative weight on this piece of evidence. In sum, the Board finds that the Veteran’s disability has remained consistent during this period of the appeal and an increased rating is not warranted. Specifically, the Board notes that the evidence of record does not demonstrate that the Veteran’s disability exhibits nonunion of the clavicle or scapula with loose movement or dislocation. The Board has also considered an increased under Diagnostic Code 5201. However, the medical evidence of record did not show limitation of motion of the arm at shoulder level, limitation of motion of the arm midway between side and shoulder, or limitation of motion of the arm to 25 degrees from side. The Board has additionally considered an increased rating under the revised Diagnostic Code 5201; however, the Veteran did not exhibit flexion and/or abduction limited to 25 degrees from side, lost range of motion from midway between side and shoulder level, or lost range of motion at shoulder level. Moreover, the Board has considered the Veteran’s reports of pain; however, the Board does not find that the Veteran’s symptomatology, even when considering pain on motion, demonstrates that his disability results in nonunion of the clavicle or scapula, dislocation of the scapula, or lost range of motion which warrants a rating in excess of 10 percent. Specifically, the Board notes that the Veteran did not have any additional functional loss or range of motion after repetitive testing. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 10 percent for residuals of a fractured left clavicle with traumatic arthritis from September 15, 2015 to February 27, 2020, must be denied. The Board has also considered a separate compensable rating for limitation of motion of the left arm under Diagnostic Code 5201. However, the medical evidence of record did not show manifestations of a left shoulder disability that are separate and distinct in this case. The evaluation of the same disability or the same manifestations of disability under multiple diagnoses is to be avoided. 38 C.F.R. § 4.14. Therefore, to assign a separate rating under this same diagnostic code would constitute pyramiding. 8. Entitlement to an evaluation higher than 30 percent for residuals, fracture left clavicle with traumatic arthritis from February 27, 2020. The Veteran’s disability was awarded a 30 percent rating according to Diagnostic Code 5003-5201 during this period of the appeal. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as left clavicle residuals of fracture with traumatic arthritis. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in February 2020. The Veteran reported flares with repetitive use or other factors occur once per week. The Veteran stated that the flares are moderate to severe and they additionally limit his activity and range of motion by approximately 80 percent of the non-flare range of motion. The Veteran also reported difficulty, with reaching, lifting, working overhead, getting dressed, and sleeping. On examination, the examiner indicated that the Veteran exhibited flexion 0 to 85 degrees, abduction 0 to 85 degrees, external rotation 0 to 33 degrees, and internal rotation 0 to 45 degrees. The examiner indicated that during a flare up, the Veteran exhibited flexion 0 to 17 degrees, abduction 0 to 17 degrees, external rotation 0 to 6 degrees, and internal rotation 0 to 9 degrees. Lastly, the examiner indicated that the Veteran did not have instability or an AC joint condition. The examiner stated that the clavicle condition affects the range of motion. The examiner also found that the Veteran does not have flail shoulder, nonunion of the shoulder, or fibrous union of the humerus. The Board has also reviewed the Veteran’s medical treatment records. After a review of the Veteran’s records, the Board finds that the Veteran’s records do not show evidence that the Veteran’s disability has manifested an additional shoulder disability separate and distinct from the lost range of motion in his arm. In sum, the Board finds that the Veteran’s disability has remained consistent during this period of the appeal and an increased rating is not warranted. The Veteran’s disability is currently receiving the maximum schedular rating under both versions of Diagnostic Code 5201. The Board has considered whether there is an alternate Diagnostic Code for granting a higher rating but has found none. The Board has also considered if the Veteran is entitled to a separate compensable rating; however, the medical evidence of record does not show that the Veteran’s left clavicle disability has manifested a separate and distinct disability from the lost range of motion in his arm. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 30 percent for residuals of a fractured left clavicle with traumatic arthritis from February 27, 2020, must be denied. 9. Entitlement to individual unemployability for the period prior to February 27, 2020 The Veteran contends that he is unable to work due to his service-connected disabilities. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is considered to be appropriate, “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340 (a)(1), 4.15. A 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. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet those percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is nonetheless unable to obtain or retain substantially gainful employment due to service-connected disability. 38 C.F.R. § 4.16(b). The phrase “substantially gainful employment” is defined as that type of employment, “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). In the process of determining whether unemployability exists, consideration may be given to a Veteran’s level of education, any special training, and any previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. VA received the Veteran’s increased rating claims in September 2015. In October 2015, VA received a VA Form 21-8940 which details the Veteran’s work experiences, education, and training. The Veteran reported that he had a four-year college degree. The Veteran reported that he last worked as a property and equipment supervisor for the local school district. The Veteran reported that he stopped working in 1997 and that was due to his service-connected disabilities. The Veteran reported that he has not tried to obtain any additional employment because he is too disabled to work. The Veteran stated that he could not work due to his service-connected hearing loss, high blood pressure, heart disability, lower back disability, arthritis, and PTSD. Initially, the Board notes that the Veteran has met the schedular criteria for a TDIU since September 2015. The Veteran is service connected for the following conditions: PTSD, ischemic heart disease, left clavicle disability, left knee disability, degenerative joint disease of the lumbar spine, residuals of a right finger fracture, hypertension, and multiple scars on the lower extremities. Turning to the medical evidence at hand, the Board notes that the Veteran’s VA examinations demonstrate that he has difficulty walking, bending, lifting, and reaching. The examinations also show that the Veteran is easily fatigued and has difficulty with occupational settings. In September 2017, the Veteran’s private doctor provided an opinion in support of the Veteran’s claim. The doctor stated that he interviewed the Veteran and reviewed his claims file and medical records before rendering this opinion, and that the Veteran’s PTSD, back, knee, clavicle, heart, disease and hypertension make him unable to sustain gainful employment. The doctor stated that the Veteran’s back and knee make it challenging for him to get around and he needs the use of a cane or walker on a consistent basis. The doctor stated that the Veteran cannot walk 100 feet without stopping to rest and cannot walk without an assistive device. The doctor additionally stated that these “conditions taken as a while lead me to believe it would be very challenging for the Veteran to participate in physical/manual labor or work in a sedentary environment where he would be required to concentrate, interact with others, or focus on tasks at hand. That is why I believe he is unable to sustain gainful employment.” After a thorough review of the record and resolving all doubt in favor of the Veteran, the Board finds that the evidence of record supports the assignment of TDIU. The record shows that the Veteran’s psychiatric symptoms impair his ability to function in an occupational setting. The record also shows that the Veteran’s muscular and skeletal disabilities impair his ability to perform manual labor tasks. Upon consideration of the record in its entirety, the Board finds that the Veteran’s service-connected disabilities render him unable to secure and follow a substantially gainful occupation in accordance with his occupational background. Based on the foregoing, the Board finds that entitlement to a TDIU is warranted effective from September 15, 2015, which is the date that VA received the Veteran’s claim for an increased rating. The Board further notes that as of February 27, 2020, the Veteran is in receipt of a combined 100 percent schedular rating such that consideration of entitlement to special monthly compensation is for consideration under 38 U.S.C. § 1114(s). However, the Veteran does not have a single disability that is rated as 100 percent disabling, and by the Veteran’s private doctor’s own opinion, the Veteran’s service-connected disabilities combine together to entitle him to TDIU, i.e., the is not rendered unemployable as a result of one of those service-connected disabilities. Therefore, the Board finds that entitlement to TDIU for the period after February 27, 2020, is moot as a result of the combined schedular rating of 100 percent. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Rescan, 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.