Citation Nr: 21012646 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 13-08 809 DATE: March 4, 2021 ORDER Entitlement to an increased rating for left knee degenerative joint disease of 20 percent, but no higher, is granted from July 18, 2014. Entitlement to an increased rating for left knee degenerative joint disease in excess of 10 percent prior to July 18, 2014 is denied. Entitlement to an increased rating for left hip degenerative joint disease in excess of 10 percent is denied. Entitlement to an increased rating for right hip degenerative joint disease in excess of 10 percent is denied. Entitlement to a compensable disability rating for right hip limitation of extension is denied. Entitlement to a compensable disability rating for left hip limitation of extension is denied. Entitlement to a compensable disability rating for right hip limitation of flexion is denied. Entitlement to a compensable disability rating for left hip limitation of flexion is denied. Entitlement to a compensable disability rating for leg length discrepancy is denied. Subject to the laws and regulations governing the payment of VA compensation, entitlement to TDIU is granted from December 6, 2010. FINDINGS OF FACT 1. The Veteran’s left knee disability DJD did not manifest in a limited range of motion to 45 degrees or less flexion, or 10 degrees or more of extension. 2. From July 18, 2014, the Veteran’s left knee disability DJD exhibited frequent episodes of locking, pain, and effusion in the joint. 3. Prior to July 18, 2014, the Veteran’s left knee disability DJD related to semilunar cartilage removal was symptomatic, but did not exhibit frequent episodes of locking, pain, and effusion in the joint. 4. During the appeal period, the Veteran’s left hip DJD manifested with inability to cross left leg over right, but not in limitation of abduction to less than 10 degrees. 5. During the appeal period, the Veteran’s right hip DJD manifested with inability to cross right leg over left, but not in limitation of abduction to less than 10 degrees. 6. The Veteran’s right hip limitation of extension disability did not manifest in extension limited to 5 degrees. 7. The Veteran’s left hip limitation of extension disability did not manifest in extension limited to 5 degrees. 8. The Veteran’s right hip limitation of flexion disability did not manifest in limitation of flexion of 45 degrees or less. 9. The Veteran’s left hip limitation of flexion disability did not manifest in limitation of flexion of 45 degrees or less. 10. The Veteran’s legs have been reported as unequal in length, but not at or exceeding 3.2 centimeters of difference. 11. The record documents that the Veteran’s service-connected disabilities prevent him from securing or following a substantially gainful occupation consistent with his work and educational background. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating of 20 percent, but no higher, have been met from July 18, 2014 for left knee with DJD. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, Diagnostic Code (DC) 5258. 2. The criteria for entitlement to a rating in excess of 10 percent have not been met prior to July 18, 2014 for left knee with DJD. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DCs 5259, 5258. 3. The criteria for an increased rating in excess of 10 percent for left hip degenerative joint disease disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DC 5253. 4. The criteria for an increased rating in excess of 10 percent for right hip degenerative joint disease disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DC 5253. 5. The criteria for a compensable disability rating for limitation of extension, right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DC 5251. 6. The criteria for a compensable disability rating for limitation of extension, left hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DC 5251. 7. The criteria for a compensable disability rating for limitation of flexion, right hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DC 5252. 8. The criteria for a compensable disability rating for limitation of flexion, left hip have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DC 5252. 9. The criteria for a compensable rating for leg length discrepancy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.59, 4.71a, DC 5275. 10. The criteria for entitlement to TDIU have been met from December 6, 2010. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.1, 4.3, 4.16, 4.19, 4.25, 4.26. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1979 to July 1992. Increased Rating 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. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 1. Entitlement to a disability rating in excess of 10 percent for left knee with degenerative joint disease (DJD) The Veteran contends that his left knee disability is worse than contemplated by the current 10 percent disability rating. After a thorough review of the evidence, the Board finds that a rating in excess of 10 percent prior to July 18, 2014 is not warranted, but a rating of 20 percent, but no higher, from that date is warranted. The RO issued a rating decision in May 2011 granting entitlement to service connection for left knee DJD with an effective date of September 2, 2010, and the Veteran perfected an appeal from that decision. The Veteran is currently rated at 10 percent for left knee with degenerative joint disease under DC 5259. 38 C.F.R. § 4.71a. Limitation of flexion for the knee to 45 degrees warrants a 10 percent rating; to 30 degrees warrants a 20 percent rating, and; to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260. Limitation of extension to 10 degrees warrants a 10 percent rating; to 15 degrees warrants a 20 percent rating; to 20 degrees warrants a 30 percent rating; to 30 degrees warrants a 40 percent rating, and; to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5261. Other diagnostic codes pertaining to the knee include DC 5256 pertaining to ankylosis, 5257 for recurrent subluxation or lateral instability, 5258 for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; 5259 for symptomatic knee after removal of semilunar cartilage; 5262 for impairment of tibia and fibula; and 5263 for genu recurvatum. The Veteran has been afforded numerous VA examinations and also has treatment records from private providers and VA medical facilities. The Veteran underwent left knee arthroscopy in August 2010 after injuring his knee while at work earlier in the year. The Veteran was afforded a VA joints examination in October 2010 including knees and hips. At the examination the Veteran’s left knee flexion was measured to 120 degrees (full range of motion is flexion to 140 degrees); the Veteran had full extension to zero degrees. There was pain reported on examination with active motion. There was no additional loss of range of motion after repetitive testing. There was no ankylosis. The Veteran reported flare-ups occurred every two to three weeks lasting “hours.” The medical examiner noted the flare-ups were of moderate severity. The examiner recorded affirmative answers for the presence of instability, pain, stiffness, decreased speed of joint motion, and swelling as a symptom of inflammation. The Veteran did not report using any assistive mobility devices. MRI of the left knee taken June 2010 documented medial meniscal tear. The Veteran reported he could stand for 15 to 30 minutes and walk about a quarter of a mile. The March 2011 general VA examination replicated these results. The Veteran had a VA examination in May 2011. At the examination the Veteran’s left knee flexion was measured to 120 degrees; the Veteran had full extension to zero degrees. There was pain reported on examination with active motion. There was no additional loss of range of motion after repetitive testing. There was no ankylosis. The examiner confirmed a diagnosis of left knee DJD. The Veteran did not report using any assistive mobility devices. The Veteran reported he could stand for 15 to 30 minutes and walk about a quarter of a mile. The examiner noted that the Veteran walked with a slight limp. The Veteran’s June 2011 Notice of Disagreement stated that the left knee was worse than the awarded 10 percent disability rating due to chronic pain and limited range of motion which affects his sleep and leaves him fatigued. An August 2012 VA visit note documents that the Veteran complained of instability when walking and that he had recently fallen down. An October 2, 2012 medical note documents the Veteran had high risk for falls, with the Veteran reporting, “I fall all the time.” On October 3, 2012, the Veteran reported falls prior to surgery and problems with his gait but that he could now walk without devices after physical therapy. VA medical records show that the Veteran was provided with a cane on October 25, 2012. At a February 2013 VA examination for the knees, the Veteran’s left knee flexion was measured to 140 degrees (full range of motion is flexion to 140 degrees); the Veteran had full extension to zero degrees. There was no pain reported on examination with active motion. There was no additional loss of range of motion after repetitive testing. There was no ankylosis. The Veteran reported the left knee has stiffness if it is in the same position for too long and unable to bend on left knee. The examiner reported no functional impact related to flare-ups. Joint stability testing was normal. There was no evidence or history of recurrent patellar subluxation or dislocation. The examiner recorded affirmative answer for meniscal tear of both knees but noted no residuals. X-ray of left knee dated February 25, 2013 showed normal left knee. The Veteran did not report using any assistive mobility devices. The Veteran reported that he had two left knee surgeries related to a worker’s compensation claim in February 2010 and August 2010. On March 11, 2013 on a phone call with VA personnel, the Veteran reported that he had fallen two days prior resulting in a neck pain. On the Veteran’s March 26, 2013 VA Form 9, the Veteran disagreed with the assigned rating for the left knee and stated that he has limited range of motion, instability, is considered a fall risk, and has been prescribed knee braces. In April 2014, VA records show multiple visits with complaints of left knee pain. At an April 4 appointment, the Veteran related that his knees had progressively worsened and had braces for both knees. He reported that he had stopped working in his previous field of radiofrequency engineering because of knee instability and cervical fusion, so climbing towers was no longer physically possible. The Veteran was wearing knee braces at the appointment and was able to extend fully. The medical provider noted bilateral meniscal problems and bilateral knee DJD with internal derangement. The provider referred the Veteran for knee injections. On April 24, 2014, the Veteran had his first injections bilaterally in the knees with viscosupplementation injections. In May 2014, the Veteran complained of ongoing pain in the knees and requested pain management. A July 24, 2014 VA orthopedic surgery medical provider note interpreted an MRI as left knee with internal derangement with medial and lateral meniscal tears and chondromalacia of the patella. The Veteran was referred for arthroscopy. The MRI report itself dated July 18, 2014 states there is a small Baker’s cyst present and notes inflammation. There are “minimal areas of tendonitis.” The overall impression listed medial tendon interstitial tear, meniscal degenerative changes, and slight chondromalacia. A private treatment record dated September 4, 2014 notes the Veteran’s left knee shows range of motion from zero to 150 degrees with “mild pain medially. No varus or valgus laxity. Good stability.” A March 10, 2015 VA visit note of a general overview of the Veteran that showed “active range of motion of knees full flexion but lacks 30 degrees for full extension both knees.” A March 13, 2015 X ray of the left knee showed small left patellar enthesophyte and negative for acute osseous findings. A May 28, 2015 VA note documents that the Veteran is ready to see orthopedics for left knee pain. The Veteran was afforded a VA examination for knees in November 2015. The Board notes that the examiner recorded that he did not review any medical records, VA or otherwise, in relation to the examination. The Veteran reported flare-ups described as stiffness and pain in the left knee resulting in difficulty standing and walking. The Veteran’s left knee flexion was measured to 130 degrees; the Veteran had full extension to zero degrees. There was no pain reported on examination with active motion. There was no additional loss of range of motion after repetitive testing. There was no ankylosis. The examiner confirmed a diagnosis of left knee DJD. The examiner reported atrophy of the right leg quadricep 10 centimeters above the knee. The examiner did not perform joint stability testing. The Veteran reported using knee braces and a cane regularly. The examiner recorded that the Veteran’s knees disabilities would result in “impaired standing and walking, relegat[ing him] to sedentary activities.” The Board notes that in the sections asking about history of meniscal or other surgeries, the examiner recorded “none,” whereas the Veteran’s history shows multiple procedures on the left knee. In March 2016, the Veteran was afforded another VA examination of the knees. The Veteran’s left knee flexion was measured to 65 degrees (full range of motion is flexion to 140 degrees); the Veteran had full extension to zero degrees. There was pain reported on examination with active motion. On repeat testing, the Veteran’s flexion and extension measure from 50 degrees to zero degrees. The examiner noted pain, fatigue, weakness, lack of endurance contributed to the functional loss of range of motion. There was no ankylosis. The Veteran reported that the decreased range of motion during flare-ups depends on how bad the flare-up is. There was no reported muscle atrophy. Joint stability testing was unable to be performed. There was no evidence or history of recurrent patellar subluxation or dislocation or lateral instability. The examiner recorded that there is a history of effusion, the Veteran reported he gets fluid on his knees from normal activities. The examiner recorded affirmative answer for meniscal symptoms of meniscal tear, frequent episodes of joint locking, joint pain, and joint effusion, and referenced prior meniscectomy in 2010. There was no reported use of assistive mobility devices. The impact on the Veteran’s ability to perform occupational tasks included inability to walk, stand, sit for prolonged periods, an unsteady gait, falls at times, and needs frequent breaks. The Veteran was afforded a VA examination for the knees in June 2016. The Veteran described the flare-ups of the left knee as contributing to an inability to sit or stand for long periods; being unable to lift, climb or drive for more than 15 to 20 minutes, and having to change positions. The examiner was unable to perform range of motion testing due to pain. There was no reported muscle atrophy. There was no ankylosis. There was no reported history of recurrent subluxation, effusion, or lateral instability. The examiner was unable to perform joint stability testing due to pain. Under the section asking about meniscus conditions, the examiner responded “no” to whether the Veteran had a history of meniscus condition and did not reference any left knee surgical history. The examiner recorded an affirmative answer to having review the Veteran’s electronic claims file. The Veteran reported occasional use of braces and crutches, regular use of a walker, and constant use of a cane. At the March 2017 Board hearing, the Veteran and his wife testified that the left knee is worse than before and is painful, resulting in the Veteran waking up at night due to bilateral knee pain. The Veteran falls a lot due to his knees, according to his testimony. The Veteran stated that he has had a lot of knee injections, but they are not working any longer. The Veteran’s wife stated that the Veteran cannot do things around the house such as cut the grass. An October 3, 2017 VA note records that the Veteran had a recent fall due to “knee instability/equilibrium.” In March 2019, the Veteran was afforded another VA examination of the knees. The examiner confirmed a diagnosis of left knee DJD. The Veteran reported left knee flare-ups result in difficulty using stairs, which he avoids, and he says he cannot walk more than two blocks before knees get painful and swell. The Veteran’s left knee flexion was measured to 100 degrees; the Veteran had full extension to zero degrees. There was pain reported on examination with active motion. On repeat testing, there was no additional loss of range of motion. The examiner noted pain contributed to the functional loss of range of motion. There was no ankylosis. There was no reported muscle atrophy. Joint stability testing showed normal left knee stability. There was no evidence or history of recurrent patellar subluxation or dislocation or lateral instability. The examiner recorded that there is a history of effusion, referencing the right knee. Under the section asking about meniscus conditions, the examiner responded “no” to whether the Veteran had a history of meniscus condition and did not reference any left knee surgical history. The Veteran reported he uses a cane if he knows he will have to go somewhere and walk a lot, like Wal-Mart. The impact on the Veteran’s ability to perform occupational tasks included that knee stiffness and pain with ambulation would interfere with jobs requiring standing or walking. The medical examiner submitted an addendum opinion that flare-ups of the hips and knees would result in “more likely than not that a 20 to 30 degrees reduction of rom in all planes of motion would be reasonably expected during a flare of moderate arthritis such as this veteran has clinically and by his history.” A private treatment record documents an emergency room visit on July 21, 2019 in the middle of the night. The record states that the Veteran stood up quickly from a chair and “blacked out” and hit his face on the coffee table. The Veteran reported loss of consciousness. The doctor concluded the blackout and resulting fall was an unspecified syncopal episode. May 2020 VA medical notes show complaints of bilateral knee pain and adjustments to pain medication accordingly. The Board finds that based on the Veteran’s left knee DJD, his currently assigned disability evaluation of 10 percent under Diagnostic code 5259 is appropriate prior to July 18, 2014, based on general medical evidence of that time period showing symptoms like pain related to semilunar cartilage removal. From that date, the Board finds that an increased rating to 20 percent, but no higher, is warranted, due to general medical evidence showing increased severity of symptoms related to left knee meniscal conditions and DJD such as effusion, frequent episodes of pain, and the Veteran’s testimony that his knee gives way sometimes. 38 C.F.R. § 4.71a, DC 5258, 5259. The Board has considered additional Diagnostic Codes but finds that separate compensable ratings based on the left knee with DJD is not warranted. The Veteran’s limitation of motion of the left knee was not consistently and credibly documented as limited to 60 degrees of flexion or 5 degrees of extension. Thus, Diagnostic Codes 5260 or 5261 are not applicable. The Veteran’s pain is a symptom considered already under DC 5258 and 5259. The Veteran’s medical records do not show that his left knee has ankylosis, recurrent subluxation or lateral instability, or impairment of the tibia and fibula, or genu recurvatum, accordingly DCs 5256, 5257, 5262, and 5263 are not applicable. 38 C.F.R. § 4.71a. 2. Entitlement to an increased rating in excess of 10 percent for left hip degenerative joint disease 3. Entitlement to an increased rating in excess of 10 percent for right hip degenerative joint disease 4. Entitlement to a compensable disability rating for limitation of extension, right hip 5. Entitlement to a compensable disability rating for limitation of extension, left hip 6. Entitlement to a compensable disability rating for limitation of flexion, right hip 7. Entitlement to a compensable disability rating for limitation of flexion, left hip 8. Entitlement to a compensable disability rating for leg length discrepancy The Veteran contends that his left and right hip degenerative joint disease (DJD) disability is worse than contemplated by the current 10 percent disability rating. After a thorough review of the evidence, the Board finds that a rating in excess of the currently assigned separate 10 percent disability ratings for each hip on the basis of DJD is not warranted. The Veteran is currently rated at 10 percent for left hip DJD from 1992 under Diagnostic Code 5253. 38 C.F.R. § 4.71a. The Veteran is currently rated at 10 percent for right hip DJD from September 2, 2010 under DC 5253. Id. In a May 2011 rating decision, the RO granted entitlement to service connection from September 2, 2010 for the right hip DJD at 10 percent and denied an increase in excess of 10 percent for the left hip DJD. The Veteran perfected an appeal from that decision. As part of the evaluation of limitation of motion of joints, relevant Diagnostic Codes are considered. The Veteran is currently rated at a noncompensable level for limitation of extension of each hip separately under DC 5251 and at a noncompensable level for limitation of flexion under DC 5252 of each hip separately, all from November 15, 2015, but arising from the same evaluation during the appeal of the May 2011 rating decision. The Veteran is also rated at a noncompensable level for leg length discrepancy under DC 5275. 38 C.F.R. § 4.71a. Under Diagnostic Code 5251 (limitation of extension of the thigh), a rating of 10 percent is assigned when extension is limited to 5 degrees. Under Diagnostic Code 5252 (limitation of flexion of the thigh), a rating of 10 percent is assigned when flexion is limited to 45 degrees. A rating of 20 percent is assigned when flexion is limited to 30 degrees. A rating of 30 percent is assigned when flexion is limited to 20 degrees. A rating of 40 percent is assigned when flexion is limited to 10 degrees. Under Diagnostic Code 5253 (impairment of the thigh), a rating of 10 percent is assigned for limitation of rotation (cannot toe-out more than 15 degrees) or for limitation of adduction (cannot cross legs). A rating of 20 percent is assigned for limitation of abduction when motion is lost beyond 10 degrees. To warrant a compensable rating under Diagnostic Code 5275, the Veteran’s leg length discrepancy would have to manifest as shortening of one lower extremity from 1.25 to 2 inches or 3.2 to 5.1 centimeters. Normal range of motion (ROM) of the hip and thigh is flexion from 0 to 125 degrees and abduction from 0 to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Additional Diagnostic Codes of the hip are 5250 for ankylosis, 5254 for flail joint, and 5255 for impairment of the femur such as fracture or malunion or nonunion. The evidence discussed below does not support a diagnosis for these conditions, consequently these DCs are not for application here. 38 C.F.R. § 4.71a. As noted above, the Veteran has been afforded numerous VA examinations and also has treatment records from private providers and VA medical facilities. In October 2010, the Veteran was afforded a VA examination for the joints to include the hips. The Veteran complained of bilateral hip pain. Left hip flexion was to 120 degrees, extension from 0 to 25 degrees, and abduction to 35 degrees. Right hip flexion was to 120 degrees, extension from 0 to 25 degrees, and abduction to 35 degrees. The Veteran was unable to cross left leg over right or right leg over left. The Veteran was able to toe-out on both right and left beyond 15 degrees. There was objective evidence of pain bilaterally with active motion. There was no additional limitation of motion after repetitive testing. Measurement of adduction was not a part of the testing at this time. There was no ankylosis. X-rays of the hips revealed for the right hip, “No evidence of fracture or dislocation. No focal osseous lesions or significant degenerative changes are appreciated.” For the left hip, X-rays revealed, “No evidence of fracture or dislocation. Very slight femoral head spurring is present. Hip joint space is maintained.” The doctor noted, “very slight left hip degenerative joint disease.” In March 2011, the Veteran underwent a VA general medical examination. The Veteran had a normal gait. The Veteran complained of bilateral hip pain. Left hip flexion was to 120 degrees, extension from 0 to 25 degrees, and abduction to 35 degrees. Right hip flexion was to 120 degrees, extension from 0 to 25 degrees, and abduction to 35 degrees. The Veteran was unable to cross left leg over right or right leg over left. The Veteran was able to toes out on both right and left beyond 15 degrees. There was objective evidence of pain bilaterally with active motion. There was no additional limitation of motion after repetitive testing. Measurement of adduction was not a part of the testing at this time. There was no ankylosis. The commentary for the X-rays from the October 2010 examination was repeated. The Veteran was claiming individual unemployment due to the service-connected right knee and left hip. The examiner noted an effect on occupational task due to these disabilities as difficulty in climbing, bending, or kneeling, but no impairment on sedentary employment. In May 2011, the Veteran was afforded a VA joints examination to include the hips. The Veteran complained of bilateral hip pain that had been worsening for about 4 years. The examiner noted a slight limp in the Veteran’s gait. The examiner noted that the Veteran’s wife responded to a lot of the questions and that she stated that the Veteran had a difficult time remembering things. The Veteran reported he could stand for about 15 to 30 minutes and could walk more than 1/4 of a mile but not more than one mile. Left hip flexion was to 115 degrees, extension from 0 to 25 degrees, and abduction to 40 degrees. Right hip flexion was to 115 degrees, extension from 0 to 25 degrees, and abduction to 40 degrees. The Veteran was able to cross left leg over right and right leg over left. The Veteran was able to toe-out on both right and left beyond 15 degrees. There was objective evidence of pain bilaterally with active motion. There was no additional limitation of motion after repetitive testing. Measurement of adduction was not a part of the testing at this time. The Veteran reported using no assistive devices for mobility. There was no ankylosis. The Veteran’s June 2011 Notice of Disagreement stated that the bilateral hips disabilities were worse than the awarded 10 percent separate disability ratings due to chronic pain and limited range of motion which affects his sleep and leaves him fatigued. In February 2013, the Veteran was afforded a VA hips examination. The Veteran complained of daily bilateral hip pain that was more pronounced with sitting or walking more than 15 minutes, in addition to reporting his hips popped. The Veteran reported flare-ups occurred twice per week for about two hours and that he would take over the counter medication to alleviate such pain. Left hip flexion was to 120 degrees, extension to 0 degrees, and abduction was not lost to beyond 10 degrees. Right hip flexion was to 125 degrees, extension to 0 degrees, and abduction was not lost to beyond 10 degrees. The Veteran was able to cross left leg over right and right leg over left. The Veteran was able to toes out on both right and left beyond 15 degrees. There was not objective evidence of pain bilaterally with active motion. There was no additional limitation of motion after repetitive testing. There was no ankylosis. There was no localized pain or tenderness to palpation for either hip. There was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The examiner confirmed arthritis of bilateral hips from X-ray. The Veteran reported using no assistive devices for mobility. The examiner noted that the Veteran’s hips would not impact ability to work. On the Veteran’s March 26, 2013 VA Form 9, the Veteran disagreed with the assigned rating for the bilateral hips and stated that he has limited range of motion, instability, is considered a fall risk, and has been prescribed knee braces. The Veteran was afforded a VA examination for hips in November 2015. The Board notes that the examiner recorded that he did not review any medical records, VA or otherwise, in relation to the examination. The Veteran reported flare-ups described as swelling, stiffness, and pain for the right hip, and left hip as swelling and pain. The Veteran described functional loss related to his bilateral hips as more difficulty standing and walking. The Veteran’s left hip flexion was measured to 100 degrees, extension from 0 to 22 degrees, abduction from 0 to 40 degrees, adduction from 0 to 16 degrees, external rotation to 54 degrees, and internal rotation from 0 to 36 degrees. The Veteran’s right hip flexion was measured to 100 degrees, extension from 0 to 20 degrees, abduction from 0 to 30 degrees, adduction from 0 to 20 degrees, external rotation to 45 degrees, and internal rotation from 0 to 30 degrees. There was no pain reported on examination with active motion bilaterally. There was no additional loss of range of motion after repetitive testing. There was no ankylosis. The Veteran was unable to cross legs on either side. The examiner reported that the Veteran was being examined after repeated use over time which resulted in limited range of motion for left hip as flexion to 96 degrees, extension from 0 to 26 degrees, abduction from 0 to 38 degrees, adduction from 0 to 20 degrees, external rotation to 50 degrees, and internal rotation from 0 to 30 degrees; and right hip as flexion measured to 90 degrees, extension from 0 to 20 degrees, abduction from 0 to 15 degrees, adduction from 0 to 16 degrees, external rotation to 42 degrees, and internal rotation from 0 to 26 degrees. The Veteran was unable to cross legs bilaterally after repeated use over time. The examiner reported that the examination was not conducted during a flare-up and that estimated range of motion was not possible, however recorded that the Veteran reported that there was “severe limitation in range of motion during flare-ups, so much so that he avoids moving his hips in any way.” There was no localized pain or tenderness to palpation for either hip. The examiner confirmed a diagnosis of left and right hip DJD. The examiner reported atrophy of the right leg quadricep 10 centimeters above the knee. There was no malunion or nonunion of the femur, or flail hip joint, but the examiner reported a leg length discrepancy of 3 centimeters related to the DJD of hips and the Veteran’s total right knee replacement. The left leg measured 94 centimeters and the right leg as 91. The Veteran reported using knee braces and a cane regularly. The examiner recorded that the Veteran’s hips disabilities regarding occupational tasks would result in “difficulty standing and walking requiring use of cane. Not able to perform activities that require walking more than one block or standing on his feet for more than half an hour.” The Veteran was afforded a VA examination for hips in March 2016. The Board notes that the examiner recorded that he did not review any medical records, VA or otherwise, in relation to the examination. The Veteran reported flare-ups for both hips described as swelling, burning, and tender to the touch. The Veteran described functional loss related to his bilateral hips as not able to drive for long periods of time or sit for more than 15 minutes. The Veteran’s left hip flexion was measured to 15 degrees, extension from 0 to 15 degrees, abduction from 0 to 20 degrees, adduction from 0 to 20 degrees, external rotation to 15 degrees, and internal rotation from 0 to 15 degrees. The Veteran’s right hip flexion was measured to 15 degrees, extension from 0 to 15 degrees, abduction from 0 to 20 degrees, adduction from 0 to 20 degrees, external rotation to 15 degrees, and internal rotation from 0 to 15 degrees. There was pain reported on examination with active motion bilaterally. There was additional loss of range of motion after repetitive testing. There was no ankylosis. The Veteran was unable to cross legs either side. There was localized pain and tenderness to palpation for both hips. The examiner reported that the Veteran was able to perform repeat testing which resulted in limited range of motion for left hip as flexion to 20 degrees, extension from 0 to 15 degrees, abduction from 0 to 15 degrees, adduction from 0 to 15 degrees, external rotation to 10 degrees, and internal rotation from 0 to 10 degrees; and right hip as flexion measured to 10 degrees, extension from 0 to 20 degrees, abduction from 0 to 15 degrees, adduction from 0 to 15 degrees, external rotation to 5 degrees, and internal rotation from 0 to 10 degrees. Notably, the Veteran was able after repeat testing to cross right leg over left, but not left leg over right. Functional loss on limitation of motion was described as the Veteran cannot sit or stand for long periods of time, cannot walk longer than 10 minutes, and cannot run. The examination was not conducted during a flare-up; the Veteran reported that the extra limitation for range of motion during a flare-up varies depending on how bad it is but can result in inability to walk or to get out of bed. There was no muscle atrophy reported. There was no ankylosis. There was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported using no assistive devices for mobility. The examiner recorded that the Veteran’s hips disabilities regarding occupational tasks would result in, “difficult standing for prolonged periods, inability to squat, walking for prolonged periods. Frequent breaks needed.” The Veteran was afforded a VA examination for the hips in June 2016. The Veteran described the flare-ups of the hips as “the pain is worse at times,” contributing to an inability to sit or stand for long periods; being unable to lift or climb; or drive for more than 15 to 20 minutes, and having to change positions. The examiner was unable to perform range of motion testing due to pain and the examination was noted to be during bilateral flare-up. There was no reported muscle atrophy. There was no ankylosis. There was local tenderness or pain on palpation to the hips bilaterally. The examiner recorded an affirmative answer to having reviewed the Veteran’s electronic claims file. The Veteran reported occasional use of braces and crutches, regular use of a walker, and constant use of a cane. There was no malunion or nonunion of the femur, or flail hip joint, but the examiner reported a leg length discrepancy of 1.25 centimeters related to the DJD of hips and the Veteran’s total right knee replacement. The left leg measured 98.75 centimeters and the right leg as 100. At the March 2017 Board hearing, the Veteran and his wife testified that the bilateral hip pain results in the Veteran waking up at night. The Veteran stated that his left hip bothers him more than his right hip. According to the Veteran’s testimony he gets injections in both his hips about every three to six months for pain. The Veteran testified that his left leg is shorter than his right leg and he has been issued a “wedge” to place in his left shoe to accommodate this discrepancy. The Veteran’s wife stated that the Veteran cannot do things around the house such as cut the grass and the Veteran stated that if he sits in the same position for more than 15 to 20 minutes, he has to readjust. The Veteran was afforded a VA examination for hips in March 2019. The Veteran reported bilateral hips are painful daily and they get stiff after sitting and that if he stands for more than 30 minutes, he gets pain. The Veteran reported flare-ups described as increased stiffness and pain for both hips. The Veteran described functional loss related to pain with standing or using stairs. The Veteran’s left hip flexion was measured to 90 degrees, extension from 0 to 20 degrees, abduction from 0 to 40 degrees, adduction from 0 to 10 degrees, external rotation to 45 degrees, and internal rotation from 0 to 0 degrees. The Veteran’s right hip flexion was measured to 80 degrees, extension from 0 to 20 degrees, abduction from 0 to 40 degrees, adduction from 0 to 10 degrees, external rotation and internal rotation from 0 to 0 degrees. There was pain reported on examination with active motion bilaterally. There was no additional loss of range of motion after repetitive testing. There was no ankylosis. There was no reported muscle atrophy. The Veteran was able to cross both legs over the other on both sides. The limited range of motion resulted in functional loss described as difficult to get shoes on and off. There was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The examiner noted that the Veteran’s legs measured 82 centimeters from anterior superior iliac spine to medial malleolus, but that “dedicated plain radiographs are most reliable way to see this.” The Veteran reported regular use of a cane, for example when he knows he will have to walk a lot like at a retail store. The examiner recorded that the Veteran’s hips disabilities regarding occupational tasks would result in, “pain in hips with walking and standing” and would interfere with jobs requiring standing, walking, or taking stairs. In July 2019, this medical examiner provided an addendum opinion wherein they state, “The loss of rom for both hips and knees is not estimateable [sic] except to say that it is more likely than not that a 20-30 degrees reduction of rom in all planes of motion would be reasonably expected during a flare of moderate arthritis such as this veteran has clinically and by his history.” Although VA examinations, CAPRI records, and other private records from medical providers are “competent” medical evidence to establish a current evaluation of disability, a determination must be made as to whether these records are “credible” to support a disability rating in excess of the currently assigned ratings for this Veteran. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Factors to consider for purposes of credibility of evidence include facial plausibility, internal consistency, consistency with other evidence, self-interest or bias, bad character, malingering, and lay statements made during treatment. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). In particular, personal interest may affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Here, the VA medical examinations have demonstrated some inconsistent findings regarding the Veteran’s disabilities. Therefore, the Board must look at the overall record of evidence for the Veteran’s disabilities of the hips and knees as competent evidence, but not credible or probative where it is demonstrably inconsistent with other evidence, in order to establish a higher disability rating. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (noting that the Board, as fact finder, is responsible for assessing the credibility, competence, and probative value of evidence). Following careful review of the record, the Board concludes that a higher rating than 10 percent for the Veteran’s left or right leg DJD disabilities is not warranted under Diagnostic Code 5253. The next highest rating is 20 percent, however, as the evidence of record does not demonstrate that the Veteran’s left or right hips have limitation of abduction beyond 10 degrees, a higher rating under DC 5253 is not warranted. The Board acknowledges that each aspect of a disability is to be rated separately, and that while rating the same disease entity under multiple diagnostic codes is to be avoided, multiple ratings for the same joint based different aspects of the same disability are not necessarily pyramiding. See 38 C.F.R. §§ 4.14, 4.25. Indeed, the Board has assigned ratings for disability of the left hip under multiple diagnostic codes. However, while DC 5253 presents multiple non-successive avenues to ratings under that code, the Board finds that the rating schedule’s inclusion of these impairments under a single diagnostic code represents the Secretary’s intent that multiple concurrent ratings under DC 5253 would be pyramiding per se. Accordingly, regardless of whether the evidence shows a consistent and credible measurement that the Veteran’s external rotation (toe-out) was limited to 15 degrees or less, assigning a separate 10 percent rating for the inability to toe-out as well as the inability to cross legs (what the current 10 percent DJD rating is based on) would be inappropriate. Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010). Regarding the Veteran’s left and right hip limitation of extension, the Board finds that a compensable rating for either side is not warranted as the record does not demonstrate that the Veteran’s extension on either side is limited to 5 degrees, which is the threshold for a 10 percent rating under DC 5251. Regarding the Veteran’s left and right hip limitation of flexion, the Board finds that a compensable rating for either side is not warranted as the record does not demonstrate credible evidence supporting that the Veteran’s limitation of flexion of the bilateral hips is limited to at least 45 degrees, the threshold for a 10 percent disability rating under DC 5252. The Veteran’s VA examinations consistently demonstrate flexion of the left and right hips of at least 90 and 80 degrees respectively with an exception of the November 2015 VA examination where limitation of flexion in the left hip was recorded as 15 degrees initially and on repetitive testing to 20 degrees and of the right hip to 15 degrees initially and 10 degrees on repetitive testing. The Board has considered the applicability of DeLuca v. Brown, 8 Vet. App. 202, including whether there is a basis for assigning a compensable rating due to additional limitation of motion resulting from pain or functional loss. See 38 C.F.R. §§ 4.40 and 4.45. Even accounting for the July 2019 addendum opinion that during a flare-up, limitation could be 20 to 30 degrees in all planes of motion, for the measurements of the March 2019 VA examination at 90 degrees of flexion on the left and 80 degrees on the right, a reduction per the addendum would bring flexion to 60 degrees and 50 degrees respectively. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Regarding the Veteran’s noncompensable leg length discrepancy disability, the evidence of record does not document a leg discrepancy of at least 3.2 centimeters which is the minimum for a compensable rating under DC 5275. At the November 2015 VA examination, the examiner noted a leg length discrepancy of 3 centimeters, measured as the left leg was longer at 94 centimeters and the right leg was 91. At the March 2016 VA examination, the examiner reported a leg length discrepancy of 1.25 centimeters related to the DJD of hips and the Veteran’s total right knee replacement. The left leg was shorter at 98.75 centimeters and the right leg was 100. At the March 2019 VA examination, the examiner noted that the Veteran’s legs measured 82 centimeters from anterior superior iliac spine to medial malleolus, but that “dedicated plain radiographs are most reliable way to see this.” The Board acknowledges that the Veteran testified at the Board hearing in 2017 that his left leg is shorter, and he said he had been given a wedge to insert in his shoe to accommodate for asserted discrepancy. As additional background, the medical evidence of record shows that on September 25, 2017, the Veteran was issued diabetic shoes. On January 23, 2018, the Veteran was issued bilateral shoe inserts for diabetes mellitus-related symptoms and referred for diabetic shoes. On June 1, 2018, the Veteran was fitted for two pairs of diabetic shoes. After reviewing the evidence, both lay and medical, the Veteran’s leg length discrepancy disability is documented to be, at worst, 3 centimeters during the period on appeal. Furthermore, there are multiple VA examinations where there is no documented leg length discrepancy, and two conflicting examinations wherein the left leg and the right leg are alternately measured as the shorter lower extremity. An initial compensable rating for service-connected leg length discrepancy is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. 9. Entitlement to a determination of total disability based on individual unemployability (TDIU) The Veteran also seeks a total disability rating based on individual unemployability (TDIU). All Veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated as totally disabled. 38 C.F.R. § 3.340. Veterans may be awarded TDIU on either a schedular or extraschedular basis. 38 C.F.R. § 4.16. The Board may only grant TDIU, in the first instance, on a schedular basis. In the present case, the Board finds that an award of TDIU is warranted from December 6, 2010. The RO denied an award for TDIU in the May 2011 rating decision. At that time the Veteran did not meet the schedular requirements for TDIU and the RO determined he did not meet the standard for extraschedular evaluation. The Veteran did not include TDIU as an issue in his appeal paperwork. This matter was last before the Board in March 2017 when it took jurisdiction over a claim for TDIU in light of the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), as a TDIU was raised by the record in the Veteran’s hearing testimony for increased rating for other disabilities herein. The Board remanded for further development and consideration of TDIU. The case has been returned to the Board at this time for appellate review. A TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. Entitlement to a total rating must be based solely on the impact of the Veteran’s service-connected disabilities on his ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran’s level of education, special training, and previous work experience in arriving at a conclusion. However, individual unemployability must be determined without regard to any nonservice-connected disabilities or the Veteran’s advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. If a Veteran does not meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extraschedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b). See also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, the Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify a TDIU rating. 38 C.F.R. §§ 3.341(a), 4.16(a), 4.19. See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. The Veteran is currently service-connected for total right knee replacement from March 31, 2015 at 100 percent, and from June 1, 2016 at 60 percent; right knee injury from August 14, 1992 at 10 percent, from October 8, 2014 at 100 percent, and from January 1, 2015 to March 30, 2015, at 40 percent; depression from December 6, 2010 at 30 percent; left hip DJD from August 14, 1992 at 10 percent, and as of this decision, at 20 percent from July 18, 2014; right hip DJD from September 2, 2010 at 10 percent; and the following at noncompensable levels: right knee surgical scars, limitation of extension of the right and left hip, limitation of flexion of the left and right hip, and leg length discrepancy. The Veteran’s total disability rating, accounting for the decision herein, is 20 percent from August 14, 1992; 40 percent from September 2, 2010; 60 percent from December 6, 2010; 80 percent from January 1, 2015; 60 percent from March 30, 2015 (note this is one day); 100 percent from March 31, 2015; and 90 percent from June 1, 2016. Since all of the Veteran’s disabilities derive from the service-connected right knee disability, and he is rated at a total of 60 percent from December 6, 2010, the Veteran meets the schedular requirements for consideration of TDIU from December 6, 2010. The Veteran reported previously working for a city division as a radioelectric engineer until June 2010. Such a job, per the Veteran, involves climbing radio towers, and driving around to work sites, among other tasks. The Veteran submitted the official city job description which requires a driving license and lists the physical demands of the job as: stooping, kneeling, crouching, reaching, standing, walking, pushing, pulling, lifting, and repetitive motions; exerting up to 50 pounds of force to move objects; and “work in high precarious places.” The record shows the Veteran reported having a high school diploma and a four-year degree in electrical engineering. The Veteran’s service record shows his specialty as ground radio communications technician until separation in 1992. The Veteran reported working for 2.5 years at the city; as a radio frequency operator for a private employer for 4 years; Radio Frequency Monolithics for 10 years; and BF Goodrich as an electronics technician for 6 years. See November 21, 2012 CAPRI, Biloxi. The evidence of record shows that the Veteran had a left knee injury during work in February 2010 at his city radiocommunications job. The record shows he went for treatment for the knee, had an operation which became septic due to MRSA, required an additional operation, and eventually went on workman’s compensation for 20 months per the Veteran. The Veteran applied for Social Security Disability, which appears to have been granted in 2014, but more recently in 2019 was denied. The 2012 Social Security Disability application listed the following disabilities as factors in the Veteran’s unemployability: diabetes mellitus with severe neuropathy, stenosis of cervical spine, carpal tunnel syndrome, chronic pain syndrome, retinal hemorrhaging syndrome, erectile dysfunction, crush back pain, right knee and left knee meniscus/torn ACL, MRSA, depression and anxiety. Social Security determined that the Veteran had not had substantial gainful employment since November 18, 2010. The Veteran had previously applied for disability in 2006 after a motorcycle accident wherein he damaged his back, but it was denied. The evidence of record refers to a double cervical fusion at Jackson VA in late 2012. A May 2013 CAPRI note describes a “significant” history of workman’s compensation with the city for chronic cervicalgia; the Veteran was being seen after a reported fall due to his knees giving out and hitting his head. The Veteran has a regular history of falls, often attributed to his knees giving out. A private treatment record documents an emergency room visit on July 21, 2019 in the middle of the night. The record states that the Veteran stood up quickly from a chair and “blacked out” and hit his face on the coffee table. The Veteran reported loss of consciousness. The doctor concluded the blackout and resulting fall was an unspecified syncopal episode. An April 2014 CAPRI note documents that the Veteran related that he was disabled from working in radiofrequency engineering because he was “used to climbing cell towers all day,” and he is no longer able to do this “due to knee instability as well as prior cervical fusion.” The Veteran stated that he “is unemployable due to his liability climbing towers.” A May 21, 2014 CAPRI psychology note documents that the Veteran had to stop working because of a severe knee injury and he stated, “I loved working.” A June 2014 note reports that the Veteran had bilateral knee pain and that injections were not working, and the Veteran was unable to walk long distances. A July 2014 MRI showed meniscal tear in the left knee and referral for arthroscopy. An October 2014 note records that the Veteran’s mental health is negatively affected by his inability to work. The evidence outlined above for the Veteran’s other issues on appeal document that he reports that he cannot walk long distances, drive for long periods, or sit in one position for too long as his joints become stiff. The Veteran has a significant history of falls, which would preclude him from climbing cell or radio towers. Although the evidence shows that the Veteran has several non-service-connected disabilities that also contribute to his inability to work, the Board must consider only his service-connected disabilities, which are generally his knees, hips, and depression. Although medical examiners have opined that the Veteran is capable of performing sedentary employment, the Board finds that, based on the Veteran’s four decades of work as a radiocommunications technician, an expectation that the Veteran transition to substantially gainful employment at a desk job even in a related field is at best unrealistic when considering that the Veteran needs frequent breaks and cannot sit in one position for significant lengths of time. See Beaty v. Brown, 6 Vet. App. 532 (1994). The Board acknowledges that the Veteran appears able to perform certain aspects of daily living. However, the law recognizes that a person may be too disabled to engage in employment, although he or she is fairly comfortable at home or upon limited activity, such as the Veteran in this case. See 38 C.F.R. § 4.10. A veteran also does not have to prove that he or she is 100 percent unemployable in order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award. See 38 C.F.R. § 3.340(a); Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). In conclusion, the Board finds that the evidence supports the grant of entitlement to TDIU from December 6, 2010. 38 C.F.R. § 4.3. The medical and lay evidence of record establishes that the Veteran’s service-connected disabilities prevent him from securing or following substantially gainful employment. 38 C.F.R. § 4.16. Accordingly, the TDIU is granted from December 6, 2010. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Miller 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.