Citation Nr: 21013552 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 15-14 081 DATE: March 9, 2021 ORDER An initial rating of 20 percent for a lumbar disability is granted. An initial rating of 20 percent for a right knee disability, from February 11, 2011, based on a meniscus tear is granted. A rating of 20 percent for a right knee disability (moderate instability), is granted effective August 4, 2013. For the period on appeal, a rating of 10 percent, but no higher, for a right knee disability (functional loss and limited flexion) is granted. A rating of 10 percent, but no higher, for a right knee disability (functional loss and limited extension) is granted effective December 17, 2013. A rating in excess of 10 percent for a left knee disability (limited flexion prior to May 15, 2012) is denied. Prior to May 15, 2012, a separate rating of 10 percent for a left knee disability (slight instability) is granted. Prior to May 15, 2012, a separate rating of 20 percent for a left knee disability based on a meniscus tear is granted. From July 1, 2013, onward, a rating of 60 percent for a left knee disability (total knee replacement) is granted. A total rating based on individual unemployability (TDIU) is granted effective November 5, 2012 onward. FINDINGS OF FACT 1. The competent and probative evidence shows that the Veteran’s lumbar disability had painful flexion causing functional loss, with flexion of greater than 45 degrees, and he did not have Intervertebral Disc Syndrome (IVDS) that required bedrest. 2. For the entire period on appeal, the Veteran’s right knee disorder is manifested by symptoms such as frequent episodes of locking, pain, and swelling. 3. From August 4, 2013 onward, the Veteran’s right knee instability was moderate. 4. For the period on appeal, the competent and probative evidence shows that the Veteran’s right knee has painful flexion causing functional loss. 5. From December 17, 2013 onward, the competent and probative evidence shows that the Veteran’s right knee has painful extension causing functional loss. 6. Prior to May 15, 2012, the Veteran had left knee flexion of 100 degrees or greater. 7. Prior to May 15, 2012 the Veteran’s left knee instability was slight. 8. Prior to May 15, 2012, the Veteran’s left knee disorder was manifested by symptoms such as frequent episodes of locking, pain, and swelling. 9. From July 1, 2013 onward, the Veteran’s left knee disability manifested as severe intermediate chronic knee replacement residuals. 10. The Veteran’s service-connected disabilities rendered him unable to secure or follow substantially gainful employment consistent with his education and work history from November 5, 2012 onward. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 20 percent for a lumbar disability are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DCs) 5242-5243. 2. The criteria for an initial rating of 20 percent for the right knee disorder (semilunar) are met from February 11, 2011. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5258. 3. From August 4, 2013 onward, the criteria for a rating of 20 percent, but no higher, for a right knee disability (moderate instability) are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 4. For the period on appeal, the criteria for a rating of 10 percent, but no higher, for the right knee disorder (limited flexion) are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 5. From December 17, 2013 onward, the criteria for a rating of 10 percent, but no higher, for the right knee disorder (limited extension) are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261. 6. Prior to May 15, 2012, the criteria for a rating in excess of 10 percent for the left knee disorder (limited flexion) are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5010-5260. 7. Prior to May 15, 2012, the criteria for a rating of 10 percent, but no higher, for a left knee disability (slight instability) are met. 38 U.S.C. § 1155 ; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 8. Prior to May 15, 2012, the criteria for a rating of 20 percent for the left knee disorder (semilunar) are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5258. 9. From July 1, 2013 onward, the criteria for a rating of 60 percent disabling for left knee disability (total knee replacement) are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5055. 10. The criteria for TDIU are met since November 5, 2012. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Marine Corps from April 1993 to March 1994. These matters are before the Board of Veterans’ Appeals (Board) on appeal from July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board last remanded these in May 2020 for additional development, to include obtaining private treatment records and Social Security Administration (SSA) records. These matters have now returned to the Board for appellate consideration. As such, the Board finds there has been substantial compliance with its prior remand directives as SSA and private treatment records were obtained in May and June 2020. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3.   Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. Where there is noncompensable limitation of motion, a 10 percent evaluation is assigned for each major joint or group of minor joints, where the limitation is objectively confirmed by swelling, muscle spasm, or satisfactory evidence of painful motion. Where there is no limitation of motion, a 10 percent evaluation is assigned for x-ray evidence of involvement of two or more major joints or minor joint groups, and a 20 percent evaluation is assigned for x-ray evidence of involvement of two or more major joints or minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003, Note (1). Effective February 7, 2021, DC 5010 provides that traumatic arthritis is now to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). However, a veteran may be entitled to a higher disability evaluation than that supported by mechanical application of the rating schedule where there is evidence that his or her disability causes “additional functional loss i.e., ‘the inability... to perform the normal working movements of the body with normal excursion, strength, speed, coordination[,] and endurance’ including as due to pain and/or other factors” or “reduction of a joint’s normal excursion of movement in different planes, including changes in the joint’s range of movement, strength, fatigability, or coordination.” Lyles v. Shulkin, 29 Vet. App. 107, 117-18 (2017) (quoting 38 C.F.R. § 4.40 and citing 38 C.F.R. § 4.45); Mitchell v. Shinseki, 25 Vet. App. 32, 36-37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). The intent of the rating schedule is to recognize painful motion with joint and periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or maligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. “The question of whether a particular medical issue is beyond the competence of a layperson—including both claimants and Board members—must be determined on a case-by-case basis.” Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring). In this case, the Board is competent to observe that voluntary range of motion testing is going to be more favorable to the Veteran than involuntary range of motion testing. In DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1592 (32nd ed. 2012), range of motion redirects the reader to “exercise.” Passive exercise “is motion imparted to a segment of the body by another individual, machine, or other outside force, or produced by voluntary effort of another segment of the patient’s own body.” Id. at 658. Active exercise is “motion imparted to a part by voluntary contraction and relaxation of muscles controlling the part.” It is reasonable from these definitions to conclude that active motion is the more difficult of the two types of motion to perform because it is done without assistance from external forces, which would be capable of pushing the Veteran’s joint farther than he would be able to move it on his own. Therefore, active motion is more favorable to the Veteran, and the results of active motion testing were provided. Similarly, it is reasonable to conclude that non-weightbearing motion is less difficult than weightbearing motion. The competent evidence of record does not tend to indicate that the structural integrity of the Veteran’s service-connected joints is compromised, such that passive range of motion in this case would be more limited than active, and because testing in weight-bearing conditions is more demonstrative of the degree of pathology, the Board finds that the failure to test for limitation of motion on passive range of motion and in non-weight-bearing is not prejudicial. The Board will therefore evaluate the Veteran’s range of motion using the available findings of active range of motion and looking at all the relevant medical and lay evidence. It is acknowledged some of the examiners did not provide an estimated loss of motion during flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, the Board finds that additional development for this purpose or for obtaining retrospective opinions would serve only to delay the claim. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). As noted below, the examination reports contain evidence regarding the frequency, severity, and duration of the Veteran’s pain level during flare-ups per his report. The Board finds such information pertinent and useful when evaluating the disability picture concerning the Veteran’s service-connected disabilities. As such, the Board finds that it has adequate competent evidence when viewed in total to assess the Veteran’s disability picture. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a). 1. Entitlement to an initial rating in excess of 10 percent for a lumbar disability prior to April 5, 2016 and 20 percent thereafter. The Veteran is rated at 10 percent disabling prior to April 5, 2016, and 20 percent thereafter. Additionally, he has received temporary total ratings from November 5, 2012 until March 1, 2013; from January 22, 2014 until May 1, 2014; and from October 16, 2018 until February 1, 2019. Under the General Rating Formula for the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted where the evidence shows forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine limited to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. The criteria for a 50 percent rating are unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Associated objective neurological abnormalities are rated separately under the appropriate diagnostic code. Id., Note (1). Alternatively, a back disorder can be rated as Intervertebral Disc Syndrome (IVDS) based on incapacitating episodes. Under those criteria, found at Diagnostic Code 5243, a ten percent evaluation requires incapacitating episodes having a total duration of at least one week, but less than 2 weeks during the past 12 months, and 20 percent evaluating requires incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks during the past 12 months. Id. DC 5243. A 40 percent rating is warranted for incapacitating episodes having a total duration of less than six weeks, but more than four weeks and a 60 percent rating is warranted if incapacitating episodes have a total duration of at least six weeks during the past 12 months. There is no corresponding note allowing for the separate evaluation of any associated neurologic abnormalities. 38 C.F.R. § 4.71a. Effective February 7, 2021, VA amended DC 5243 to include “assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses.” 38 C.F.R. § 4.71a, DC 5243 (2021). The Veteran underwent an examination in June 2011. He reported limited walking and could walk half a mile in an hour (due to his knees and spine). He reported stiffness, decreased motion, and numbness. He reported pain that occurred two times per week and lasted up to three days. Pain was relieved with rest, NSAIDS, and heat/or cold. During flare-ups, he had functional impairment with prolonged sitting, standing, walking, repetitive bending, and heavy lifting. He had mild muscle spasms, which did not produce an abnormal gait. He also had tenderness, but no guarding. His muscle tone was normal. His range of motion was normal, but he had pain at 75 degrees for flexion, 20 degrees for extension and right/left lateral flexion, and 25 degrees for right and left rotation. He was able to perform repetitive use testing, but it resulted in additionally reduced range of motion for all ranges of motion and his forward flexion was 75 degrees with an additional 15 degrees of limitation. He had fatigue, lack of endurance, and pain. A disability benefits questionnaire (DBQ) was completed on August 4, 2013. The November 2012 lower back diskectomy was reported. He acknowledged twice weekly flare-ups where he would not be able to walk due to the pain. He had forward flexion of 85 degrees with pain beginning at 80 degrees and extension of 15 degrees with pain beginning at 10 degrees. He had right lateral flexion of 25 degrees without pain; left lateral flexion of 25 degrees with pain at 15 degrees; and normal right (without pain) and left lateral rotation (30 degrees) with left lateral rotation pain at 30 degrees. He was able to perform three times repetitive use testing. His range of motion for extension was reduced to 10 degrees. He had less movement than normal, weakened movement, pain on movement, and interference with sitting, standing and/or weight-bearing. Pain and fatigability significantly limited functional ability during flare-ups. An additional 10 to 30 degrees of range of motion loss was reported during flare-ups due to pain. He did not have localized tenderness/pain on palpation or guarding or muscle spasms. Intervertebral disc syndrome (IVDS) was reported with at least four weeks but less than six weeks of incapacitating episodes over the past 12 months. The Board acknowledges that IVDS with prescribed bed rest was reported. However, the Board finds this prescribed bed rest corresponds with his temporary total ratings for his November 2012 diskectomy as the Veteran received a temporary total rating from November 5, 2012 until March 1, 2013, which would be within the past 12-month period from the August 2013 DBQ. The other evidence of record, including examinations and DBQs, do not show IVDS that required prescribed bed rest. Additional range of motion testing was performed in December 2013. He had forward flexion of 45 degrees with pain, extension of 10 degrees with pain, right and left lateral flexion/rotation of 15 degrees with pain. He was able to perform three times repetitive use testing with the same range of motion. The Veteran participated in an examination for his back on April 6, 2016. He reported flare-ups with motion in any direction or with repetitive motion or lifting anything more than 30 pounds. He had functional loss/impairment with bending and tying his shoes and entering vehicles. He had forward flexion of 60 degrees, extension of 15 degrees, and right/left lateral flexion and rotation of 20 degrees. His range of motion contributed to functional loss with picking up objects. He had pain on all ranges of motion and evidence of pain with weight-bearing. He had pain on palpation. He was able to perform three times repetitive use testing with no additional loss of function or range of motion. Pain significantly limited functional ability with repeated use over a period of time. His forward flexion was reduced to 50 degrees, extension to 10 degrees, and right/left lateral flexion and rotation to 15 degrees. The examiner found that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare-ups and was unable to say without mere speculation whether his functional ability was further limited. He had localized tenderness that resulted in abnormal gait. IVDS was reported, but he did not require bed rest in the past 12 months. His most recent examination for his lumbar disability is from November 2018. He had flare-ups and functional impairment with decreased ability to bend, lift, stand, walk, squat, kneel, and climb. He had forward flexion of 65 degrees, extension, right and left lateral flexion and rotation of 30 degrees. He had decreased ability to flex. He had pain on all ranges that caused functional loss. He had pain with weight bearing. He was able to perform three times repetitive use testing with five degrees less range of motion for forward flexion and extension due to lack of endurance and pain. The examination was medically consistent with his statements for repetitive use and during flare-ups. Pain and lack of endurance caused functional loss and his range of motion testing was reduced to 60 degrees for forward flexion and 25 degrees of extension during repetitive use and flare-ups. He did not have guarding or muscle spasms. IVDS was not reported. He had evidence of pain when used in non-weight bearing, but passive range of motion testing could not be performed. Treatment records show that his lumbar pain worsened in June 2013. He had flexion of 60 degrees, right and left lateral rotation of 45 degrees, and tenderness. He had lumbar decompression fusion in January 2014.   After review of the competent and probative evidence, the Board resolves reasonable doubt in favor of the Veteran, and finds that the competent, probative evidence warrants an initial rating of 20 percent. The evidence from the 2011 examination suggests that the Veteran experienced pain that limited his range of motion for forward flexion at 60 degrees after repetitive use testing. The Board acknowledges that the examination is somewhat unclear as to whether the Veteran’s forward flexion was limited to 75 degrees after repetitive use or to 60 degrees. However, the Board resolves reasonable doubt in favor of the Veteran, and initial 20 percent is warranted. 38 C.F.R. § 4.3. A rating in excess of 20 percent is not warranted during the period on appeal outside of the temporary total ratings. In this regard, the Veteran has had no worse than 45 degrees of flexion with pain (forward flexion limited to 30 degrees or less for the next higher rating), nor had he had IVDS with prescribed bed rest that is not from his treatment where he received temporary total ratings. Additionally, at no point during this period, has he had either favorable or unfavorable ankylosis per the competent evidence of record, to include the noted examination reports. In this regard, the examinations and DBQs show that while the Veteran has pain and functional impairment because of his limited range of motion, he is able to perform some range of motion which demonstrates that he does not have ankylosis. See 38 C.F.R. § 4.71a, Note (5) (“unfavorable ankylosis is a condition in which... the entire thoracolumbar spine . . . is fixed in flexion or extension”). Lastly, the weight of the evidence does not support a finding that the Veteran’s disability picture due to functional loss/limitations is more nearly approximated by a higher rating. Considering the Deluca and Mitchell factors, and the evidence of record, the Board finds that the current 20 percent rating already compensates Veteran for any functional loss due to pain affecting the spine, to include pain and limited motion. Deluca, 8 Vet. App. at 204-07. In light of the foregoing, the Board finds that an increased rating due to functional impairment is not be appropriate under the criteria for 38 C.F.R. §§ 4.40 and 4.45. 2. Entitlement to an initial rating in excess of 10 percent for a right knee disability prior to November 30, 2018 and 20 percent thereafter. 3. Entitlement to a rating in excess of 10 percent prior to July 1, 2013, 30 percent until July 1, 2018, and 60 percent thereafter for a left knee disability. The Veteran’s right knee is rated at 10 percent prior to November 30, 2018 under DC 5010-2260 and 20 percent thereafter under DC 5258. For his left knee, he received a 10 percent rating prior to May 15, 2012. He next received a 30 percent rating from July 1, 2013 until April 29, 2014. He has received temporary total ratings from May 15, 2012 until July 1, 2013; from April 29, 2014 until July 1, 2015; and from May 1, 2017 until July 1, 2018. From July 1, 2018 onward, he receives a 60 percent rating. 38 C.F.R. § 4.71, DC 5055. Normal flexion of the knee is to 140 degrees, and normal extension of the knee is to 0 degrees. 38 C.F.R. § 4.71, Plate II. DC 5055 provides for prosthetic replacement of the knee joint assigns a 100-percent evaluation for one year following implantation of prosthesis. With chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60-percent rating is assigned. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is to be rated by analogy to DCs 5256 (ankylosis), 5261 (limitation of extension), or 5262 (impairment of tibia and fibula). The minimum rating is 30 percent. 38 C.F.R. § 4.71a. VA revised this DC on February 7, 2021, but it is not applicable here as the period under consideration is prior to the 2021 effective date. Under 38 C.F.R. § 4.71a, DC 5257 covers “other impairment of the knee,” and an assignment of a 10 percent rating is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability. A 30 percent evaluation is for severe knee impairment with recurrent subluxation or lateral instability. Additionally, DC 5258 covers dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint; this warrants a 20 percent rating. DC 5259 covers removal of symptomatic semilunar cartilage, which warrants a 10 percent rating. Other DCs concern motion and under DC 5260 leg flexion limited to 60 degrees warrants a noncompensable rating. Leg flexion limited to 45 degrees warrants a 10 percent rating. Leg flexion limited to 30 degrees warrants a 20 percent rating. Leg flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, leg extension limited to 5 degrees warrants a noncompensable rating. Leg extension limited to 10 degrees warrants a 10 percent rating. Leg extension limited to 15 degrees warrants a 20 percent rating. Leg extension limited to 20 degrees warrants a 30 percent rating. Leg extension limited to 30 degrees warrants a 40 percent rating. Leg extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5261. A knee disability can be rated for both limitation of leg flexion under DC 5260 and limitation of leg extension under DC 5261. See VAOPGCPREC 9-2004 (Sept. 17, 2004). Additionally, General Counsel Opinion 9-98 directs that with respect to Diagnostic Code 5259, limitation of motion can be a relevant consideration so the provisions of 38 C.F.R. § 4.40 and 4.45 must be considered. Effective February 7, 2021, VA amended DC 5257. For recurrent subluxation or lateral instability, a 10 percent rating is assigned for a sprain, incomplete ligament tear or complete ligament tear causing persistent instability without prescribed assistive device or bracing for ambulation. A 20 percent rating is warranted when a) a sprain, incomplete ligament tear, or repaired complete ligament tear causes persistent instability; or b) an unrepaired or failed repair of a complete ligament tear causes peristent instability. A prescribed assistive device or bracing for ambulation is required. A 30 percent rating requires unrepaired or failed repair of complete ligament tear causing persistent instability and a prescription for both an assistive device and bracing for ambulation. For patellar instability also rated under DC 5257, a 10 percent rating is assigned for a diagnosed condition that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted when there is a diagnosed condition with a prescription for either a brace, cane, or walker. A 30 percent rating requires a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription for brace and either a cane or a walker. Diagnostic Code 5262 was amended to now provide that “malunion of” the tibia and fibula is now rated under appropriate knee or ankle diagnostic codes. Additionally, a noncompensable rating is assigned for medial tibial stress syndrome (MTSS) or shin splints for treatment of less than 12 consecutive months, one or both lower extremities. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Prior to February 7, 2021, the Board will apply the prior rating criteria. From February 7, 2021 onward, the Board applies the criteria that is more favorable to the Veteran. The Veteran underwent an examination in June 2011. For his knees, he had bilateral weakness, stiffness, tenderness; and for his left knee, he also had swelling, giving way, lack of endurance, locking, and dislocation. He had right knee flare-ups (three out of ten severity) up to twice a week and could last for three days. For his left, he had flare-ups three times per week flare-ups (five out of ten severity) and 5-hour duration. His flare-ups were alleviated with rest, NSAIDs, and hot/cold topical application. He had functional impairment during flare-ups with prolonged standing, walking, kneeling, squatting, and running. The examiner reported the Veteran had a right knee meniscal tear with frequent episodes of joint locking and pain. He had had a right knee meniscectomy and left knee meniscus tear, ACL repair, and meniscectomy in the past. He had objective signs of tenderness and crepitus. He did not have instability, effusion, weakness, or subluxation. His range of motion was normal for his right knee (140 degrees of flexion and zero extension), but had pain at 120 degrees for flexion. He was able to perform repetitive use testing and had pain at 120 degrees. For his left knee, he had 120 degrees of flexion with pain at 10 degrees. His extension was normal (zero degrees). He performed repetitive use testing and had reduced flexion of 100 degrees and normal extension. He had additional functional loss bilaterally with fatigue, lack of endurance, and pain. His joint stability testing (medial/lateral collateral ligaments, anterior/posterior collateral ligaments, and medial/lateral meniscus) was normal. The examiner reported that the functional impact from his bilateral knees was impaired prolonged sitting, standing, walking, running, repetitive bending, kneeling, squatting and heavy lifting. The Board acknowledges the representative’s assertions in 2011 that his left knee flexion was completely limited to 10 degrees as shown by when his pain began. However, the Board does not find that his limitation of flexion was so severely limited. While acknowledging that he had pain, the evidence shows that he could perform repetitive use testing with flexion of 100 degrees. Additionally, the other competent and credible evidence of record does not tend to show his left knee flexion was limited to 10 degrees. A disability benefits questionnaire (DBQ) was completed on August 4, 2013. He reported flare-ups for his left knee in that it would swell every other day which prevented him from standing or walking. He reported painful flare-ups in his right knee when he would rest. His right knee flexion was 130 degrees, and his extension was normal without evidence of painful motion. His left knee had flexion of 120 degrees with pain at 100 degrees and extension of 25 degrees with pain. He was able to perform three times repetitive use testing. His right knee range of motion remained the same, and his left knee range of motion was 115 degrees for flexion and normal extension. He had less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing bilaterally. Pain significantly limited functional ability during flare-ups and instability was reported for the left knee. Popping and crunching was reported on the right. He had an additional five degrees less range of motion on repeat testing. He had normal Lachman testing and Posterior Drawer testing. However, he had 2+ (5-10 millimeters) for medial-lateral instability bilaterally. He did not have a history of recurrent patellar subluxation or dislocation. He did not have recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. His right knee meniscus condition was reported in that he had a meniscal tear with frequent episodes of joint locking and pain. Right and left knee meniscectomies were reported with pain and limitation of motion. For his left knee, he had intermediate degrees of residual weakness, pain and/or limitation of motion following his total knee replacement in May 2012. He constantly used a brace for stabilizing his left knee. Additional range of motion testing was performed December 17, 2013. He had right knee flexion of 95 degrees with pain and normal extension (zero degrees) but had painful motion at 10 degrees. For his left knee flexion, he had 85 degrees with pain and extension of 10 degrees with pain. He was able to perform three times repetitive use testing with no additional los of range of motion. The Veteran underwent an examination for his knees in April 2016. He had flare-ups in both knees, but the right knee was worse. Repeated use or activity against resistance caused flare-ups. He had functional impairment with entering or exiting vehicles, longer walks, stairs, and prolonged standing. For his knees, he had 130 degrees of flexion and 10 degrees of extension, but with normal extension for his left knee. He had pain on all ranges of motion other than left knee extension, and the pain caused functional loss. He had pain with weight bearing bilaterally and localized tenderness for his right knee. He was able to perform three times repetitive use testing with no additional functional loss or range of motion. The examination was neither medically consistent or inconsistent with his statements describing functional loss with repetitive use over time or during flare-ups for either knee. Pain significantly limited functional ability with repeated use over a period of time for his right knee, and his flexion was reduced to 120 degrees. He had reduced muscle strength for his right knee extension (4/5 active movement against some resistance). He did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. However, the Board finds this to be inconsistent with the evidence of recording showing repeated instability and swelling. Joint stability testing was not performed for the right knee (too painful to adequately test and Veteran declined force on knee), and his left knee instability testing (Anterior, Posterior, Medial, and Lateral) was normal. He did not have recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. While meniscus conditions were reported for both knees (right knee meniscectomy, left knee total knee replacement) he did not have any current symptoms. The examiner reported intermediate degrees of residual weakness, pain or limitation of motion. The Veteran regularly used a brace for his left knee. His most recent examination is from November 2018. He reported flare-ups and functional loss where he had decreased ability to walk, stand, squat, kneel, and climb. For his right knee, he had flexion of 130 degrees and normal extension, both had pain. He had localized tenderness, pain with weight bearing, and objective evidence of crepitus. His left knee had 120 degrees of flexion and normal extension. He had pain on both ranges of motion, objective evidence of localized tenderness, pain with weight bearing, and objective evidence of crepitus. He was able to perform three times repetitive use testing with the same range of motion for his right knee and had 115 degrees of flexion for his left knee. He had functional loss because of fatigue, pain, and lack of endurance for both knees. The examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and during flare-ups for both knees. Pain and lack of endurance significantly limited functional ability with repeated use over a period of time and during flare-ups for both knees. For range of motion following repetitive use and during flare-ups, his right knee had 130 degrees of flexion and normal extension, and his left knee had 115 degrees of flexion and normal extension. He had bilateral disturbance of locomotion. Recurrent effusion was reported weekly. Joint stability testing (anterior, posterior, medial, and lateral) was normal bilaterally. He had a history of shin splints, but no current symptoms and they did not affect the range of motion for his knees or ankles. For his bilateral meniscus conditions (tears), he had frequent episodes of joint locking, pain, and effusion. The examiner reported chronic residuals consisting of severe painful motion or weakness for his left knee. He occasionally used a brace bilaterally for support. He had objective evidence of pain when his knees were used in non-weight bearing and his passive range of motion and accompanying pain was the same as active testing. A review of the Veteran’s treatment records show that he had left knee pain in March 2012. He had 110 degrees of flexion. He has had swelling and redness. Additionally, his left knee would lock up in 2012. For his right knee, he had 80 degrees of flexion and 10 degrees of extension in April 2014. He had a history of pain and swelling for his right knee. A total left knee arthroplasty was performed in April 2014. He had significant left knee instability after his surgery. He had 135 degrees of flexion with no instability in October 2015 and in January 2016. He had increased left knee pain in December 2016. Three to four millimeters of medial opening of his left knee joint was reported in January 2017. His left knee continued to give out. He had an additional total left knee arthroplasty revision in May 2017. Severe right knee pain was reported in January 2019. Right Knee The Veteran was originally rated under DC 5010-5260 for his right knee disability from February 11, 2011. A February 2020 rating decision changed the diagnostic code to 5258 and granted a 20 percent rating effective November 30, 2018. After review of the competent and probative evidence, the Board finds that an initial rating of 20 percent is warranted under 5258. In this regard, the Veteran has had a right knee meniscal tear. He has had locking, pain, and effusion as reported in the Veteran’s examinations and medical records. Moreover, the Board finds the pain associated with the Veteran’s meniscus tear is separate than the pain associated with his painful range of motion, so this is not a pyramiding of benefits. As such, an initial rating of 20 percent is warranted from February 11, 2011. As the Veteran receives a 20 percent rating under DC 5258, the Board finds that the Veteran’s symptomatology, such as locking and effusion, do not warrant a separate rating under 5259 as this would constitute impermissible pyramiding. 38 C.F.R. § 4.14. The Board finds a separate rating under DC 5259 is not warranted without discontinuing the rating under DC 5258. Here, DC 5258 provides the greater benefit. As a result, a rating under DC 5259 is not warranted. The Board also finds a rating of 20 percent under DC 5257 is warranted as the evidence shows that the Veteran has right knee instability based on his medical records and his statements from August 4, 2013 onward. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018) (finding that DC 5257 does not require objective medical evidence of lateral instability for a rating to be assigned and when weighing evidence to determine whether there is lateral instability, the Board cannot find objective medical evidence is automatically more probative than lay evidence). The August 2013 DBQ reported medial-lateral instability 2+ (5-10 millimeters), which tends to show moderate instability in light of the evidence of record. Given the tests performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are of probative value and assigned weight. Additionally, higher ratings are not warranted at any point during this period on appeal for the knee as the relevant examination reports, as detailed above, do not show a history of recurrent subluxation or lateral instability of the knee. Moreover, the Veteran does not assert that he falls frequently or that his knee is giving out frequently. Also, for example, the 2018 VA examination report does not show normal joint stability testing of 3+ (10-15 millimeters). As such, a rating in excess of 20 percent from August 4, 2013 for right knee moderate instability is not warranted. Additionally, from February 7, 2021 onward, a rating of 30 percent is not warranted under the revised criteria as the evidence does not tend to show that the Veteran has a prescription for both assistive and bracing devices. A compensable rating for right knee instability is also not warranted prior to August 4, 2013. In this regard, the competent and probative lay and medical evidence of record does not show right knee instability. The 2011 examination reported normal stability testing without a history of recurrent instability or subluxation. Additionally, the Veteran’s medical records and his lay statements do not tend to show a right knee instability. He did not contend that his right knee would give out. As such, the Board finds that a compensable rating for right knee instability is not warranted prior to August 4, 2013. Additionally, the Board finds that a rating of 10 percent, but no higher, under DC 5260 is warranted for the period on appeal. The Veteran had painful flexion at the June 2011 examination. The Board acknowledges the Veteran has had flexion range of motion that typically does not warrant a compensable rating. Additionally, the Board acknowledges the August 2013 report showing normal range of motion for flexion without pain. However, when viewed with all evidence of record, to include the later reported December 2013 range of motion testing, the Board finds the August 2013 right knee range of motion testing without pain to be more of an anomaly as the Veteran has largely had painful motion for the period on appeal for his right knee flexion. At the multiple examinations, he has had pain and functional loss in the right knee. These reports indicate that there was weakness, functional limitation with sitting, standing, and walking, and pain, and the Board finds that his symptoms are more nearly approximated by a rating of 10 percent for limited flexion under DC 5260 and functional loss. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Lyles v. Shulkin, 29 Vet. App. 107, 117-18 (2017) (quoting 38 C.F.R. § 4.40 and citing 38 C.F.R. § 4.45 ); Mitchell v. Shinseki, 25 Vet. App. 32, 36-37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). Moreover, the Board finds several factors produce a disability picture more nearly approximated by a compensable schedular rating. In this regard, the Veteran reports flare-ups, pain, and has had documented disturbance of locomotion, and interference with sitting, standing, and pain on movement. As such, a rating of 10 percent for the right knee is warranted. 38 C.F.R. § 4.3, 4.7. Also, there is no indication of flexion limited to 30 degrees on any of the examination reports detailed above. Therefore, the Board finds that under the DeLuca factors and § 4.59, he is entitled to a rating of 10 percent, but no higher, for limited flexion resulting in documented functional loss. 38 C.F.R. §§ 4.40, 4.45. The Board also finds that a rating of 10 percent for limited extension is warranted under DC 5261 from December 17, 2013 onward. The Veteran has had repeated periods of when his right knee extension had pain at 10 degrees, or his range of motion was limited to 10 degrees. The Board acknowledges that at times he has had normal range of motion for extension, but finds that similar to his flexion, those periods without pain were less likely. These reports indicate that there was weakness, functional limitation with sitting, standing, and walking, and pain, and the Board finds that his symptoms are more nearly approximated by a rating of 10 percent for limited extension under DC 5261 and functional loss. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Lyles v. Shulkin, 29 Vet. App. 107, 117-18 (2017) (quoting 38 C.F.R. § 4.40 and citing 38 C.F.R. § 4.45 ); Mitchell v. Shinseki, 25 Vet. App. 32, 36-37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). Moreover, the Board finds several factors produce a disability picture more nearly approximated by a compensable schedular rating. In this regard, the Veteran reports flare-ups, pain, and has had documented disturbance of locomotion, and interference with sitting, standing, and pain on movement. As such, a rating of 10 percent for the right knee extension is warranted. 38 C.F.R. § 4.3, 4.7. A rating in excess of 10 percent is not warranted as there is no indication of extension limited to 15 degrees. Therefore, the Board finds that under the DeLuca factors and § 4.59, he is entitled to a rating of 10 percent, but no higher, for limited extension resulting in documented functional loss. 38 C.F.R. §§ 4.40, 4.45. Additionally, a compensable rating prior to December 17, 2013 is not warranted as the two prior examinations show that the Veteran had normal range of motion for his right knee extension and did not have painful motion. Additionally, ratings under 5256 and 5262 are also not warranted as the Veteran does not have ankylosis or impairment of the tibia and fibula. The Board acknowledges the Veteran has had shin splints, but he does not have treatment or symptoms attributable to shin splints. Left Knee The Veteran previously was rated under DC 5010-5260 for his left knee disability. A December 2012 rating decision changed the diagnostic code to 5055. After review of the competent and probative evidence, a rating in excess of 10 percent is not warranted for limited flexion prior to May 15, 2012. In this regard, he did not have flexion limited to 30 degrees or less as shown at the 2011 examination. Additionally, a rating under 5261 is not warranted as he had normal extension (zero degrees) as reported at the June 2011 examination. Also, prior to May 15, 2012, the weight of the evidence does not support a finding that the Veteran’s disability picture due to functional loss/limitations or flare-ups with limitation of motion is more nearly approximated by higher ratings. Considering the Deluca and Mitchell factors, and the evidence of record, the Board finds that the current rating already contemplates and compensates the Veteran for any functional loss due to pain affecting the knee, to include pain and limited motion. Deluca, 8 Vet. App. at 204-07. For example, as noted above, the medical reports reflect that he had pain and swelling. In light of the foregoing, the Board finds that increased ratings due to functional impairment would not be appropriate under the criteria for 38 C.F.R. §§ 4.40 and 4.45. In this regard, VA regulations state that the knee is considered a single major joint. 38 C.F.R. § 4.45. Prior to May 15, 2012, the Board finds that a separate rating under DC 5257 is warranted as the evidence shows that the Veteran has left knee instability based on his statements at the June 2011 examination reporting that his left knee gives out. See English v. Wilkie, 30 Vet. App. 347. 352-53 (2018) (finding that DC 5257 does not require objective medical evidence of lateral instability for a rating to be assigned and when weighing evidence to determine whether there is lateral instability, the Board cannot find objective medical evidence is automatically more probative than lay evidence). The Board acknowledges the medical testing showing normal stability. Notably, as discussed with the right knee, there are specific medical tests that are designed to reveal instability and laxity of the joints. These tests were administered by the medical professionals in this case and revealed no instability or laxity. However, when resolving reasonable doubt in favor of the Veteran, the Board finds that a rating of 10 percent is warranted prior to May 15, 2012 as he reported that his left knee has given out. A higher rating is not warranted as there is not competent evidence of instability (such as positive instability testing) or 3/5 weakness during this period on appeal as shown in the medical records and the examination reports (reflecting normal joint stability testing by a competent medical professional). Given the tests performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are afforded high probative value and given great weight. Nor does the Veteran assert that his left knee gives out frequently. This tends to weight against moderate subluxation or lateral instability. As such, a rating in excess of the now assigned 10 percent is not warranted under DC 5257 prior to May 15, 2012. The Board also finds that a separate rating of 20 percent under DC 5258 is warranted for the Veteran’s left knee prior to May 15, 2012. He has had a documented left knee meniscus tear. Additionally, the evidence shows locking, pain, and swelling, to include as noted on the above examination reports. Moreover, the Board finds the pain associated with the Veteran’s meniscus tear is separate than the pain associated with his painful range of motion, so this is not a pyramiding of benefits. 38 C.F.R. § 4.14. As such, a rating of 20 percent, but no higher, is warranted prior to May 15, 2012. As the Veteran is now receiving a 20 percent rating under DC 5258, a separate rating under 5259 would constitute impermissible pyramiding, and the Board finds a separate rating under DC 5259 is not warranted without discontinuing the rating under DC 5258. Here, DC 5258 provides the greater benefit. As a result, a rating under DC 5259 is not warranted. 38 C.F.R. § 4.14. Additionally, ratings under 5256 and 5262 are also not warranted as the Veteran does not have ankylosis or impairment of the tibia and fibula. Lastly, the Board finds that a rating of 60 percent is warranted from July 1, 2013 (the date the Veteran’s left knee temporary total rating expired) onward. The Board acknowledges that the Veteran’s DBQ/examinations found intermediate chronic residuals. However, he has had frequent pain, limited motion, repeat surgeries, and functional impairment that the Board finds is more approximated by a 60 percent rating for chronic residuals with severe painful motion or weakness when viewing the totality of the evidence. In this regard, the Veteran has asserted that following his surgeries he has had increased instability. As the Veteran has a rating of 60 percent for this period on appeal, the Board need not consider whether higher or separate ratings are warranted. In this regard, the “amputation rule” precludes the Board from assigning the Veteran a rating higher than 60 percent or any further separate ratings. The “amputation rule” provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. 38 C.F.R. § 4.68. A 60 percent rating is provided for an amputation of the thigh, above the knee, at the middle or lower third. 38 C.F.R. § 4.71, DCs 5162, 5163, 5164. Because the Veteran’s disability is in the knee, or below the middle third of the thigh, the amputation rule precludes a schedular evaluation in excess of 60 percent. TDIU 4. Entitlement to a TDIU. A total disability rating may be granted where the schedular rating is less than 100 percent and the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Generally, to be eligible for a TDIU, a percentage threshold must be met. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining unemployability for VA purposes, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). The sole fact that a veteran is unemployed or has difficulty securing employment is not enough, as a high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Entitlement to TDIU is based on an individual’s particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). The United States Court of Appeals for Veterans Claims (Court) has held that the term unable to secure and follow a substantially gainful occupation in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran’s ability to follow and secure employment. For the second component, attention must be given to: (a) the veteran’s history, education, skill and training, (b) the veteran’s physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). The Court has stated that “a veteran can establish marginal employment either by demonstrating an income less than the poverty threshold established by the U.S. Census Bureau or by the facts of his particular case.” Ortiz-Valles v. McDonald, 28 Vet. App. 6, 71 (2016). Regardless of the method, “if the evidence or facts reflect that a veteran is capable only of marginal employment, he [or she] is incapable of securing or following a substantially gainful occupation and is therefore entitled to [TDIU] if his service-connected disabilities are the cause of that incapability.” Id. In making a determination, the Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran’s service-connected disabilities include left knee disability rated at 60 percent (when not receiving a temporary total rating), adjustment disorder rated at 50 percent, lumbar disability rated at 20 percent, and other knee and radiculopathy disabilities. He received a 100 percent rating from May 15, 2012 until July 1, 2013. His right knee now includes ratings of 20 percent, 20 percent, 10 percent, and 10 percent from February 11, 2011 onward. He has a combined rating of 70 percent with a single disability rated at 40 percent or higher from February 11, 2011 onward. Therefore, his evaluation for compensation due to his service-connected disabilities met the percentage rating standards for TDIU under 38 C.F.R. § 4.16(a) from February 11, 2011 onward. The Veteran’s VA Form 21-8940 reported that he last worked fulltime in November 2012. He previously worked as a facilities manager, and he has some college education. His submitted form states he last worked 40 hours per week until December 2012. However, an exact date is not provided. His social security records state that he last worked on November 5, 2012. As he stated that he last worked fulltime in November 2012, the Board will resolve reasonable doubt in favor of the Veteran. Therefore, the Board finds that he has been unemployed since November 5, 2012. In this case, the record reflects that the Veteran suffered from service-connected disabilities which hindered his ability to maintain gainful employment from November 5, 2012 (the date of his last employment) onward. The Veteran’s service-connected orthopedic disabilities hinder any physically intensive position as the Veteran is unable to stand or walk for extended periods. He has difficulty climbing stairs. He is unable to lift or carry objects due to his service-connected back disability. Concerning sedentary employment, the Veteran’s service-connected psychiatric disorder reports occupational and social impairment with reduced reliability and productivity. His symptoms include depressed mood, anxiety, panic attacks that occur weekly or less, chronic sleep impairment, and disturbances of motivation and mood. The Veteran has frequently required time to recover from his multitude of surgeries for his knees and back. Combined with his acquired psychiatric disorder, and his frequent need to miss work because of his orthopedic disabilities, the Veteran would be unable to maintain gainful employment in a sedentary position. (Continued on the next page)   As such, when resolving reasonable doubt in favor of the Veteran, the Board finds that his service-connected disabilities prevented him from being able to secure or follow a substantially gainful occupation from November 5, 2012 onward. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Morales, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.