Citation Nr: 21014022 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-43 266 DATE: March 11, 2021 ORDER A disability rating in excess of 10 percent for right meniscal tear with posttraumatic changes of the lateral tibial plateau (right meniscus disorder) is denied. A disability rating in excess of 10 percent for right ankle osteochondral lesion (right ankle disorder) is denied. A total disability rating based upon individual employability due to service-connected disabilities (TDIU) prior to November 22, 2011 is denied. FINDINGS OF FACT 1. The Veteran’s service connected right meniscus disorder is not shown to have been manifested compensable limitations of flexion or extension, recurrent subluxation or lateral instability, dislocated or symptomatic post-removal semilunar cartilage, genu recurvatum, or malunion of tibia or fibula, and is not shown to have been ankylosed. 2. At worst, the Veteran’s right ankle disorder results in moderate limited right ankle motion; marked limitation of motion, ankylosis, malunion, or astragalectomy has not been shown. 3. Prior to November 22, 2011, the evidence of record does not show that the Veteran was unable to secure or follow substantially gainful employment as a result of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for a right meniscus disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5056-63. 2. The criteria for a disability rating in excess of 10 percent for a right ankle disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5270-74. 3. Prior to November 22, 2011, the criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 2005 to October 2006. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2018, the matters were remanded for additional development. In November 2020, the RO granted service connection for a bladder disability and granted special monthly compensation based on aid and attendance. This represents a complete grant of her appeal in regard to these claims. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). These issues are no longer before the Board.   Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. Deluca v. Brown, 8 Vet. App. 202 (1995). 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 enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by 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.  38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202, 206-8 (1995). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint.  38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable Diagnostic Code. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain and numbness in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. See Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). Musculoskeletal VA examinations, to be adequate, must address particular issues when are where that are practicable and medically possible to include active and passive motion; weight bearing and non-weight bearing; range of motion of an opposing joint; and findings as to loss of motion during flare-ups. See Correia v. McDonald, 28 Vet. App. (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). Right Meniscus Disorder The Veteran asserts that she is entitled to a higher rating for her right meniscus disorder. Disabilities of the knee and leg are generally rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 through 5263. The RO has rated the Veteran’s right meniscus disorder under Diagnostic Code 5257-5010, which evaluates arthritis due to trauma under Diagnostic Code 5003, which in turn evaluates disabilities based on the degree of limitation of motion under the appropriate Diagnostic Codes. 38 C.F.R. § 4.71a. If the disability is noncompensable under the appropriate Diagnostic Code for the joint involved, a 10 percent rating will be for application for such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, The rating criteria pertaining to Diagnostic Code 5010 was revised effective February 7, 2021. Posttraumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under an affected joint. If there are two or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Prior to February 7, 2021, under Diagnostic Code 5257 for recurrent subluxation or lateral instability, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability of the knee; a 20 percent rating is warranted for medical evidence showing that the recurrent subluxation or lateral instability can be characterized as moderate; and a 30 percent rating is warranted for recurrent subluxation or lateral instability which medical evidence discloses can be characterized as severe. The rating criteria pertaining to Diagnostic Code 5257 was revised effective February 7, 2021. A 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker; a 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker; and a 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Under Diagnostic Code 5260 for limitation of flexion, a noncompensable rating is assigned for flexion limited to 60 degrees; a 10 percent rating is assigned for flexion limited to 45 degrees; a 20 percent rating is assigned for flexion limited to 30 degrees; and a 30 percent rating is assigned for flexion is limited to 15 degrees. Under Diagnostic Code 5261 for limitation of extension, a noncompensable rating is assigned for extension limited to 5 degrees; a 10 percent rating is assigned for extension limited to 10 degrees; a 20 percent rating is assigned for extension limited to 20 degrees; a 30 percent rating is assigned for extension is limited to 20 degrees; a 40 percent rating is assigned for extension is limited to 30 degrees; and a 50 percent rating is assigned for extension is limited to 15 degrees. Separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. Diagnostic Code 5256 pertains to ratings for ankylosis of a knee. Diagnostic Code 5262 applies to ratings for impairment of the tibia and fibula. Diagnostic Code 5258 applies to a dislocated semilunar cartilage. Diagnostic Code 5259 applies to removal of the semilunar cartilage. Diagnostic Code 5263 applies to rating genu recurvatum. The rating criteria pertaining to Diagnostic Code 5262 were revised effective February 7, 2021. However, as those Codes are not applicable in this matter, and the February 7, 2021 effective revision does not require further discussion. In July 2013, the Veteran was afforded a VA examination. A clinician reviewed the claims file, considered the Veteran’s subjective accounts, and conducted an examination. The Veteran reported flare-ups resulting in difficulty walking. On examination, the Veteran demonstrated right knee flexion to 100 degrees with pain and normal extension. Repetitive use testing resulted in no additional limitation in range of motion. The clinician indicated that the Veteran had functional loss that included less movement than normal and pain on movement. The Veteran retained 4/5 right knee strength. The clinician indicated that the Veteran did not have joint instability, recurrent patellar subluxation/dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The clinician reported that the Veteran had undergone a meniscectomy, but did not have frequent episodes of joint locking, pain, or effusion. In April 2014, the Veteran was noted to use a wheelchair due to her history of pulmonary embolism which caused fatigue with ambulation. In an October 2014 VA Form 21-2680 (“Housebound Status or Permanent Need for Regular Aid and Attendance” Examination), a physician noted that the Veteran, among other disabilities, suffered from morbid obesity and bilateral knee pain. The physician also noted that the Veteran was wheelchair-bound and unable to ambulate without assistance. The physician also conveyed that that Veteran was prone to falls and had an unsteady gait. In June 2016, the Veteran was afforded a VA examination. A clinician reviewed the claims file, considered the Veteran’s subjective accounts, and conducted an examination. The Veteran reported flare-ups that occurred daily and lasted for hours. The Veteran reported having functional impairment of a loss of standing and ambulation tolerance. On examination, the Veteran demonstrated right knee flexion to 90 degrees and extension to -10 degrees. The clinician noted pain and on flexion and extension. There was evidence of pain on weight-bearing. There was objective evidence of pain or tenderness on palpation of the right joint line or associated soft tissue. Specifically, the clinician located this tenderness or pain at the right peripatellar region. There was no evidence of crepitus. Repetitive use testing resulted in no additional limitation in range of motion. The clinician noted that pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups during flare-ups or when the right knee is used repeatedly over a period of time. However, this clinician did not quantify these losses in ranges of motion. As a rationale for this lack of quantification, the clinician opined that it is not feasible to provide a quantification of additional limitations here, including range of motion loss. For such to be discerned, examination must take place during a flare-up. The Veteran retained 4/5 right knee strength with no muscle atrophy. The clinician indicated that the Veteran did not have joint instability, recurrent patellar subluxation/dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The clinician reported that the Veteran had undergone meniscal repair surgery and had frequent episodes of joint locking and pain. In September 2020, the Veteran was afforded a VA examination. A clinician reviewed the claims file, considered the Veteran’s subjective accounts, and conducted an examination. The Veteran reported flare-ups that did not allow her to stand for any period of time and prevented her from climbing stairs. She reported having functional loss. On examination, the Veteran demonstrated right knee flexion to 120 degrees and normal extension to 0 degrees, both with pain. The clinician indicated that knee pain and muscle stiffness in range of motion contributed to a functional loss. The clinician reported localized tenderness or pain of a moderate nature existed at the lateral and medical aspect of the right knee. The clinician indicated that there was no pain on weight bearing or non-weight bearing. The clinician indicated that there was no evidence of crepitus. Repetitive use testing resulted in no additional limitation in range of motion. The clinician indicated that pain, weakness, and incoordination caused functional loss with repetitive use over a period of time and during flare-ups but did not result in any additional limitation of range of motion. The clinician indicated that the Veteran had additional factors contributing to disability that included weakened movement, swelling, interference with sitting, and interference with standing. The Veteran retained normal 5/5 right knee strength with no muscle atrophy. The clinician indicated that the Veteran did not have ankylosis, joint instability, recurrent patellar subluxation/dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The clinician reported that the Veteran had a meniscal tear that did not result in frequent episodes of joint locking, pain, or effusion. The Veteran believes that her right meniscus disorder is more severe than that contemplated by a 10 percent disability rating. Indeed, the Veteran is competent to report that which is discernable, such as right knee pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran lacks the medical knowledge and orthopedic expertise to assess the clinical severity of a right meniscus disorder. See 38 C.F.R. § 3.159(a)(1). As such, this lay evidence does not constitute competent medical evidence. The current 10 percent rating under Diagnostic Code 5257-5010 is assigned for the Veteran’s right knee pain, and is the maximum rating available for pain without a showing of compensable functional limitations. The pertinent evidence is summarized above. No examination during the evaluation period found limitations of flexion or extension that would be compensable under Diagnostic Codes 5260 or 5261 criteria. Consequently, a rating in excess of 10 percent under those Diagnostic Codes is not warranted. Likewise, no examination found ankylosis, subluxation or instability, genu recurvatum, tibia or fibula impairment, or dislocated or symptomatic post-removal semilunar cartilage. Consequently, separate compensable ratings under Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, 5262, or 5263 are not warranted. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, the minimal compensable rating for the left knee is already assigned, and the analysis must turn to whether functional loss warranting a higher than 10 percent rating is reasonably shown. The most recent September 2020 VA clinician indicated that pain, weakness, and incoordination caused functional loss with repetitive use over a period of time and during flare-ups but did not result in any additional limitation of range of motion. The Veteran’s treatment records likewise do not show functional limitations warranting compensable ratings. Consequently, an increased rating based on functional limitations due these factors is not warranted. While the Veteran has been shown to experience right knee pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but of itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011). Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” to constitute functional loss warranting an increased rating. Id. at 43; see 38 C.F.R. § 4.40. The Board has no reason to question that the Veteran’s right meniscus disorder results in the functional limitations she has reported, such as difficulty walking, loss of standing and ambulation tolerance, and inability to climb stairs. Such limitations are contemplated by the criteria for the 10 percent rating that is assigned. The Board also finds that the right knee symptoms and impairment shown do not include any that are not adequately addressed by the schedular rating criteria. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim for a rating higher than 10 percent for a right meniscus disorder. Accordingly, the appeal in this matter must be denied. Right Ankle Disorder The Veteran asserts that she is entitled to a higher rating for her right ankle disorder. Disabilities of the ankle are generally rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5270 through 5274. The RO has rated the Veteran’s right ankle disorder under Diagnostic Code 5271. Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected ankle disorders, including Diagnostic Code 5270 (ankylosis of the ankle); Diagnostic Code 5272 (ankylosis of subastragalar or tarsal joint); Diagnostic Code 5273 (malunion of os calcis or astragalus); and Diagnostic Code 5274 (astragalectomy). However, the Veteran’s right ankle disorder is not shown to have not been manifested by ankylosis, malunion of os calcis or astragalus, or astragalectomy. Therefore, these Diagnostic Codes are not for application here. Diagnostic Code 5271 (limited motion of ankle) provides a 10 percent rating for moderate limited ankle motion and a 20 percent rating for marked limited ankle motion. The rating criteria pertaining to Diagnostic Code 5271 was revised effective February 7, 2021. A moderate ankle limitation of motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) is assigned a 10 percent rating and a marked ankle limitation of motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) is assigned a 20 percent rating. Normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. In July 2013, the Veteran was afforded a VA examination. A clinician reviewed the claims file, considered the Veteran’s subjective accounts, and conducted an examination. The Veteran reported flare-ups that resulted in difficulty with prolonged walking. On examination, the Veteran demonstrated right ankle plantar flexion to 30 degrees and right ankle dorsiflexion to 15 degrees. Objective evidence of painful motion coincided with these end-degree points. Repetitive use testing resulted in no additional limitation in range of motion. The Veteran had localized tenderness or pain on palpation of the right ankle joint line or associated soft tissue. She retained normal 5/5 right ankle strength. The clinician indicated that there was no evidence of joint instability or ankylosis. In June 2016, the Veteran was afforded a VA examination. A clinician reviewed the claims file, considered the Veteran’s subjective accounts, and conducted an examination. The Veteran denied having flare-ups. She reported having functional loss or impairment resulting in her being unable to walk distances as she could in the past. On examination, the Veteran demonstrated right ankle plantar flexion to 40 degrees and right ankle dorsiflexion to 15 degrees with pain. The clinician indicated that range of motion did not contribute to functional loss. The clinician indicated that there was pain with weight-bearing. The clinician indicated that there was localized tenderness at the anterior aspect of the mortise. The clinician indicated that there was no objective evidence of crepitus. Repetitive use testing resulted in no additional limitation in range of motion. She had reduced 4/5 right ankle strength with no muscle atrophy. The clinician indicated there was no evidence of ankylosis. The clinician reported that right ankle instability or dislocation was suspected. In September 2020, the Veteran was afforded a VA examination. A clinician reviewed the claims file, considered the Veteran’s subjective accounts, and conducted an examination. The Veteran endorsed flare-ups resulting in an inability to move her right ankle. The Veteran reported that they were no precipitating factors for these “very frequent” flare-ups. She reported having functional loss that resulted in her being unable to drive or walk long distances. She also reported that her ankle locked up while she worked. On examination, the Veteran demonstrated right ankle plantar flexion was 30 degrees and dorsiflexion to 15 degrees, both with pain. The clinician indicated that range of motion did not contribute to functional loss. The clinician indicated there was localized tenderness of moderate severity at the right ankle medial and lateral aspect. The clinician indicated that there was no evidence of pain with weight bearing, but there was evidence of pain with non-weight bearing. The clinician indicated that there was no evidence of crepitus. The Veteran was not able to perform repetitive use testing due to right ankle pain incurred upon initial range of motion testing. The clinician noted that pain and weakness significantly limited functional ability with repeated use over time. However, there were no losses whatsoever in range of motion in plantar flexion or dorsiflexion. The clinician indicated that the Veteran had additional factors contributing to disability that included swelling, instability of station, interference with sitting, and interference with standing. The Veteran also added that episodes of right ankle strain were frequent; and she experienced dull ache and locking. She had reduced 4/5 right ankle strength with no muscle atrophy. The clinician indicated that there was no evidence of ankylosis. The clinician indicated that right ankle instability or dislocation was suspected. The Veteran believes that right ankle disorder is more severe than that contemplated by a 10 percent disability rating. Indeed, the Veteran is competent to report that which is discernable, such as right ankle pain. See Jandreau, 492 F. 3d 1372. However, the Veteran lacks the medical knowledge and orthopedic expertise to assess the clinical severity of a right ankle disorder. See 38 C.F.R. § 3.159(a)(1). As such, this lay evidence does not constitute competent medical evidence. As noted above, to receive a higher disability rating there would need to be a showing of marked limited ankle motion under both versions of Diagnostic Code 5271. Such is not disclosed in the evidence of record. At worst, right ankle dorsiflexion was to zero to 15 degrees and right ankle plantar flexion was zero to 30 degrees. As noted above, normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. The Board finds that the limitation of motion, pain requiring limitation in walking endurance; lack of driving; and locking and pressure is best assessed as moderate indicative of a 10 percent disability rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim for a rating higher than 10 percent for a right ankle disorder. Accordingly, the appeal in this matter must be denied. Entitlement to a TDIU Prior to November 22, 2011 In order to establish entitlement to a TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. §§ 1155; 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). Consideration may be given to the veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. §§ 4.16(a), “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. § § 4.16(a) The regulatory scheme for a TDIU provides both objective and subjective criteria. Hatlestad, supra; VAOPGCPREC 75-91 (Dec. 27, 1991) 57 Fed. Reg. 2317 (1992). The objective criteria, set forth at 38 C.F.R. § § 3.340(a)(2), provide for a total rating when there is a single disability or a combination of disabilities that results in a 100 percent schedular evaluation. Subjective criteria, set forth at 38 C.F.R. §§ 4.16(a), provide for a TDIU when, due to service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). As of November 22, 2011, the Veteran had the following service-connected disabilities: 1) acquired psychiatric disorder at 10 percent, effective from December 12, 2006; 2) lumbar myositis at 10 percent, effective from October 25, 2006; 3) left lower extremity radiculopathy at 10 percent, effective from October 25, 2006; 4) right lower extremity radiculopathy at 10 percent, effective from October 25, 2006; 5) right meniscus disorder at 10 percent, effective from October 25, 2006; and 6) right ankle disorder at 10 percent, effective from October 25, 2006. Thus, the Veteran did not meet the schedular requirements for entitlement to a TDIU prior to November 22, 2011. See 38 C.F.R. §§ 4.16(a). Nevertheless, the Board will assess whether entitlement to a TDIU was warranted based on an extraschedular basis. Upon a November 2007 VA mental disorders examination, a VA clinician opined that acquired psychiatric disorder was best summarized as productive of occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although functioning satisfactorily, with normal routine behavior, self-care and conversation. VA behavioral nursing notes from October 2011 disclose that the Veteran’s thought process was coherent; her memory was intact; her judgment was good; and her insight was good. Moreover, there were no deviations in the Veteran’s behavior and psychiatric assessments. The Veteran has indicated that she has completed 4 years of college and has been employed by a department of education in a clerical capacity. During active duty service, the Veteran’s military occupation specialty (MOS) was that of an aviation resource management helper. Otherwise, the Veteran has had professional experiences as a line worker, an office clerk, a store clerk, and a server in the hospitality industry. The evidence of record from this period of time also shows that the Veteran drives. While the Veteran asserts that her service-connected disabilities rendered her unable to obtain or retain employment consistent with her education and experience prior to November 22, 2011, the evidence of record shows that the Veteran has a college education and a host of professional experiences in the clerical, retail, and hospitality industries. Collectively, the Board finds that this combination of education and work experiences, prior to November 22, 2011, were more-than-sufficient for the Veteran to obtain and maintain substantial employment considering her specific education and specific work in several professions. See Withers v. Wilkie, 30 Vet. App. 139 (2018). The Board recognizes that prior to November 22, 2011, the Veteran experienced intermittent periods of inability to perform occupational tasks attributable to her acquired psychiatric disorder. And, the record does disclose that the Veteran experienced periodic difficulties ambulating due to her other service-connected disabilities prior to November 22, 2011. However, these limitations did not rise to the level of rendering the Veteran totally impaired physically, occupationally, or socially. Indeed, the evidence of record does not reveal that any one of her service-connected disabilities, or the entirety of her service-connected disabilities, precluded her from obtaining and maintaining gainful employment prior to November 22, 2011. Prior to November 22, 2011, the Veteran’s job skills would have lent themselves to employment in any clerical capacity, office situations, and hospitality work—as a server or a “behind-the-scene” helper capacity. Here, the Board notes that many employers, as early as November 2011, offered accommodations pursuant to the ADA, to allow for downtime due to disabilities. In the Veteran’s case, it would have been feasible for an employer to provide breaks in quiet settings where the Veteran could collect herself during periods of intermittent distraction and bouts of symptoms associated with her service-connected disabilities. As already noted, the Veteran did not meet the schedular requirements for entitlement to a TDIU prior to November 22, 2011. And, the evidence of record fails to reveal that exceptional circumstances existed prior to November 22, 2011 which would warrant consideration under 38 C.F.R. § 4.16(b). The rating schedule was created as a guide to evaluating disabilities resulting from all types of diseases and injuries encountered, and the percentage ratings that are assigned represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Accordingly, a TDIU on an extraschedular basis is denied. Timothy Berryman Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. J. Komins, 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.