Citation Nr: 21023377 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-06 604 DATE: April 20, 2021 ORDER A rating in excess of 10 percent for osteoarthritis with chondromalacia patella of the right knee is denied. A rating in excess of 10 percent for osteoarthritis with chondromalacia patella of the left knee is denied. As of April 23, 2015, a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted, subject to the laws and regulations governing the payment of monetary awards. REMANDED Entitlement to a TDIU on an extra-schedular basis prior to April 23, 2015, is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s right knee osteoarthritis with chondromalacia patella is manifested by objective evidence of arthritis and painful motion, with flexion limited to, at most, 65 degrees, and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination or as a result of repetitive motion and/or flare-ups, without ankylosis, recurrent subluxation or lateral instability, dislocation of semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 2. For the entire appeal period, the Veteran’s left knee osteoarthritis with chondromalacia patella is manifested by objective evidence of arthritis and painful motion, with flexion limited to, at most, 50 degrees, and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination or as a result of repetitive motion and/or flare-ups, without ankylosis, recurrent subluxation or lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 3. Resolving all doubt in the Veteran’s favor, his service-connected disabilities render him unable to secure or follow a substantially gainful occupation consistent with his education and work history as of April 23, 2015. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for osteoarthritis with chondromalacia patella of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5010-5260. 2. The criteria for a rating in excess of 10 percent for osteoarthritis with chondromalacia patella of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5010-5260. 3. As of April 23, 2015, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1970 to June 1974. He died in August 2018 and the appellant is his surviving spouse, who was accepted as a substitute claimant for the purpose of processing this appeal to its completion in October 2019. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In November 2017, the Veteran and the appellant testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In July 2018, the Board remanded the appeal for additional development and it now returns for further appellate review. 1. Entitlement to a rating in excess of 10 percent for osteoarthritis with chondromalacia patella of the right knee. 2. Entitlement to a rating in excess of 10 percent for osteoarthritis with chondromalacia patella of the left knee. 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 veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. 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. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The appeal period before the Board stems from the Veteran’s August 15, 2013, claim for a TDIU, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). His right and left knee disabilities have been rated as 10 percent disabling for the entire appeal period pursuant to DC 5010-5260. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria as of February 7, 2021, applying the criteria that is more favorable to him. The Board notes that DC 5010 was amended; however, DC 5260 was not. In this regard, prior to the regulatory change, DC 5010 pertains to traumatic arthritis and is evaluated as degenerative arthritis. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. DC 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. In the absence of limitation of motion, DC 5003 provides for a 10 percent rating with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating under DC 5003 requires involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. For the purpose of rating disability from arthritis, the knee is considered a major joint. See 38 C.F.R. § 4.45. As of February 7, 2021, under the amended criteria, DC 5010 still pertains to post-traumatic arthritis, but such is now rated as limitation of motion, dislocation, or other specified instability under the affected joint rather than degenerative arthritis. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Thus, in practice, both versions of DC 5010 ultimately provide that arthritis of an affected joint will be rated based on limitation of motion. In this regard, normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, DCs 5260 and 5261. DC 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. DC 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where extension is limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. VA’s General Counsel has stated that separate ratings under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 2004). Based upon a review of the record, the Board finds that ratings in excess of 10 percent for the Veteran’s right and left knee disabilities are not warranted. In this regard, at an April 2014 VA examination, the Veteran reported that he had severe bilateral knee pain, which resulted in difficulty ambulating, and his knees were locking up after about a half an hour of sitting. He also stated that, if he fell on his knees, he could not get back up without help. The Veteran also reported that he had flare-ups that were brought on with prolonged sitting, standing, and walking. Active range of motion testing showed right knee flexion to 70 degrees with pain and extension to zero degrees. Left knee flexion was to 50 degrees with pain and extension to zero degrees. After repetitive-use testing with 3 repetitions, the Veteran had right knee flexion to 65 degrees with extension to zero degrees, and his left knee flexion remained at 50 degrees with extension to zero degrees. The examiner also found his knee joint pain could significantly limit functional ability during flare-ups or when the joint was repeatedly used over a period of time, but she was unable to express the degrees of additional range of motion loss due to pain on use or during flare-ups as to do so would be merely speculation. The Veteran had bilateral knee tenderness or pain to palpation for joint line or soft tissues. His muscle strength tests revealed that both of his knee had active movement against some resistance, and he had normal joint stability tests. The examiner noted there was no evidence or history of recurrent subluxation, lateral instability, recurrent patellar subluxation or dislocation, impairment of the tibia and/or fibula, meniscal conditions, or surgery. The Veteran regularly used a wheelchair and occasionally used a cane as assistive devices. Subsequent treatment records reveal that, in July 2014, the Veteran heard a popping noise come from his right knee and had pain that was made worse by walking. He had full range of motion of his right knee with crepitus, and the clinician was unable to assess for joint laxity or subluxation due to the Veteran’s body habitus. Right knee X-rays revealed that there was no fracture or dislocation and overall had a similar appearance to March 2012. In October 2014, the clinician noted that a magnetic resonance imaging (MRI) showed the Veteran’s ligaments to be intact, but he had severe arthritis and his medial meniscus (cartilage) was severely damaged. She also noted that, while she was not an orthopedist, she did not see how it could be repaired. She further noted that she thought the only reason surgery would be indicated if the Veteran got locking of the knee or if he was getting a knee replacement, but he would need to lose weight beforehand. Another October 2014 VA treatment record noted that the Veteran had bilateral passive flexion to 90 degrees and full extension. In July 2015, the Veteran was having problems with his left knee, which prevented him from standing for significant periods of time and would give out on him at times, but did not lock. The clinician noted that, while there was tenderness medially, there was no left knee erythema, induration, or effusion. However, the Veteran’s obesity limited a further examination as he could not lay on the table for range of motion testing, but he did flex to at least 90 degrees while sitting. There was also no appreciable ligamentous laxity, but the examination was severely limited. Subsequent treatment records continued to note that the Veteran had bilateral knee osteoarthritis with severe degenerative changes, and weight loss was encouraged. See April 2016, October 2016, April 2017, October 2017, November 2017, December 2017, and March 2018 VA treatment records. During the November 2017 Board hearing, the Veteran testified that he experienced locking in both of knees, worse on the left side, he had fallen due to his knees giving way, and he believed that his knees were unstable. Additionally, he noted that he constantly used his wheelchair unless he was crawling up the stairs. Accordingly, in July 2018, the Board remanded the Veteran’s appeal to afford him another VA examination to determine the current nature and severity of his bilateral knee disability. Regrettably, in August 2018, the Veteran passed away before such could be completed. Nonetheless, in July 2020, an examiner offered opinions regarding the severity of the Veteran’s bilateral knee disability based on a review of the record. Specifically, the examiner found that the Veteran’s bilateral knee range of motion noted on initial examination would likely be similar to range of motion during flare-ups, repetitive use, pain on motion, weakness, excess fatigability and/or incoordination. She additionally noted that review of evidence indicated that the Veteran was still able to ambulate and thus, any further reduction of range of motion of the bilateral knee during flare-ups, repetitive use, pain on motion, weakness, excess fatigability and/or incoordination would be incompatible with locomotion. Therefore, she concluded that the Veteran right knee flexion likely remained at 70 degrees and extension to 0 degrees and left knee flexion likely remained at 50 degrees with extension to 0 degrees. With regard to Correia, the examiner found that the Veteran’s initial range of motion noted on examination more than likely would be similar to findings on both active and passive range of motion, and weight and non-weight bearing. She also noted that range of motion on initial examination was already severe enough to indicate significant pain on active and passive motion, and weight and non-weight bearing, and further reduction of range of motion would be incompatible with locomotion as the Veteran was still able to ambulate on his own. Additionally, the examiner determined that a review of the evidence showed no information pertaining to objective findings or treatment indicating the Veteran had a dislocated or removed semilunar cartilage of both knees, and his current bilateral knee diagnosis was unlikely to result in recurrent subluxation or lateral instability. Furthermore, she noted that the Veteran was able to ambulate for short periods of time and was able to walk with assistance, but was unable to bear weight for more than 30 minutes without assistance. The Veteran also needed assistance to perform instrumental activities of daily living and activities of daily living. Thus, based upon the foregoing, the Board finds that the Veteran’s right and left knee disabilities do not warrant ratings in excess of 10 percent under DC 5260. In this regard, the record does not show that his range of motion was limited to the extent necessary to warrant a higher rating under such DC. Specifically, the evidence demonstrates that the Veteran’s right and left knee flexion is limited to, at most, 65 degrees and 50 degrees, respectively, and does not result in additional functional loss more nearly approximating limitation of flexion to 30 degrees, which is necessary for the assignment of a 20 percent rating under DC 5260, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Moreover, a higher or separate rating is not warranted pursuant to DC 5261 as the evidence of record shows that the Veteran’s right and left knee extension remained full and does not result in additional functional loss more nearly approximating limitation of extension to 5 degrees, which is required for a separate noncompensable rating under such DC, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Further, the Veteran is in receipt of the minimal compensable rating under DC 5003 for painful limitation of motion due to arthritis that is not otherwise compensable, and such only involves a single major joint. Thus, ratings in excess of 10 percent for the Veteran’s right and left knee disabilities pursuant to DC 5003 is not warranted. In light of the Veteran’s reports of laxity and giving way in his right and left knees, the Board has considered whether a higher or separate rating is warranted under DC 5257, which provides ratings for recurrent subluxation and lateral instability. VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). In this regard, the Court has held that DC 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. English v. Wilkie, 30 Vet. App. 347 (2018). However, while the Veteran is competent to describe feelings of laxity and giving way, he is not competent as a lay person to diagnose lateral instability or recurrent subluxation, or relate such feelings to a specific diagnosis, as such requires the administration and interpretation of specialized testing of the ligaments and patella, respectively. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Rather, the April 2014 and July 2020 VA examiners, who have the training to administer and interpret ligament and patellar testing, found that there was no laxity or subluxation in the right and/or left knee. Consequently, the Board affords greater probative weight to the VA examiners’ conclusions than the Veteran’s generalized statements. See, e.g., Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, a higher or separate rating under DC 5257 is not warranted. Further, while an October 2014 MRI reflected that the Veteran’s medial meniscus (cartilage) was severely damaged in the right knee, such was not noted to result in frequent episodes of locking, pain, and effusion into the joint. Further, there is no indication of a meniscal condition affecting his left knee. Thus, a higher or separate rating under DC 5258 is not warranted. Finally, as the evidence does not show ankylosis, removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum, higher or separate ratings under DCs 5256, 5259, 5262, and 5263, respectively, are not warranted. In reaching its conclusions in the instant case, the Board acknowledges the Veteran’s belief that his right and left knee disabilities are more severe than as reflected by the currently assigned disability ratings. However, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, supra. Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of his right and left knee disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of such disabilities. The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected right and left knee disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disabilities are not warranted. Further, neither the Veteran nor the appellant have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). In sum, the Board finds that ratings in excess of 10 percent for the Veteran’s right and left knee disabilities are not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the instant claims, such doctrine is inapplicable and they must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a TDIU as of April 23, 2015. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service (Director) for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran’s master’s degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, 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). In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court held that the initial extra-schedular referral decision under § 4.16(b) should address whether there is “sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities.” The Court also defined the term “unable to secure and follow a substantially gainful occupation” in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means 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. The non-economic component includes consideration of the veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. While the appeal period stems from August 15, 2013, the date of receipt of his TDIU claim, the Veteran only meets the schedular threshold for consideration of a TDIU as of April 23, 2015. Specifically, as of such date, service connection was in effect for unspecified depressive disorder, rated as 70 percent disabling; osteoarthritis with chondromalacia patella of the right and left knee, both rated as 10 percent disabling; lumbar disc disease, rated as 10 percent disabling; and bilateral hearing loss, rated as noncompensably disabling, which results in combined rating of 90 percent. The appeal period prior to April 23, 2015, when the Veteran does not meet the schedular threshold for consideration of a TDIU will be addressed in the Remand section below. In this regard, the record reflects that the Veteran last worked full-time in June 2008, previously worked as a driver and supervisor, and completed high school. Specifically, in his July 2016 application for a TDIU (VA Form 21-8940), he reported that he last worked for Renzenberger Inc. as a driver and supervisor from April 2005 to June 2008, and had completed high school with no further education. The Veteran’s employer, Renzenberger Inc., also confirmed that he worked there from April 2005 to June 2008, as a driver and transported crew members. It was noted that the Veteran resigned due to medical reasons. Thus, he has not been employed in a gainful occupation at any point pertinent to the appeal period. As such, the remaining inquiry is whether the Veteran is unable to secure or follow a substantially gainful occupation consistent with his education and work history due to his service-connected disabilities for the appeal period beginning April 23, 2015. As an initial matter, the Board notes that, while the Veteran was substantially physically impaired due to left leg cellulitis, he was not service-connected for such disorder and, thus, it may not be considered in adjudicating his claim for a TDIU. With respect to the functional impairment associated with his service-connected disabilities, at an April 2014 VA examination, he reported that he worked previously as a transport coordinator, driving in a seated position all the time. He had to be drug free for the job but was taking hydrocodone for his pain, which made him ineligible for the job. With regard to physical constraints, the Veteran reported that he could only stand for 5 to 6 minutes before he had to sit down and rest due to pain, and could only walk for less than 100 feet with a cane before he would have to sit down and rest. He also stated that he needed to use a wheelchair or cart for any longer distances. The Veteran indicated that he could lift 50 to 60 pounds, but it was nearly impossible for him to go up and down stairs as he had to literally crawl up them. He further stated that he was unable to do any bending, kneeling, or crawling as he would not be able to get off the ground without extreme assistance. Regarding sedentary limitations, the Veteran stated he could only sit half an hour before he would have to stand up and move around. He also stated that he could not work an 8 to 10 hour day because of chronic pain issues and the need to take narcotic medications, which could affect his concentration. The Veteran also reported that he did not have any significant computer skills and could not do a desk job due to his limited mobility and chronic pain issues. In July 2015 and October 2015, the Veteran underwent VA psychiatric examinations. At such time, the Veteran reported that he retired in 2008 due to physical health problems of leg cellulitis and being “unable to continue in job” because of medications as he was taking pain killers. He reported that, while he was employed, he experienced difficulty following instruction, poor social interaction, and occasionally had difficulty completing tasks at work due to mental health symptoms. The examiner determined that, if the Veteran would attempt to return to work, he would be expected to experience a moderate to severe level of occupational impairment in both physical and sedentary employment due to his mental health symptoms. In July 2016, a letter was received form Dr. M.C., who noted that he considered the Veteran unable to maintain or sustain gainful employment due to his service-connected disabilities of intervertebral disk syndrome and bilateral knee osteoarthritis/limitation of range of motion as he has not made any significant improvement since 2013. In August 2016, the Veteran was afforded a VA back examination. At such time, he reported that he was now in a wheelchair all the time due to low back pain and weakness and pain in his knees. The examiner noted that the Veteran’s back disability impacted his ability to work. Specifically, while he was not limited in sitting or reaching, fingering, handling, and feeling, he was only able to stand for 2 to 3 minutes and was not able to walk more than 12 steps. In January 2018, the Veteran underwent another VA psychiatric examination. He reported that he had little motivation to be in work setting and preferred to socially isolate himself. His symptoms included difficulty in adapting to stressful circumstances, including work or a worklike setting, and an inability to establish and maintain effective relationships. Furthermore, the July 2020 examiner opined that, due to the Veteran’s bilateral knee disability, he was only able to ambulate for short periods of time, walk with assistance, and was unable to bear weight for more than 30 minutes without assistance. She also noted that the Veteran needed assistance to perform instrumental activities of daily living and activities of daily living. Based on a review of the foregoing evidence, the Board concludes that the Veteran is entitled to a TDIU as of April 23, 2015. In this regard, the record reflects that his service-connected disabilities hinder his ability to work in a physical and sedentary environment as he has problems with standing, sitting, and other physical activities for long periods of time, and his psychiatric disorder affected his ability to function in a work setting. Therefore, resolving all doubt in the Veteran’s favor, the Board finds that the requirements for a TDIU are met as of April 23, 2015. REASONS FOR REMAND 4. Entitlement to a TDIU on an extra-schedular basis prior to April 23, 2015. As indicated previously, the Veteran does not meet the schedular threshold for a TDIU for the appeal period stemming from his August 15, 2013, claim, prior to April 23, 2015. Specifically, for such period, service connection was in effect for unspecified depressive disorder, rated as 10 percent; osteoarthritis with chondromalacia patella of the right and left knee, each rated as 10 percent; lumbar disc disease, rated as 40 percent; and bilateral hearing loss, rated as noncompensable. Thus, his combined rating was 60 percent for the appeal period prior to April 23, 2015. Nonetheless, the Board finds that the Veteran’s claim should be submitted to the Director for a determination as to whether a TDIU should be awarded on an extra-schedular basis prior to April 23, 2015. See Bowling v. Principi, 15 Vet. App. 1 (2001); Barringer v. Peake, 22 Vet. App. 242 (2008). As detailed above, the evidence suggests that the Veteran was unable to secure and follow a substantially gainful occupation consistent with his education and work history due to his service-connected disabilities prior to April 23, 2015. Therefore, the Board finds that the claim should be submitted to the Director for extra-schedular consideration of a TDIU pursuant to 38 C.F.R. § 4.16(b). The matter is REMANDED for the following action: Refer this case to the Director of Compensation Service for consideration of a TDIU on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b), for the appeal period stemming from the Veteran’s August 15, 2013, claim prior to April 23, 2015. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Clark, 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.