Citation Nr: 21024919 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 15-35 646 DATE: April 26, 2021 ORDER Entitlement to service connection for a left knee disability, to include as secondary to service-connected disability, is denied. Entitlement to an increased evaluation in excess of 10 percent from May 25, 2012 to December 10, 2015 for medial meniscus bucket handle tear, status post medial meniscectomy, with mild degenerative changes, excluding a period of temporary total evaluation, is denied. Entitlement to an increased rating in excess of 30 percent from December 10, 2015, excluding a period of temporary total evaluation, is denied. Entitlement to a total disability evaluation based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran’s degenerative joint disease of the left knee was not manifest during active service, or until many years after service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 2. Degenerative joint disease of the left knee was not caused or aggravated by service-connected disability. 3. From May 25, 2012 to December 10, 2015, the Veteran’s service-connected medial meniscus bucket handle tear, status post medial meniscectomy, with mild degenerative changes, excluding a period of temporary total evaluation, was manifested by limitation of flexion at worst to 95 degrees, limitation of extension at worst to zero degrees, occasional swelling, weakness, and pain on motion; ankylosis, subluxation, and instability have not been shown. 4. From December 10, 2015 forward, exclusive of a period of temporary total evaluation, the Veteran’s service-connected right knee disability is productive of total knee replacement with intermediate degrees of residual weakness, pain, or limitation of motion, limitation of flexion at worst to 90 degrees, extension at worst to zero degrees; ankylosis, subluxation, and instability have not been shown. 5. The evidence of record does not show that the Veteran’s service-connected disabilities alone preclude him from obtaining or maintaining substantially gainful employment consistent with his level of education and work history on a schedular or extraschedular basis. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative joint disease of the left knee have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2020). 2. The criteria for an increased evaluation in excess of 10 percent from May 25, 2012 to December 10, 2015 for right knee medial meniscus bucket handle tear, status post medial meniscectomy, with mild degenerative changes, excluding a period of temporary total evaluation, have not been met. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 3. From December 10, 2015, exclusive of a period of temporary total evaluation, the criteria for the assignment of a disability rating in excess of 30 percent for a right knee total arthroplasty have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.30, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2020). 4. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16, 4.19 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1974 to March 1977. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a August 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In April 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) in a videoconference hearing. A transcript of the hearing is of record. The Board remanded the issues on appeal for additional development in September 2018. The directives having been substantially complied with, the matter again is before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2020). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board….to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); 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). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection Legal Criteria for Service Connection - General Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2020); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For arthritis, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been “shown in service,” there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson, 581 F.3d at 1313; Kahana v. Shinseki, 24 Vet. App. 428 (2011). After the evidence is assembled, it is the Board’s responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3. In making that decision, the Board must determine the probative weight to be ascribed as among multiple medical opinions, and state the reasons and bases for favoring one opinion over another. See Winsett v. West, 11 Vet. App. 420, 424-25 (1998); see also Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). This responsibility is particularly important where medical opinions diverge. The Board is also mindful that it cannot make its own independent medical determinations, and that there must be plausible reasons for favoring one medical opinion over another. See Evans at 31; see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’’ in order to prevail.” To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Evidence and Analysis The Veteran is claiming entitlement to service connection for a left knee disability, asserting during his April 2017 hearing with the undersigned VLJ that he hurt his left knee during active service by falling on his knees while aboard ship, injuring his kneecaps and causing knee pain. When the Veteran made his initial claim with VA in March 1980, he only cited his now-service-connected right knee, and made no mention of the left knee. The Veteran received a VA examination for his knees in November 2010 which was focused on the already service-connected right knee. No diagnosis of any left knee disability was made during this examination. The examiner noted the Veteran worked as a construction superintendent and had so for the last thirty years, and had never lost a day of work due to a knee disability. The Veteran made his initial claim for service connection for the left knee on May 25, 2012, along with an increased rating claim for his service-connected right knee, which will be discussed further below. The Veteran’s first VA examination for his left knee pertinent to the claim on appeal occurred in July 2013. The examiner noted the recent right knee arthroscopy with meniscal debridement on March 11, 2013, and described the formal diagnosis of the right knee as medial meniscus bucket handle tear, status post medial meniscectomy with degenerative changes of the right knee, and resolved chondromalacia of both knees. Physical examination of each knee revealed no edema in either knee and no obvious deformities. Range of motion measurements for the left knee were 140 degrees in flexion to zero degrees in extension with no objective evidence of painful motion. After repetitive use testing, there was no change in range of motion measurements. There was no tenderness or pain to palpation for the joint line or soft tissues for either knee. Joint stability tests were normal with no findings of instability for either knee and no evidence or history of recurrent patellar subluxation or dislocation. X-rays taken as part of the examination show degenerative arthritis in each knee. This Veteran received a negative opinion for service connection, with the examiner saying it was less likely than not, less than 50 percent probability, that the Veteran’s left knee degenerative arthritis was incurred in or due to service, or secondary to the service connected right knee disability. The examiner’s rationale was that the Veteran did report left kneecap pain during active service after a fall in 1975 that was diagnosed at the time as chondromalacia patella. The Veteran remained on a medical profile for six months and the service medical examiner considered the left knee symptoms resolved. The service exit examination was silent for any chronic left knee problem. After leaving military service in April 1977, the Veteran then worked in aerial communications labor positions for over 35 years, which required a degree of mobility and fitness. The examiner pointed out that the Veteran’s left knee degenerative arthritis for a 59-year old male is typical based on the age and the activity profile of the Veteran since service. The examiner pointed out that the aging process has an impact on cartilage structure its components, and in combination with declining chondrocyte function and response to physical stimuli, the individual’s risk of degenerative arthritis increases over time. The examiner also spoke to secondary service connection to include as due to the service-connected right knee, that the left knee degenerative arthritis was not caused by or aggravated by the Veteran’s right knee, given the disability is diagnosed degenerative arthritis without any affect on gait or other condition from the right knee that might affect the left. This examiner also noted the Veteran’s diagnosed but non-service-connected hepatitis C can cause joint pain and swelling. The examiner concluded that while the Veteran had an acute left kneecap injury in service as documented in the service records, that it resolved without any chronic condition noted. The Veteran received another VA examination for each knee in August 2019. The examiner noted diagnoses of right knee status post complete total arthroplasty and left knee degenerative joint disease. The examiner noted the Veteran’s history that during active service from 1974 to 1977 that he fell aboard ship, landing on both knees, in 1975. Subsequent examination diagnosed a right knee injury treated with a meniscotomy in 1977. The left knee was treated for a patellar condition in service which then resolved by service separation. Current symptoms were noted as pain in each knee, dependent on the activity level, with swelling in each knee, per the Veteran. The Veteran reported daily flareups in each knee, with pain measured at a 7 on a scale of 10, lasting several hours each time. The Veteran also reported that at times he has decreased range of motion, and is unable to get on his knees and can’t squat or crawl. Pain was noted during examination and caused functional loss. There was not any objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. For the left knee, range of motion was measured at 95 degrees in flexion and zero degrees in extension, with tenderness and pain in the left knee patellar area when pressure was applied. The Veteran indicated his left knee pain was due to his knee arthritis. For each knee, there was change in the range of motion measurements after three repetitions, with 90 degrees for the left knee, but pain was noted with weight bearing and there was objective evidence of crepitus. There was no change in the extension measurement for either knee. Functional impacts included interference with sitting and interference with standing. Muscle strength in each knee was four on a scale of five in flexion and five on a scale of five in extension. No muscle atrophy was noted in either knee and no ankylosis was noted in either knee. For either knee, there was no history of recurrent subluxation or lateral instability. Joint stability testing was considered normal in each the right knee and the left knee. The examiner recorded that the Veteran used a cane constantly to assist his ambulation as due to his knee disabilities. The examiner noted the Veteran was retired after approximately 35 years in the aerial communication construction field, with most of the latter years spent a supervisor in that field. The August 2019 VA examiner provided a negative opinion for both direct and secondary service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran’s left knee degenerative arthritis was incurred in or due to a service injury or incident. The examiner’s rationale was that the Veteran’s left knee patellar injury in 1975 had resolved by the time of service separation in 1977 and that there was no chronic injury after service. The examiner also noted in an opinion for secondary service connection that it was less likely than not, less than 50 percent probability, that the Veteran’s left knee degenerative arthritis was proximately due to or the result of the service-connected right knee condition. The examiner’s rationale was that degenerative arthritis in one knee joint does not cause arthritis in the other knee joint. The examiner also pointed out in the examination report that there were diagnoses of any chronic left knee disability in service or shortly after service, and that the injuries of the right knee that led to its service connection in 1980 did not have a causative or proximate effect of the left knee, which the examiner opined were related to age. 1. Entitlement to service connection for a left knee disability, to include as secondary to service-connected disability The Board finds all of the discussed VA examinations and opinions, especially of July 2013 and August 2019, to be of great probative value. The examiners went into detail with the Veteran’s medical and service history, conducted a thorough review of the claims file, and considered the Veteran’s contentions and clinical medical evidence before providing a negative opinion for both direct and secondary service connection. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). The negative VA opinions of July 2013 and August 2019 considered all of the Veteran’s contentions as to his theories of service connection for his left knee disability. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The VA examiners’ negative opinions of July 2013 and August 2019 were supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran’s contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board acknowledges that the Veteran is competent to testify as to his belief that his left knee disability is related to service. In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; “[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of [his] personal knowledge.” Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran is competent to testify about his symptoms relating to his claimed left knee disability. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology of a left knee disability. See 38 C.F.R. § 3.159 (a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. The Board also notes that the Veteran’s service records were silent for any chronic left knee disability symptoms or related complaint beyond the acute but resolved left kneecap injury in 1975. The Veteran was not diagnosed with any left knee disability until July 2013, and his first complaint does not arise until May 2012 at the earliest. The Board notes the Veteran has made consistent complaints about his service-connected right knee since his initial claim in March 1980 but did not make a claim for the left knee until May 2012. The Board finds the gap in time between the end of active service in 1977 until the 2012 occurrence of symptoms of the left knee degenerative arthritis to be probative of a lack of nexus between service and the current complaints. There are no competent medical opinions of probative value in favor of a positive nexus to active service from any VA examiner or medical treatment provider from any source, under any theory of service connection. Upon review of the record, the Board concludes that entitlement to service connection for a left knee disability is not warranted. The Board notes a current diagnosis of left knee degenerative arthritis, and thus the requirement for a current disability is shown. The Board acknowledges the Veteran’s contentions, and the Veteran’s post-service statements are noted. The Board notes that the Veteran’s entrance examination, his service treatment records, and his separation examination were all silent for any chronic left knee disability symptoms, or related injury or incident that led to the current left knee complaint. The final physical of March 1977, a month prior to separation from active service, is silent for any existing chronic left knee disability symptoms or related injury at the time of separation from active service, and there is no competent evidence to tie the current assertions to any in-service disease or injury. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. With regard to presumptive service connection for left knee disability, the weight of evidence shows no chronic symptoms of this condition during active service, no continuous symptoms of the condition since service, and that the conditions did not manifest to a compensable degree within one year of service. As such, presumptive service connection as a chronic condition is not warranted. 38 C.F.R. §§ 3.303, 3.309. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran’s claimed left knee disability was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a left knee disability on a direct or secondary basis and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Schedular Ratings - General Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. § Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § §§ 3.321(a), 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 U.S.C. § 5107(b); 38 C.F.R. § § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In assigning hyphenated diagnostic codes, the number assigned to the residual condition on the basis of which the rating is determined will generally represent injuries. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27. Separate disability 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 condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also VAOPGCPREC 9-04 (holding that separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned). 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.”). The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, the United States Court of Appeals for Veterans’ Claims (Court) recently addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. The Board also notes recent case law where the Court held that 38 C.F.R. § 4.59 does not solely condition the evaluation based on range of motion measurements for a particular diagnostic code, but rather “it conditions that award on evidence of an actually painful, unstable, or maligned joint or periarticular region and the presence of a compensable evaluation in the applicable diagnostic code.” Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Board considers not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § § 4.25. However, the evaluation of the same “disability” or the same “manifestations” under various diagnoses is not allowed. See 38 C.F.R. § § 4.14. A claimant may not be compensated twice for the same symptomatology as “such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity.” See 38 U.S.C. § 1155 (2012); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The terms “slight,” “marked,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Right Knee Legal Criteria The Veteran is seeking an increased rating for his right knee disability, saying his conditions are worse than described in previous evaluations. He was originally granted service connection for degenerative joint disease of the right knee in a June 1980 rating decision, with an initial rating of 10 percent under Diagnostic Code 5259 for postoperative residuals meniscectomy of the right knee, effective from the date of original claim of March 28, 1980. After a June 16, 2010 claim for an increased rating, the RO continued the previous 10 percent rating in a November 2010 rating decision. The Veteran did not appeal that decision, and thus it went final. On May 25, 2012, the Veteran filed another claim for an increased rating for his right knee. The RO continued the 10 percent rating for the right knee in an August 2013 rating decision, which is the decision on appeal here. As such, the Board will focus on the disability level of his right knee disability from one year immediately preceding the claim. See 38 U.S.C. § 5110 (b)(2) and 38 C.F.R. § 3.400 (o)(2) (stating that in assessing the present level of disability, the relevant temporal focus is from one year immediately preceding the filing of the increased-rating claim); Hart v. Mansfield, 21 Vet. App. 505 (2007). During the course of the appeal, the Veteran underwent a right knee arthroscopy with meniscal debridement on March 11, 2013. A June 2014 rating decision awarded a temporary evaluation of 100 percent effective from the date of the procedure on March 11, 2013 pursuant to 38 C.F.R. §§ 3.400 & 4.30, and then the 10 percent rating resumed, now under Diagnostic Code 5260 for right knee limitation of flexion, and also for Diagnostic Code 5003 for degenerative arthritis, effective from May 1, 2013. In assigning hyphenated diagnostic codes, the number assigned to the residual condition on the basis of which the rating is determined will generally represent injuries. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27. The Veteran underwent another right knee surgery on December 10, 2015, this time for a right knee total arthroplasty. The Veteran filed another claim for his right knee based on the replacement procedure just performed, and a February 2016 rating decision awarded a temporary evaluation of 100 percent effective from the date of the total right knee arthroplasty on December 10, 2015 pursuant to 38 C.F.R. §§ 3.400 & 4.30 for 13 months, and then a 30 percent evaluation under Diagnostic Code 5055 for knee replacement, prosthesis, from February 1, 2017 forward. Neither period of the two temporary total evaluations are on appeal and therefore will not be discussed further. 38 C.F.R. §§ 3.400, 4.30, 4.71a. (2020) VA’s schedule of musculoskeletal rating changes, found in 38 C.F.R. § 4.71a, was modified with the changes in effect on February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). Pertinent to this particular appeal, Diagnostic Code 5055, has been substantially modified and will be noted below. A small modification was also made to Diagnostic Code 5003, which was announced in a corrected final rule. See 85 Fed. Reg. 85523 (Dec. 29, 2020). Diagnostic Code 5003 was modified in its title to now read “Degenerative arthritis, other than post-traumatic.” Id. No other changes pertinent to this claim are applicable for this particular appeal. Absent any Congressional intent or directive with regard to new or revised regulations, when a claim originates prior to the effective date of the new language but is decided after the effective date, VA will use the version that provides the Veteran a greater benefit. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Separate disability 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 condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also VAOPGCPREC 9-04 (holding that separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned). Moreover, in VAOPGCPREC 23-97, VA Office of General Counsel (OGC) opined that it was not pyramiding to assign ratings under DC 5257 (knee instability) and DC 5260/61 based on additional disability. The opinion explained that DC 5257 addressed instability of the knee without reference to limitation of motion, and DC 5003 referenced limitation of motion without instability. Id. at para. 2. In other words, the two DCs addressed different manifestations or symptoms. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability. VAOPGCPREC 23-97 (July 1, 1997). VA’s Office of the General Counsel (OGC) opined that it was not pyramiding to assign ratings under DC 5257 (knee instability) and DC 5260/61 based on additional disability. The opinion explained that DC 5257 addressed instability of the knee without reference to limitation of motion, and DC 5060/61 referenced limitation of motion without instability. Id. at para. 2. In other words, the two diagnostic codes addressed different manifestations or symptoms. In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court held that evaluation of a knee disability under Diagnostic Codes 5260 and/or 5261 does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under Diagnostic Code 5258 or 5259, and vice versa. The Court further held that entitlement to a separate evaluation in a given case depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different Diagnostic Code. In the context of evaluating musculoskeletal disabilities based on limitation of motion, a manifestation of disability has not been compensated, for separate evaluation and pyramiding purposes, if that manifestation did not result in an elevation of the evaluation under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the principles set forth in DeLuca v. Brown, 8 Vet. App. 202 (1995). Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). However, based on the medical evidence before the Board, ankylosis, symptomatic removal of semilunar cartilage, impairment of the tibia and fibula, and genu recurvatum have not been found or associated with the Veteran’s knee disability and thus will not be considered here. Under Diagnostic Code 5055 (prior to February 7, 2021), for prosthetic replacement of the knee joint, a 100 percent rating is warranted for one year following implantation of the prosthesis. A 60 percent rating is warranted if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is to be rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5261 (limitation of extension) or 5262 (impairment of the tibia and fibula). The regulation prescribes a minimum rating of 30 percent under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (prior to Feb. 7, 2021). The new language of Diagnostic Code 5055, now described as “knee, resurfacing or replacement (prosthesis),” in effect as of February 7, 2021, a 100 percent rating is warranted for four months following implantation of prosthesis or resurfacing. A 60 percent rating is warranted for prosthetic replacement of the knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, rate by analogy to diagnostic codes 5256, 5261, or 5262. A 30 percent minimum evaluation is warranted for total replacement only. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (effective Feb. 7, 2021). In addition, there are new notes under the section title “Prosthetic Implants and Resurfacing,” which includes all diagnostic codes involving prosthetic implants, to include Diagnostic Code 5055. Note (1): When an evaluation is assigned for joint resurfacing or the prosthetic replacement of a joint under diagnostic codes 5051–5056, an additional rating under § 4.71a may not also be assigned for that joint, unless otherwise directed. Note (2): Only evaluate a revision procedure in the same manner as the original procedure under diagnostic codes 5051–5056 if all the original components are replaced. Note (3): The term “prosthetic replacement” in diagnostic codes 5051–5053 and 5055–5056 means a total replacement of the named joint. However, in DC 5054, “prosthetic replacement” means a total replacement of the head of the femur or of the acetabulum. Note (4): The 100 percent rating for 1 year following implantation of prosthesis will commence after initial grant of the 1-month total rating assigned under § 4.30 following hospital discharge. Note (5): The 100 percent rating for 4 months following implantation of prosthesis or resurfacing under DCs 5054 and 5055 will commence after initial grant of the 1-month total rating assigned under § 4.30 following hospital discharge. 38 C.F.R. § 4.71a (effective Feb. 7, 2021). Diagnostic Code 5256 provides ratings for ankylosis of the knee. A favorable angle in full extension, or in slight flexion between zero and 10 degrees warrants a 30 percent rating. Ankylosis of the knee in flexion between 10 and 20 degrees warrants a 40 percent rating, and between 20 and 45 degrees warrants a 50 percent rating. Extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more, warrants a 60 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Diagnostic Code 5257 provides ratings for recurrent subluxation and/or lateral instability of the knee. A 10 percent rating is assigned for slight recurrent subluxation and/or instability of the knee. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5259, symptomatic removal of semilunar cartilage, there is only a single rating of 10 percent specified: semilunar cartilage, removal of, symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, a non-compensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a non-compensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5262, impairment of tibia and fibula, a 10 percent rating is awarded for malunion with slight knee or ankle disability, a 20 percent rating is awarded for malunion with moderate knee or ankle disability, and a 30 percent rating is awarded for malunion with a marked knee or ankle disability. A 40 percent rating is awarded for nonunion of, or loose motion, requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Right Knee Evidence and Analysis The Veteran’s first VA examination for his left knee pertinent to the periods on appeal occurred in July 2013. The examiner noted the recent right knee arthroscopy with meniscal debridement on March 11, 2013, and described the formal diagnosis of the right knee as medial meniscus bucket handle tear, status post medial meniscectomy with degenerative changes of the right knee, and resolved chondromalacia of both knees. Physical examination of each knee revealed no edema in either knee and no obvious deformities. Range of motion measurements for the right knee were 110 degrees in flexion to zero degrees in extension with no objective evidence of painful motion. Functional impacts included less movement than normal and pain on movement. Range of motion measurements for the left knee were 140 degrees in flexion to zero degrees in extension with no objective evidence of painful motion. After repetitive use testing, there was no change in range of motion measurements. There was no tenderness or pain to palpation for the joint line or soft tissues for either knee. Joint stability tests were normal with no findings of instability for either knee and no evidence or history of recurrent patellar subluxation or dislocation. X-rays taken as part of the examination show degenerative arthritis in each knee. The Veteran received another VA examination for each knee in August 2019. The examiner noted diagnoses of right knee status post complete total arthroplasty and left knee degenerative joint disease. The examiner noted the Veteran’s history that during active service from 1974 to 1977 that he fell aboard ship, landing on both knees. Subsequent examination diagnosed a right knee injury treated with a meniscotomy in 1977. The left knee was treated for a patellar condition in service which then resolved by service separation. Current symptoms were noted as pain in each knee, dependent on the activity level, with swelling in each knee, per the Veteran. The Veteran reported daily flareups in each knee, with pain measured at a 7 on a scale of 10, lasting several hours each time. The Veteran also reported that at times, that he has decreased range of motion, and is unable to get on his knees and can’t squat or crawl. Range of motion measurements for the left knee were 70 degrees in flexion to zero degrees in extension. Pain was noted during examination and caused functional loss. There was not any objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. For the left knee, range of motion was measured at 95 degrees in flexion and zero degrees in extension, with tenderness and pain in the left knee patellar area when pressure was applied. The Veteran indicated his left knee pain was due to his knee arthritis. For each knee, there was change in the range of motion measurements after three repetitions, 65 degrees in flexion for the right knee, and 90 degrees for the left knee, but pain was noted with weight bearing and there was objective evidence of crepitus. There was no change in the extension measurement for either knee. Functional impacts included interference with sitting and interference with standing. Muscle strength in each knee was four on a scale of five in flexion and five on a scale of five in extension. No muscle atrophy was noted in either knee and no ankylosis was noted in either knee. For either knee, there was no history of recurrent subluxation or lateral instability. Joint stability testing was considered normal in each the right knee and the left knee. The examiner recorded that the Veteran used a cane constantly to assist his ambulation as due to his knee disabilities. The examiner noted the Veteran was retired after approximately 35 years in the aerial communication construction field, with most of the latter years spent a supervisor in that field. 2. Entitlement to an increased evaluation in excess of 10 percent from May 25, 2012 to December 10, 2015 for medial meniscus bucket handle tear, status post medial meniscectomy, with mild degenerative changes, excluding a period of temporary total evaluation For the Veteran’s right knee under Diagnostic Codes 5003 and 5260, for the period on appeal, the Board finds that a 10 percent evaluation for the right knee, but no higher, is warranted. Flexion measurements in this period would warrant a 10 percent rating for the right knee and even in the lack of a flexion range of motion limit, a rating of 10 percent is appropriate here due to painful motion of the right knee, where the minimum compensable evaluation is 10 percent because 38 C.F.R. § 4.59 allows for consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. Painful, unstable, or misaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint, which for the right knee, is 10 percent. 38 C.F.R. § 4.59; see Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016); Petitti v. McDonald, 27 Vet. App. 415 (2015). A higher evaluation of 20 percent is not warranted for limitation of flexion unless the evidence shows a limitation of flexion of 16-30 degrees under Diagnostic Code 5260, or under Diagnostic Code 5261, limitation of extension, if the limitation of range of motion is 15 degrees.. This has never been shown, even with consideration of additional loss of motion due to pain and swelling during flare-ups. The Board also notes that an evaluation under Diagnostic Code 5259, there is only a single rating of 10 percent specified and no higher: semilunar cartilage, removal of, symptomatic. While the Veteran’s disability in this appeal period would qualify under this diagnostic code, there is no increased benefit to the Veteran. 38 C.F.R. § 4.71a, Diagnostic Code 5259. 3. Entitlement to an increased rating in excess of 30 percent from December 10, 2015, excluding a period of temporary total evaluation, For the Veteran’s right knee, for the period from December 10, 2015, exclusive of periods of temporary total evaluation that expired February 1, 2017, the Board finds that an evaluation in excess of 30 percent is not met or approximated. The Board notes the Veteran’s right knee total arthroplasty and the language of Diagnostic Code 5055, which requires a minimum evaluation of 30 percent following prosthetic replacement of the knee joint. Pursuant to Diagnostic Code 5055, the Veteran’s temporary total evaluation for one year following beginning the first of the month after the month of the total right knee arthroplasty is appropriate. For the right knee replacement in this appeal period, the RO awarded a temporary total evaluation for one year pursuant to Diagnostic Code 5055 and 38 C.F.R. § 4.30 to February 1, 2017, at which time the Veteran’s evaluation for his right knee reverted to 30 percent. 38 C.F.R. § 4.71a. The Board notes a VA examination in August 2019 following the right knee total arthroplasty and found intermediate degrees of residual weakness, pain, or limitation of motion, which under Diagnostic Code 5055 meet or approximate the criteria for a 30 percent evaluation. A higher evaluation of 60 percent under Diagnostic Code 5055 is not warranted unless evidence demonstrates chronic residuals consisting of severe painful motion or weakness in the affected extremity. A higher evaluation of 100 percent under Diagnostic Code 5055 is only warranted for one year following prosthetic replacement of the knee joint. A higher evaluation of 40 percent is not warranted for ankylosis of the knee unless the evidence shows ankylosis in flexion between 10 degrees and 20 degrees under Diagnostic Code 5256. Additionally, a higher evaluation of 40 percent is not warranted for limitation of extension unless the evidence shows extension limited to 30-44 degrees under Diagnostic Code 5261. A higher evaluation under Diagnostic Code 5262 for impairment of the tibia and fibula is not warranted unless the evidence shows nonunion of the tibia and fibula with loose motion, requiring a brace. No VA examiner found ankylosis, limitations of flexion or extension, or nonunion of tibia and fibula such as to qualify for those diagnostic codes. The Board notes the new criteria for Diagnostic Code 5055 that took effect on February 7, 2021 but considers the Veteran benefits greater for his disability under the criteria in effect prior to February 7, 2021, and thus makes its decision under those earlier criteria as a greater benefit to the Veteran. 38 C.F.R. § 4.71a (effective Feb. 7. 2021). The Board has considered the findings regarding objective evidence of knee instability versus subjective reporting of instability by the Veteran in this case. See English v. Wilkie, 30 Vet. App. 347, 353 (2018) (holding that the Board cannot categorically favor objective stability test results over lay reports of instability). Here, the Board notes there were no reports of instability by VA medical examiners pertinent to this period since the date of claim of this increased rating of May 25, 2012 to the date of his right knee total arthroplasty of December 10, 2015. Id.; see also Tedesco v. Wilkie, 31 Vet. App. 360, 367 (2019). After the right knee arthroplasty of December 2015, no VA examiner found evidence of right knee instability post-replacement. For the Veteran’s right knee, therefore, from December 10, 2015, the Board finds that an evaluation in excess of 30 percent is not met or approximated, exclusive of the periods of temporary total evaluation under Diagnostic Code 5055 or 38 C.F.R. § 4.30 as noted and appropriate. As such, pursuant to Diagnostic Code 5055, the Veteran’s temporary total evaluation for one year following December 10, 2015, to February 1, 2017 is appropriate. A higher evaluation of 100 percent under Diagnostic Code 5055 is only warranted for one year following prosthetic replacement of the knee joint. The Board has considered other diagnostic codes for the Veteran’s right knee disability, to include ankylosis (Diagnostic Code 5256), disabilities involving cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint (Diagnostic Code 5258), removal of the semilunar cartilage (Diagnostic Code 5259), and genu recurvatum (Diagnostic Code 5263), and found them to not apply to the Veteran’s right knee disability picture in this period. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5260, 5261, 5262, 5263. The Board notes the Veteran’s limitations of flexion and extension and impairment of the tibia and fibula pursuant to the medical evidence and Diagnostic Codes 5260, 5261, and 5262, but finds the Veteran’s highest possible ratings and therefore the greatest possible benefit to the Veteran derive from evaluations under Diagnostic Code 5055 in effect prior to February 7, 2021. Additionally, the Board has considered the statements regarding flareups by the Veteran, but based on the medical evidence, even with estimates of motion loss in terms of degrees during periods of flare-ups, the criteria for higher evaluations based on range of motion have not been met or approximated. Sharp v. Shulkin, 29 Vet. App. 26 (2017). For the foregoing reasons, then, the Board finds that a 30 percent rating, but no higher, for the left knee disability is warranted for the period from the initial date of service connection of January 2, 2004, pursuant to Diagnostic Code 5055 and 38 C.F.R. § 4.30. All potentially applicable diagnostic codes have been considered, and there is no basis to assign an alternative evaluation for the Veteran’s right knee disability other than that discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Staged ratings are not warranted beyond that discussed, as the Veteran has had a stable level of symptomatology throughout the appeal period beyond the temporary total evaluation following the 2013 right knee arthroplasty, as already discussed. Any increases in severity were not sufficient for a higher rating for the reasons discussed above. See Hart, 21 Vet. App. 505. TDIU The Board found in this Veteran’s previous appeal before the Board dated September 6, 2018 that a TDIU was inferred as part of that claim pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). That issued was remanded with the remaining issues already described above, and is now again before the Board. A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling; or (2) that the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system are considered as one disability. Id. Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to TDIU is based on an individual’s particular circumstance.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009) (quoting Thun v. Peake, 22 Vet. App. 111, 116 (2008)); see also Todd, 27 Vet. App. at 85-86. Therefore, in 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, 168 (1991) (level of education is a factor in deciding employability); see 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 degree in education and his part-time work as a tutor). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran’s favor. 38 C.F.R. § 4.3. As noted, consideration may not be given to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. However, when it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant’s favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.10. In discussing the unemployability criteria, the United States Court of Appeals for Veterans Claims (Court) has indicated that, in essence, the unemployability question, that is, the veteran’s ability or inability to engage in substantial gainful activity, has to be looked at in a practical manner, and that the thrust is whether a particular job is realistically within the capabilities, both physical and mental, of the appellant. See Moore v. Derwinski, 1 Vet. App. 83 (1991). The VA General Counsel has concluded that VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities shall be rated as totally disabled, without regard to whether an average person would be rendered unemployable by such circumstances. Thus, the criteria include a subjective standard. It was also held that unemployability is synonymous with the inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91 (1991). As noted above, in determining whether the veteran is entitled to individual unemployability, neither his non-service-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Thus, in deciding the claim, the Board may not favorably consider the effects of the non-service-connected disabilities with respect to their degree of interference with his employability. Indeed, the Court stated that in order for a veteran to prevail on a claim for TDIU, the record must reflect some factor which takes his case outside of the norm. The sole fact that he is unemployed or has difficulty obtaining employment is not enough. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose v. Brown, supra. If total industrial impairment has not been shown, the VA is not obligated to show that a veteran is incapable of performing specific jobs in considering a claim for a total rating based on individual unemployability. See Gary v. Brown, 7 Vet. App. 229 (1994). Under applicable criteria, VA shall consider all lay and medical evidence of record in a case with respect to benefits under laws administered by VA. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 4. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities Schedular TDIU A total disability rating for individual unemployability may be granted where the schedular rating is less than total and the service-connected disabilities preclude the veteran from obtaining or maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). The Veteran is service-connected for his right knee disability with a 30 percent rating from February 1, 2017, tinnitus with a 10 percent rating from May 25, 2012, and noncompensable ratings for bilateral hearing loss and a right knee scar. The total current combined evaluation for compensation is 40 percent from February 1, 2017. Because the Veteran does not have a combined evaluation of at least 70 percent with at least one disability evaluated at 40 percent or higher, or a single service-connected disability that has been rated 60 percent or higher during the period at issue, under the 38 C.F.R. § 4.16(a) criteria outlined above, the Veteran does not meet the schedular criteria for a schedular TDIU rating. Consequently, a TDIU rating on a schedular basis, under 38 C.F.R. § 4.16(a), is not warranted. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Extraschedular TDIU If the above percentage thresholds are not met, the Veteran’s claim may still be referred to the Director, Compensation Service for consideration of an extraschedular rating, when the evidence of record shows that Veteran is “unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities.” 38 C.F.R. § 4.16(b). The Veteran was provided a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, but did not return it. The Board notes from medical evidence that the Veteran completed 12 years of school graduated from high school. He was trained as a Navy sailor and served on ship with duties afloat. Since service, he has worked for approximately forty years in the aerial communications construction line of work, to include supervisory work in the latter part of his career. The Veteran noted during testimony with the undersigned VLJ in April 2017 that he was no longer working and considered himself retired. The Board notes from the July 2013 VA examination for the knees about the examiner’s discussion of functional impact. Here, the examiner noted the Veteran had difficulty climbing stairs or squatting, due to his right knee, and that both of his knees were painful, reaching seven on a scale of ten. The Board also notes that July 2013 VA examination for the Veteran’s right knee ad left knee that indicated his service-connected disabilities may preclude strenuous labor but would not preclude light or sedentary work. The Board acknowledges that the Veteran’s service-connected disabilities of his right knee, related scar, tinnitus, and bilateral hearing loss may very well result in some occupational impairment. However, such interference is contemplated in the ratings assigned for those service-connected disabilities, and the weight of the evidence does not demonstrate total occupational impairment from the Veteran’s service-connected disabilities of his right knee, related scar, and hearing disabilities at the current time or at any time in the period on appeal. The evidence of record does not demonstrate that the service-connected disabilities of record alone render the Veteran unemployable. The Board notes and acknowledges the limitations of the Veteran’s other diagnosed conditions, to include hepatitis C, chronic obstructive pulmonary disorder (COPD), and hypertension. However, those other disabilities are not service-connected, and are thus not pertinent to the Veteran’s claim for a TDIU. In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Under these circumstances, the Board concludes that extraschedular referral for TDIU is not warranted. Gilbert, supra. Based on the foregoing, the Board finds that referral to the Director of Compensation Service for consideration of TDIU on an extraschedular basis under 38 C.F.R. § 4.16(b) is not warranted because the most credible, competent, and probative evidence of record does not reflect that the Veteran is unable to follow or secure substantially gainful employment due his service-connected disabilities for the entire period on appeal. See also Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369–70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Setter, 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.