Citation Nr: 21025944 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 12-04 237 DATE: April 29, 2021 ORDER A rating higher than 10 percent for limitation of motion due to right knee degenerative arthritis is denied. A rating higher than 10 percent for left knee residuals of donor site surgery with chondromalacia patella is denied. A compensable rating for left knee limitation of flexion is denied. A rating higher than 10 percent for instability due to right knee status post anterior cruciate ligament (ACL) reconstruction prior to February 7, 2021 is denied. From February 7, 2021, a 30 percent rating for instability due to right knee status post ACL reconstruction is granted. A separate 20 percent rating for right knee semilunar cartilage condition with frequent episodes of locking, pain, and effusion is granted. A total disability rating based on individual unemployability (TDIU) is granted effective July 16, 2010. REMANDED A TDIU prior to July 16, 2010 is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s right knee degenerative arthritis manifested by no more than flexion limited to 45 degrees and extension limited to 0 degrees. 2. Throughout the period on appeal, the Veteran’s left knee residuals of donor site surgery with chondromalacia patella manifested by painful motion and no more than flexion limited to 60 degrees and extension limited to 0 degrees. 3. Prior to February 7, 2021, the Veteran’s right knee status post ACL reconstruction manifested by no more than slight instability. 4. From February 7, 2021, resolving reasonable doubt in the Veteran’s favor, his right knee status post ACL reconstruction manifested by persistent instability with a medical prescription for an assistive device and bracing for ambulation. 5. Throughout the period on appeal, the Veteran’s right knee disability manifested by dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 6. Resolving all reasonable doubt in the Veteran’s favor, his service-connected bilateral knee and back disabilities preclude him from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent for limitation of motion due to right knee degenerative arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5003, 5010, 5260, 5261. 2. The criteria for a rating higher than 10 percent for left knee residuals of donor site surgery with chondromalacia patella are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5003, 5010, 5260, 5261. 3. The criteria for a compensable rating for left knee limitation of flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260. 4. The criteria for a rating higher than 10 percent for instability due to right knee status post ACL reconstruction prior to February 7, 2021 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257. 5. The criteria for a 30 percent rating for instability due to right knee status post ACL reconstruction are met from February 7, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257. 6. The criteria for a separate 20 percent rating for right knee semilunar cartilage condition with frequent episodes of locking, pain, and effusion are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5258. 7. The criteria for entitlement to a TDIU are met effective July 16, 2010. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1987 to May 1994 in the U.S. Navy. This matter comes before the Board of Veterans’ Appeals (Board) from a December 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. This case was most recently before the Board in May 2017, at which time the issues on appeal were remanded for additional development. This case has now returned to the Board for appellate consideration. The Board finds that there has been substantial compliance with the May 2017 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In evaluating the severity of a disability, it is essential to consider its history. 38 C.F.R. § 4.1. 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). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different DCs, is to be avoided when evaluating a veteran’s service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The regulations pertaining to rating musculoskeletal disabilities were revised, effective February 7, 2021. Claims, such as this, pending prior to the effective date will be considered under both old and new rating criteria from that date, and whichever criteria is more favorable to the Veteran will be applied from that date. Preliminary Matter As a preliminary matter, the Veteran’s right knee degenerative arthritis was rated at 10 percent from April 18, 2002 pursuant to DC 5010 and his right knee status post ACL reconstruction was rated at 10 percent from April 1, 2005 under DC 5257. In an October 2011 rating decision, the RO increased the Veteran’s rating for right knee degenerative arthritis to 20 percent effective February 20, 2008 under DC 5258 and changed the assigned DC from DC 5010 to DC 5258. In a September 2015 Deferred Rating, the RO found that the rating under DC 5258 was incorrectly assigned while keeping a separate evaluation under DC 5257 because it constituted pyramiding. Thereafter, the RO changed the DC from DC 5258 to DC 5299-5010 but continued to assign a 20 percent rating based on the criteria under DC 5258. See January 2021 Supplemental Statement of the Case. However, the Board finds that the Veteran should have been assigned separate ratings under DCs 5010, 5257, and 5258. See Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that, as a matter of law, separate ratings are not precluded for limitation of motion (DCs 5003, 5260 and 5261), meniscal disability (DCs 5258 and 5259), and instability or subluxation (DC 5257)). As such, the Board is correcting the DC for the Veteran’s 20 percent rating for his right knee degenerative arthritis from DC 5099-5010 and changing it back to DC 5258. Additionally, the Board is continuing the 10 percent rating for the Veteran’s right knee degenerative arthritis under DC 5010 from February 20, 2008. The Board is free to change the DCs used when appropriate based on the facts of the case, provided that any such change is specifically explained. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (stating the assignment of a particular DC is “completely dependent on the facts of a particular case”); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Furthermore, these changes do not in any way sever service connection for the Veteran’s right knee disability. See Read v. Shinseki, 651 F. 3d. 1296,1302-1302 (Fed. Cir. 2011) (holding that reassignment of a DC does not sever service connection when the diagnostic code is changed to reflect more accurately the nature of the Veteran’s disability). Additionally, the changes do not result in a reduction of the Veteran’s combined rating. To the contrary, effective February 20, 2008, changing the DC and assigning a separate rating results in an increased combined rating for the Veteran’s right knee. Accordingly, for the period from February 20, 2008, the Board finds that the Veteran was in receipt of a separate 20 percent rating under DC 5258 based on right knee dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion, a 10 percent rating under DC 5257 for right knee instability, and a 10 percent rating for right knee degenerative arthritis under DC 5010. Based on the foregoing, the issues have been restated on the title page. Having resolved these administrative issues, the Board will now address the underlying merits of the claims. Right Knee Degenerative Arthritis and Left Knee Residuals of Donor Site Surgery with Chondromalacia Patella and Limitation of Flexion As noted above, the Veteran’s right knee degenerative arthritis is assigned a 10 percent rating under DC 5010 throughout the period on appeal. The Veteran’s left knee residuals of donor site surgery with chondromalacia patella is assigned a 10 percent rating under DC 5271-5010 for painful motion with noncompensable motion loss under DC 5260 for limitation of flexion. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Prior to February 7, 2021, DC 5010 (traumatic arthritis) directs that arthritis be rated under DC 5003 (degenerative arthritis), which states that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of arthritis involving two or more major or minor joint groups will warrant a 10 percent rating, and two or more major or minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The 10 percent and 20 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, DC 5003 Note 1. Effective February 7, 2021, DC 5010 (post-traumatic arthritis) is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with §4.25. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, DCs 5260 and 5261. DC 5260 provides a noncompensable rating for flexion limited to 60 degrees, a 10 percent rating for flexion limited to 45 degrees, a 20 percent rating for flexion limited to 30 degrees, and a 30 percent rating for flexion limited to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating is assigned when extension is limited to 5 degrees, a 10 percent rating is assigned when extension is limited to 10 degrees, a 20 percent rating is assigned when extension is limited to 15 degrees, a 30 percent rating is assigned when extension is limited to 20 degrees, a 40 percent rating is assigned when extension is limited to 30 degrees, and a 50 percent rating is assigned when extension is limited to 45 degrees. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Moreover, joint testing is to be conducted on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range-of-motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 170 (2016). Turning to the evidence of record, the Veteran was afforded VA examinations in October 2008, June 2016, and October 2019. The Board finds that the October 2008 VA examination is inadequate for adjudication purposes because while the Veteran reported flareups, the examiner did not provide an estimate of additional range of motion loss during flareups. Additionally, the Board notes that the May 2017 Board Remand found that the June 2016 VA examination report is inadequate. As such, the Board will not consider the October 2008 and June 2016 VA examinations. During the October 2019 VA examination, the Veteran reported that he experiences flareups causing locking and swelling. Regarding functional impairment, the Veteran reported that he cannot get down on the floor, has to go up steps one leg at a time, and he uses a knee scooter to go any distances. On examination, the Veteran’s right knee initial range of motion was limited to 80 degrees of flexion and 0 degrees of extension and his left knee initial range of motion was limited to 90 degrees of flexion and 0 degrees of extension. The examiner noted that range of motion itself contributes to functional loss and noted that the Veteran is limited with deep or repetitive knee bending motions. Pain was noted during flexion and extension and with weight-bearing. The Veteran was able to perform repetitive use testing with at least three repetitions for each knee, however there was no additional loss of function or range of motion after three repetitions. The examiner noted that pain significantly limits functional ability with repeated use over time and during flareups and estimated that the Veteran’s right knee flexion is limited to 45 degrees and extension is limited to 0 degrees and his left knee flexion is limited to 60 degrees and extension is limited to 0 degrees. The examiner found that the Veteran has less movement than normal, disturbances of locomotion, and interference with sitting and standing. The Veteran’s left and right knee flexion and extension was reduced in muscle strength with active movement against some resistance. Muscle atrophy was found with two centimeters less circumference of the right thigh when compared to the left side. No ankylosis was found. The Veteran had right knee mild anterior instability, however no joint instability was found on the left knee. The examiner noted that the Veteran constantly wears a knee brace on both knees and regularly uses a right knee scooter. The Board finds the October 2019 VA examination probative to the issue of the severity of the Veteran’s right and left knee disability throughout the appeal period. Specifically, the October 2019 examiner interviewed the Veteran and conducted physical examination. Moreover, the examiner had the requisite medical expertise and had sufficient facts and data on which to base the conclusions. Additionally, the examination findings are consistent with the Veteran’s medical records. As such, the Board accords the examination findings great probative weight. After review of the record, the Board finds that throughout the period on appeal, the Veteran’s right knee showed, at worst, flexion limited to 45 degrees and extension limited to 0 degrees, even when accounting for pain, repetitive testing, and flareups. Therefore, a rating higher than 10 percent is not warranted for the Veteran’s right knee degenerative arthritis based on limitation of motion. There is no evidence to indicate that his right knee degenerative arthritis resulted in limitation of flexion to 30 degrees or less, or extension limited to 15 degrees or more, which is required by the rating criteria for a rating higher than 10 percent. Accordingly, the Board finds that the assigned 10 percent rating for the Veteran’s right knee degenerative arthritis is appropriate. The Board also does not find that a rating higher than 10 percent is warranted for the Veteran’s left knee residuals of donor site surgery with chondromalacia patella. Additionally, a compensable rating is not warranted for left knee limitation of flexion. Throughout the period on appeal, the Veteran’s left knee showed, at worst, flexion limited to 60 degrees and extension limited to 0 degrees, even when accounting for pain, repetitive testing, and flareups. There is no evidence to indicate that the Veteran’s left knee disability resulted in a limitation of flexion to 45 degrees or less or extension limited to 10 degrees or more, which is required by the rating criteria for a compensable rating based on limitation of motion. Accordingly, the Board finds that the assigned 10 percent rating is appropriate based on painful motion for the Veteran’s left knee residuals of donor site surgery with chondromalacia patella and a compensable rating for left knee limitation of flexion is not warranted. The Board has considered the Veteran’s lay statements of evidence and has concluded that the medical evidence, prepared by skilled professionals, is more probative regarding the Veteran’s degree of disability. For the foregoing reasons, the Board finds the preponderance of the evidence is against assignment of a rating higher than 10 percent for the Veteran’s right knee degenerative arthritis, a rating higher than 10 percent for left knee residuals of donor site surgery with chondromalacia patella, and a compensable rating for left knee limitation of flexion for the entire rating period on appeal, under both the old and revised rating criteria. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a. Instability due to Right Knee Status Post ACL Reconstruction The Veteran’s right knee status post ACL reconstruction has been rated at 10 percent throughout the period on appeal under DC 5257 for instability. Prior to the 2021 revisions, DC 5257 provided that a 10 percent rating was assigned when slight impairment is shown, a 20 percent rating was warranted for moderate disability, and a maximum 30 percent evaluation was warranted for severe disability. 38 C.F.R. §§ 4.71a. See also Johnson v. Brown, 9 Vet. App. 7, 11 (1996) (holding that DC 5257 is not predicated on loss of range of motion). Descriptive terms such as “slight,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Under the revised version of DC 5257, for recurrent subluxation or lateral instability, a 30 percent rating is assigned for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. 38 C.F.R. § 4.71a, DC 5257 (2021). In cases of patellar instability, a 30 percent rating is warranted for diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Under Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Per Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). 38 C.F.R. § 4.71a, DC 5257 (2021). After review of the record, the Board finds that a rating higher than 10 percent under the old rating criteria is not warranted. The medical evidence of record shows that the Veteran’s right knee instability manifested, at worst, by slight instability. The October 2019 VA examiner noted mild anterior instability. This finding is consistent with the other medical evidence of record and has been consistent throughout the period on appeal. At no time during the appeal period has any of the Veteran’s physicians or VA examiners noted the Veteran to have moderate recurrent subluxation or lateral instability. Further, the Board does not find the record to contain any evidence, to include the Veteran’s lay statements, which may suggest the disability picture more nearly approximates moderate instability. As such, a rating higher than 10 percent is not warranted. However, the Board finds that a 30 percent rating is warranted under the new rating criteria. Notably, the Veteran’s VA treatment records show that he has difficulty ambulating, is at risk for falls due to his right knee disability, and he has been prescribed a knee brace and a scooter for his right knee. See VA Treatment Records received January 2021. Accordingly, a 30 percent rating is granted effective February 7, 2021, the date that the new rating criteria went into effect. Right Knee Dislocated Semilunar Cartilage Throughout the period on appeal, the Veteran has had a diagnosis of right knee meniscal tear with frequent episodes of locking, pain, and effusion. See e.g. October 2019 VA Examination. DC 5258 provides that a 20 percent rating is warranted for cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint. Accordingly, the Board finds that a separate 20 percent rating under DC 5258 is warranted. As this is the highest rating available under this DC 5258, a higher rating is not warranted. The Board has considered other potentially applicable DCs for rating the Veteran’s service-connected right and left knee disabilities. However, as the record does not reflect any ankylosis of the right or left knee (DC 5256), left knee instability (DC 5257), left knee meniscal disability (DCs 5258 and 5259), tibia and fibula impairment of the right or left knee (DC 5262), or genu recurvatum of the right or left knee (DC 5263), those DCs are not for application. TDIU The Veteran contends that he is unable to work due to his service-connected bilateral knee disabilities, back disability, and posttraumatic stress disorder (PTSD). The issue of entitlement to a TDIU has been raised as part and parcel to the Veteran’s claim for an increased rating for his bilateral knee disabilities. Rice v. Shinseki, 22 Vet. App. 447 (2009). After a review of all evidence, lay and medical, the Board finds that entitlement to a TDIU is warranted effective July 16, 2010. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15. A TDIU 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 a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran is service connected for PTSD (30 percent from October 15, 2013 and 70 percent from February 3, 2021), right knee degenerative arthritis (10 percent), lumbosacral strain (10 percent from April 18, 2002 and 20 percent from July 16, 2010), left knee residuals of donor site surgery with chondromalacia patella (10 percent), bronchial asthma (10 percent), tinnitus (10 percent), right knee status post ACL reconstruction (10 percent from April 1, 2005 and 30 percent from February 7, 2021), right knee dislocated semilunar cartilage (20 percent from February 20, 2008), bilateral pes planus (noncompensable), laceration scar on scalp (noncompensable), left knee scar (noncompensable), right knee scar (noncompensable), and left knee limitation of flexion (noncompensable). The Veteran is also service connected for herniated disc L3-4, L4-5; however as explained in the Remand section of this decision, the grant of service connection has not been effectuated by the RO. Nonetheless, the Veteran has had a combined disability rating of 70 percent from July 16, 2010. Additionally, the Veteran’s combined disability rating for his bilateral knee disabilities is 40 percent from February 20, 2008. Because the Veteran’s combined disability rating is 70 percent, and “one disability” (defined as disabilities of one or both upper or lower extremities, including the bilateral factor) is ratable at least 40 percent, the Board finds that the Veteran’s claim meets the threshold for TDIU consideration effective July 16, 2010. The remaining question is whether the Veteran’s service-connected disabilities cause him to be unable to secure or follow a substantially gainful occupation. The central inquiry is whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration may be given to the Veteran’s education, special training, and previous work experience, but not to his age or to the impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The record shows that the Veteran has completed four years of college. See March 2007 VA 21-8940 Application for Increased Compensation Based on Unemployability. After military service, the Veteran owned his own construction company, which he ultimately closed due to personal choices. Thereafter, he worked as a social worker. See October 2008 VA Examination. The Veteran stopped working in 2004 due to medical problems, including his knee disabilities. Id. Regarding functional impairment of the Veteran’s service-connected disabilities, in October 2008 a VA examiner opined that the Veteran’s employability in a position of labor would be difficult due to his right knee and lumbar back strain and that sedentary employment would be limited by the Veteran’s radiating pain down his leg with prolonged sitting. The examiner explained that the Veteran’s disc herniations more likely than not cause radiating pain down the Veteran’s extremity and is an obstacle to sedentary employment. The examiner noted that the Veteran has difficulty shopping and walking long distances due to his service-connected knee disabilities. The examiner also noted that the Veteran would have difficulty with occupations that require lifting, bending, or stooping due to his service-connected back disability. Additionally, the record shows that the Veteran can only stand and walk for a maximum of 1-2 hours due to his service-connected knee and back disabilities and can only sit for less than 6 hours due to his service-connected back disability. See Medical Treatment Records – Furnished by SSA received September 2020. The October 2019 VA examiner stated that the Veteran’s service-connected knee disabilities prevent him from heavy lifting, prolonged sitting, standing, or extended ambulation, and high impact exercises or activities. The examiner also noted that the Veteran takes narcotic pain medication, which prevents him from driving and operating heavy machinery or equipment due to sedation and somnolence. In August 2020, a VA examiner opined that the Veteran is capable of sedentary work, however the examiner only considered the Veteran’s service-connected back disability. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence of record establishes that his service-connected bilateral knee and back disabilities are significant enough to preclude him from securing or following a substantially gainful occupation. Accordingly, entitlement to a TDIU is granted effective July 16, 2010. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND In April 2015, the Board granted service-connection for herniated disc L3-4, L4-5 as secondary to his service-connected bilateral knee disabilities and lumbosacral strain. An August 2020 Deferred Rating requested an addendum medical opinion, which stated that the Veteran is only service connected for lumbosacral strain. Thereafter, the RO continued a 20 percent evaluation of lumbosacral strain. There is no indication that the RO has effectuated the grant of service connection for herniated disc L3-4, L4-5. Accordingly, the matter is referred to the RO. TDIU Prior to July 16, 2010 Finally, because a decision on the referred issue of service connection for herniated disc L3-4, L4-5 could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU prior to July 16, 2010 is required. The matter is REMANDED for the following action: 1. Take any action necessary to effectuate the grant of service connection for herniated disc L3-4, L4-5. (Continued on the next page)   2. After the above development, and any additionally indicated development, has been completed, readjudicate the inextricably intertwined issue of entitlement to a TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Kernen, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.