Citation Nr: 21026686 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 15-16 592 DATE: May 3, 2021 ORDER Entitlement to an initial evaluation in excess of 10 percent for service-connected degenerative joint disease of the right knee status post a patellar tendon repair is denied. Entitlement to an initial evaluation in excess of 10 percent for service-connected degenerative joint disease of the left knee status post an open reduction internal fixation (ORIF) procedure is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted. FINDINGS OF FACT 1. The Veteran has right knee degenerative joint disease status post a patellar tendon repair with objective pain and crepitus, and with limitation of motion of flexion but flexion has been greater than 45 degrees. The Veteran has also had no symptoms of dislocated semilunar cartilage like episodes of locking, pain, effusion, or any ankylosis of the knee. 2. The Veteran has left knee degenerative joint disease status post an open reduction internal fixation (ORIF) procedure and a patellar tendon repair with objective pain and crepitus, and with limitation of motion of flexion but flexion has been greater than 45 degrees. The Veteran has also had no symptoms of dislocated semilunar cartilage like episodes of locking, pain, effusion, or any ankylosis of the knee. 3. Since October 11, 2019, the Veteran's service-connected disabilities prevented him from obtaining and maintaining a substantially gainful occupation CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for painful limitation of motion of a right knee disability has not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. 2. The criteria for an evaluation in excess of 10 percent for painful limitation of motion of a left knee disability has not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. 3. The criteria for the assignment of TDIU due to service-connected disabilities has been met as of October 11, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Marine Corps from March 1966 to June 1989. The Veteran testified at a hearing before the undersigned Veterans Law Judge in Washington, D.C., in October 2018. A written transcript of that hearing has been prepared and associated with the evidence of record. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU rating is part of an appeal for an increased rating claim when such claim is raised by the record. Here, the Board notes that the Veteran and his attorney have asserted that his service-connected disabilities prevented him from engaging in or returning to employment. As such, the Board finds that the record raises a claim for TDIU. See Hearing Transcript received October 2018. Increased Rating Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes (DCs). 38 C.F.R. § 4.27. If two evaluations are potentially applicable, the higher evaluation 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. Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); see also 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.1, 4.2. As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. In rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126 (1999). VA's determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In assigning a higher disability rating, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. 1. Entitlement to an evaluation in excess of 10 percent disabling for service-connected degenerative joint disease of the right knee status post a patellar tendon repair is denied. See argument below in section 2. 2. Entitlement to an evaluation in excess of 10 percent disabling for service-connected degenerative joint disease of the left knee status post an open reduction internal fixation (ORIF) procedure is denied. The Veteran contends that he is entitled to an increased evaluation for a service-connected bilateral knee disability. He stated that he has a high level of pain in both knees, which makes it hard to sleep and do other physical things. He stated that his pain in his knees is often an eight out of ten on the pain scale. See Correspondence received July 2015. He has also reported reduced stability in both knees. At the hearing he was using compression sleeves for both his knees. See Hearing Transcript received October 2018. Both the Veteran's knees were rated at 10 percent disabling pursuant to DC 5003-5260 since March 12, 2014. The diagnostic codes relevant to rating knee disabilities are summarized below. Under DC 5003 (prior to the regulatory change on February 7, 2021) arthritis shown by x-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, DC 5003. 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, Diagnostic Code 5003, Note 1. Under DC 5003 (as of February 7, 2021, under the amended regulatory criteria) the rating for degenerative arthritis is as above with the exception that post traumatic arthritis is no longer considered under the Diagnostic Code. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). Under DC 5260 (same before and after the February 7, 2021 regulatory change), a zero percent evaluation is warranted where flexion of the leg is limited to 60 degrees, a 10 percent evaluation is warranted where flexion is limited to 45 degrees, a 20 percent evaluation is warranted where flexion is limited to 30 degrees, a 30 percent evaluation is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261 (same before and after the February 7, 2021 regulatory change) a zero percent evaluation is warranted where extension of the leg is limited to five degrees, a 10 percent evaluation is warranted where extension is limited to 10 degrees, a 20 percent evaluation is warranted where extension is limited to 15 degrees, a 30 percent evaluation is warranted where extension is limited to 20 degrees, a 40 percent evaluation is warranted where extension is limited to 30 degrees, a 50 percent evaluation is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Under DC 5257 (prior to the regulatory change on February 7, 2021), a 10 percent rating is assigned when there is slight recurrent subluxation or lateral instability; a 20 percent rating is assigned when there is moderate recurrent subluxation, or lateral instability; and a 30 percent rating is assigned when there is severe recurrent subluxation, or lateral instability. Under DC 5257 (as of February 7, 2021, under the amended regulatory criteria) instability of the knee is broken into two categories, (1) recurrent subluxation or instability, and (2) patellar instability. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). For (1), recurrent subluxation or instability due to sprains or ligament tears causing persistent instability, a 10 percent rating is warranted when there is no prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted when there is a medical provider who prescribes either a brace or an assistive device for ambulation and there is persistent instability from ligament tears or sprains. A 30 percent rating is warranted when there is a prescription from a medical provider for both an assistive device and bracing for ambulation. Id. For (2), patellar instability is defined as a diagnosed condition involving the patellofemoral complex with recurrent instability. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Note (1) defines patellofemoral complex for Code 5257 as consisting of the quadriceps tendon, the patella, and the patellar tendon. Note (2) clarifies that a surgical procedure that does not involve repair to at least one of the patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for this Code. Id. For patellar instability, a 10 percent rating is warranted when there is a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without a surgical repair) that does not require a prescription from a medical provider for a brace cane or walker. A 20 percent rating is warranted when there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following a brace, cane or walker. A 30 percent rating is warranted when there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, and either a cane or walker. Id. Under DC 5258 (same before and after the February 7, 2021 regulatory change), a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the knee joint. 38 C.F.R. § 4.71a, DC 5258. Under DC 5259 (same before and after the February 7, 2021 regulatory change), a 10 percent rating is warranted for symptomatic residuals of removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. Normal range of motion in the knee is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Multiple diagnostic codes are potentially applicable to evaluation of the knees. Simultaneous compensation under several Codes is permissible so long as differing symptomatology is being compensated by each Code. For example, limitations of flexion (Code 5260) and extension (Code 5261) may both be rated, but a rating for arthritis (Code 5003) cannot be combined with either, as it refers to general limitations of motion and would include both flexion and extension. Similarly, instability (Code 5257) and meniscal disabilities (Codes 5258 and 5259) can be rated with limits of motion, and with each other, so long as differing symptoms and manifestations are being compensated. VAOGCPREC 9-2004; VAOPGCPREC 23-97; VAOPGCPREC 9-98. All of these potentially applicable Codes have been considered. In considering the evidence of records and the law and regulation as set forth above, the Board concludes that the Veteran was not entitled to a rating in excess of 10 percent for arthritis and limited range of motion of the knees, under diagnostic codes 5003-5260. In July 2014, the Veteran had a VA examination. He reported constant bilateral knee pain, worse on the left side. He stated his knee pain was also worse in the last five years. He had pain of an eight to nine out of ten in the left knee and pain at a five out of ten in the right knee. For pain relief the Veteran reported using topical creams, and over the counter pain medication. He also used a left knee brace. See C&P Exam received July 2014. The initial range of motion of the Veteran's right knee was zero degrees extension to 135 degrees flexion. For the left knee, initial range of motion was zero degrees extension to 130 degrees flexion, but pain began at 125 degrees flexion. The range of motion was the same with repetitive motion and flare-ups were not reported. The Veteran had full strength in both knees. He had normal anterior stability, normal posterior stability, and normal medial-lateral stability in both knees. The Veteran used a brace occasionally for his knees. Id. In August 2016, the Veteran had imaging of his left knee. The imaging found an old patellar fracture deformity status post internal fixation with cerclage wires. The main cerclage wire had several fractures with a probable small cerclage wire fragment along the lateral posterior margin of the proximal tibia. The Veteran also had mild tricompartmental osteoarthritis of the left knee with mild chondrocalcinosis. See CAPRI received December 2016. Then in October 2016, the Veteran had an appointment with an orthopedic specialist at the VA. The Veteran reported pain in his knees for over twenty years, worse in the left knee. His knee pain was aggravated by standing, walking, sitting, climbing stairs, and descending stairs. He reported stiffness in his knees after sitting and in the morning. The Veteran's knees had essentially full range of motion, zero degrees to 135 degrees. The Veteran's knees did not swell, lock, or catch, and were stable. The VA provider recommended that the Veteran use bracing for his knee and he was referred for a Don Joy brace. Id. The Veteran was also prescribed NSAID medications and cortisone or viscosupplementation injection was discussed. Id. In March 2017, the Veteran had imaging of his right knee showing mild medial and lateral compartment osteoarthritis. See CAPRI received February 2018. In March 2018, the Veteran had another knee and lower leg conditions VA examination. See C&P Exam received March 2018. The Veteran reported that he had a decreased ability to stand or walk for prolonged periods of time secondary to bilateral knee pain. Id. The initial range of motion of the Veteran's right knee was two degrees extension to 110 flexion, and for the left was four degrees extension to 100 flexion. Repetitive testing did not change the range of motion of the knees. Id. The Veteran had full strength on flexion but four of five, reduced strength, on extension. He had normal anterior stability, normal posterior stability, normal medial stability and normal lateral stability in both knees. The Veteran had no ankylosis, and no shin splints. The Veteran regularly used braces and a cane. He also had crepitus, pain, and diffuse tenderness in both knees. Id. Then in June 2019, the Veteran had another VA examination. See C&P Exam received June 2019. The Veteran reported that he had constant pain, swelling, and aching in his knees. He reported that at night his knees would lock up at times. The Veteran reported flare-ups of pain in his knees about three to four times a month and during changes in weather. The Veteran stated that pain contributed to loss of function in his knees. The range of motion of the Veteran's right knee on repetitive use or flare-ups was zero degrees to 135 degrees flexion. For the left knee, range of motion on repetitive use was zero degrees to 130 degrees flexion. The Veteran had no ankylosis, no shin splints, and normal stability testing in the knees. The Veteran used over the counter immobilizers for his knees for comfort and support. The Veteran reported occasionally using a cane. Id. Then in October 2019, the Veteran had another VA knee and lower leg conditions examination. See C&P Examination received October 2019. The Veteran reported constant aching in his knees at about a four to an eight out of ten on the pain scale. The Veteran also reported instability of both knees since 1987. The range of motion of the Veteran's right knee on repetitive use over time was zero degrees to 120 degrees flexion. For the left knee, range of motion on repetitive use over time was zero degrees to 120 degrees flexion. The Veteran's knees had full strength, no ankylosis, and normal joint stability. The Veteran had no shin splints. Id. The examiner at the October 2019 examination stated that the Veteran could walk for only five to ten minutes at one time. The examiner stated that the Veteran could stand in one position for no more than 25 minutes, and he could not climb stairs, not squat, and never run. Id. The Board considered all the evidence of record, not just the evidence discussed above. However, the Veteran's range of motion in his knees on examination does not warrant a higher rating. The Veteran is currently rated under DC 5003 (prior to the regulatory change on February 7, 2021) based on arthritis in his knees as well as limitation of flexion. Specifically, the Veteran's limitation of flexion in his knees still falls under the noncompensable range under DC 5260. 38 C.F.R. § 4.71a, DC 5003. The Board notes the rule change after February 7, 2021 but finds that the rule prior to the change is more favorable to the Veteran. The range of motion in the Veteran's knees does not warrant a higher rating under DC 5260. In order to receive a rating of higher than 10 percent for his knees, the Veteran would need flexion to be limited to 45 degrees or less. The Veteran clearly has pain and slightly reduced flexion on examinations in both knees; however, examinations do not show flexion even around 45 degrees at any time since the claim was filed. As to DC 5261, examinations also do not show limitations of extension in a compensable range. As to the other Diagnostic Codes available and applicable to the knee, the evidence does not show ankylosis of the knee. The evidence of record has not shown recurrent subluxation or lateral instability of the knee throughout this portion of the appeal. The evidence does not show dislocated semilunar cartilage with frequent episodes of locking, pain and effusion. There is no evidence of tibia impairment, fibula impairment, genu recurvatum, or shin splints. The Board recognizes that the Veteran has reported some instability in his knees. Lay evidence as to lateral instability should be weighed on a case-by-case basis. English v. Wilkie, 30 Vet. App. 347 (2018). The Board properly considered the Veteran's statements about knee instability. However, the Board finds in this case the evidence of recurrent subluxation or lateral instability of the knee was not well supported. For example, in October 2019, the examiner considered the Veteran's reports of knee instability. The Veteran reported to the examiner that he had a feeling of knee instability since 1987 when walking. See C&P Exam received October 2019. The VA examiner stated that no instability was found on orthopedic examination dated in September 2019, June 2019 and that the examiner's testing on that day was also unremarkable. Id. The Board finds the statements or opinions of the October 2019 VA examiner to be significantly more probative than the Veteran's lay assertions as to knee instability in this case. As of February 7, 2021, the Board also considered the new criteria related to knee instability under DC 5257. However, for the same reasons discussed above, the evidence does not well support persistent or recurrent knee instability. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). In the present case, the Veteran's pain has been considered in the application of the current 10 percent disability rating under Diagnostic Code 5003-5260. As such, any assignment of a separate disability rating based purely on painful motion would result in "pyramiding." 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. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In conclusion, looking at the record as a whole, the Veteran's service-connected right knee disability was properly evaluated under Diagnostic Code 5003-5260, at 10 percent. As a preponderance of the probative, credible evidence of record weighs against a finding of a rating in excess of 10 percent, at any time during the pendency of the appeal, for the Veteran's bilateral knee disability rated under DC 5003-5260, the benefit of the doubt doctrine does not apply, and the appeal for a rating in excess of 10 percent must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to TDIU due to service-connected disabilities is granted. The Veteran testified at the hearing that he had not worked in three years. While the Veteran retired from his last job, he mainly left work due to prostate cancer. He explained that dealing with prostate cancer was very difficult and that after that he lost his son. He reported that he had more difficulty with PTSD after that time. The Veteran also reported that he has had ongoing difficulty with his knees. See Hearing Transcript received October 2018. After a thorough review of the evidence, the Board concludes that the Veteran's service-connected bilateral knee disabilities, post-traumatic stress disorder (PTSD), and prostate cancer prevented him from obtaining and maintaining substantially gainful employment since October 2019. Entitlement to TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestead v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran has a combined rating of between 100 percent and 80 percent since August 4, 2015. The Veteran's residuals from prostate cancer have also been rated above 40 percent since August 4, 2015. The Veteran is also rated at 30 percent for PTSD since November 17, 2016, and degenerative joint disease of the knee at 10 percent for each knee since March 2014. Therefore, the Veteran meets the basic eligibility for TDIU since August 4, 2015. Next, the Board considered whether the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, including his residuals from prostate cancer, PTSD, and degenerative joint disease in both knees. The Veteran reported that he was last employed around November 2015 as a regional engineering service manager. The Veteran reported two years of college and no recent education or training since he was disabled. See VA 21-8940 received May 2019. The Veteran's last employer stated that the Veteran retired December 31, 2015. See VA 21-4192 received August 2019. Before retiring the Veteran worked a 40-hour work week. The Veteran lost no time the last twelve months of work due to disability. The Veteran was provided no concessions for reasons of age or disability. Id. Considering the evidence, the Board finds the Veteran's claimed unemployment to be credible since December 31, 2015. See 38 C.F.R. § 3.303(b); see also Charles v. Principi, 16 Vet. App. 370 (2002); Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Board notes that just because the Veteran retired in December 31, 2015, that does not mean that the Veteran's worsening service-connected injuries did not prevent him from working at a later date. The Veteran testified that dealing with prostate cancer was hard for him and that was part of why he retired or left work. See Hearing Transcript received October 2018. During the VA examination for PTSD, the Veteran stated that he retired due to the prostate cancer diagnosis and that he was having some difficulty dealing with others on the job. See C&P Exam received June 2019. The Veteran also testified that he had increased difficulties with his mental health after he left work. The Veteran also had a reoccurrence of prostate cancer. See Hearing Transcript received October 2018, see also C&P Exam received June 2019. Based on symptoms of PTSD, a VA examiner stated in June 2019, that the Veteran had mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks during periods of significant stress or symptoms. Id. See C&P Exam received June 2019. In October 2019, the Veteran had another knee VA examination. The examiner stated that the Veteran could not walk more than five to ten minutes and that he could not stand in one position for more than 25 minutes. The Veteran also could not walk up or down stairs. He could not squat or run. See C&P Exam received October 2019. The Veteran also reported in February 2020, that he felt his ability to work was limited by his frequent symptoms related to prostate cancer. His provider stated that he had stress incontinence with physical activity and that he used up to eight pads a day due to urine leakage. See Medical Treatment Record Non-Government Facility received February 2020. In January 2021, a VA examiner performing a urinary tract examination stated that the Veteran's residual from prostate cancer required absorbent materials which needed changing multiple times a day. The Veteran also needed to be in close proximity to a restroom. See C&P Exam received January 2021. As discussed above, the Veteran also has frequently described pain in his knees to VA examiners and treatment providers. He reported worse pain in the left knee than the right. At the VA, orthopedic treatment providers suggested that the Veteran use bracing, shock absorbing heel inserts and assistive devices for management of his bilateral knee condition. See CAPRI received February 2018. In February 2019, the Veteran outpatient visits with primary care reported that the Veteran used a cane and orthopedic brace for his knees. See CAPRI received May 2019 The Board finds that the evidence is at least in equipoise as to whether the Veteran's service-connected disabilities rendered him unemployable. The VA examinations did not conclude that the Veteran's service-connected disabilities resulted in total occupational impairment; however, this does not preclude a finding that his service-connected disabilities substantially affected employment. The evidence of record shows that the Veteran's service-connected disabilities, PTSD, prostate symptoms, and severe knee pain, altogether had a significant effect on his ability to work. Given the impairment produced by his service-connected disabilities, it appears that the Veteran would not have been capable of more than marginal employment in any type of work setting. See Ortiz-Valles v. McDonald, 28 Vet. App. 65, 72 (2016). Thus, the Board will resolve reasonable doubt in the Veteran's favor and find that he was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. 38 U.S.C. § 5107, 38 C.F.R. § 4.16. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Associate Counsel, C. Parnell 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.