Citation Nr: 21028096 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 15-32 678 DATE: May 10, 2021 ORDER Entitlement to an increased rating in excess of 10 percent for left knee degenerative joint disease is denied. Entitlement to an increased rating in excess of 30 percent for right knee tendonitis/tendinosis with prosthetic knee, status post revision surgery is denied. Entitlement to a finding of total disability based individual unemployability due to service-connected disabilities (TDIU), on an extraschedular basis prior to June 20, 2016, is denied. REMANDED Entitlement to service connection for hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. Throughout the appellate period, the Veteran's left knee degenerative joint arthritis has manifested by no more than flexion to limited to 115 degrees. 2. Throughout the appellate period, the Veteran's right knee tendonitis/tendinosis manifested as prosthetic replacement of the right knee with intermediate degrees of residual weakness, pain, or limitation of motion. 3. The evidence does not establish that the Veteran's service-connected bilateral knee disabilities and back disability prevented him from obtaining and maintaining substantially gainful employment due to his service-connected disabilities prior to June 20, 2016. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for degenerative joint disease, left knee are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260. 2. The criteria for an initial evaluation in excess of 30 percent for right knee tendonitis/tendinosis status post total knee replacement are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055. 3. The criteria for entitlement to TDIU, on an extraschedular basis, prior to June 20, 2016 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from February 1982 to January 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2014, December 2015, and February 2016 rating decisions by the Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran testified at a December 2018 videoconference hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided in Fully Developed Claims forms submitted by the Veteran. The RO associated the Veteran's service and VA private outpatient treatment records with the claims file. All released or submitted private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding. Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. As such, VA has satisfied its duty to assist with the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating 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. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; 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). 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). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 (West 2002); 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. It should also be noted that, when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. The intent of the rating schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. The Veteran's left knee degenerative joint disease has been assigned a 10 percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5260-5003. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. The Veteran's right knee tendonitis/tendinosis with prosthetic knee status post revision surgery has been assigned a 30 percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board notes that the rating criteria for musculoskeletal disorders were revised on February 7, 2021. The amended regulations became effective on February 7, 2021 and claims that were pending on this date must be considered under the former and revised criteria with the most favorable version applied to the claim. 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 Codes 5003, 5055, 5257, 5262). Code 5003, for degenerative arthritis, does not permit assignment of an evaluation greater than the currently rated 10 percent, and so will not be discussed further. 38 C.F.R. § 4.71a, Code 5003. There are numerous Diagnostic Codes which are potentially applicable to evaluation of a knee disability. Code 5256 is utilized for evaluation of ankylosis or the functional equivalent; as there is motion of the left knee, this Code is not applicable here. Code 5257 evaluates disabilities of the knee based on the degree of subluxation and instability of the joint, which is not shown here. Codes 5258 and 5259 evaluate impairment of the semilunar cartilage, or menisci, but no involvement of those tissues is noted here. While evaluations under Code 5262 may be based in part upon knee disability, the underlying impairment must be related to damage to the bones of the lower leg. No tibia or fibula impairment is shown here. 38 C.F.R. § 4.71a. For limitation of motion, there are two potentially applicable Diagnostic Codes; the rating criteria for these codes were unaffected by the new regulations. Code 5260 assigns evaluations based on limitation of flexion. Limitation to 60 degrees merits a noncompensable, or 0 percent, evaluation. A 10 percent evaluation is assigned for limitation to 45 degrees. Limitation to 30 degrees flexion warrants a 20 percent evaluation, and a 30 percent evaluation is assigned for limitation to 15 degrees of flexion. 38 C.F.R. § 4.71a, Code 5260. Limitation of extension is rated under Code 5261. Simultaneous ratings for impairments in both planes are allowable, but in this instance, no limitation of extension is noted. Pursuant to the former criteria for Code 5055, knee replacement (prosthesis), a prosthetic replacement of the knee joint with intermediate degrees of residual weakness, pain or limitation of motion was rated by analogy to diagnostic codes 5256, 5261 or 5262 minimum rating was 30 percent. A 60 percent evaluation was assigned for prosthetic replacement of the knee with chronic residuals consisting of severe or painful motion or weakness in the affected extremity. A 100 percent evaluation was assigned for one year following implantation of prosthesis. 38 C.F.R. § 4.71A, Diagnostic Code 5055 (2020). Under the new rating criteria, Code 5055 applies to knee resurfacing or replacement. Prosthetic replacement of the knee joint with intermediate degrees of residual weakness, pain or limitation of motion is rated by analogy to diagnostic codes 5256, 5261, or 5262; a minimum 30 percent evaluation is assigned for a total replacement only. Prosthetic replacement of the knee joint with chronic residuals consisting severe painful motion or weakness in the affected extremity is assigned a 60 evaluation. A 100 percent evaluation is assigned for 4 months following implantation of prosthesis or resurfacing. 38 C.F.R. § 4.71A, Diagnostic Code 5055 (2021). The words "intermediate" and "severe" as used in the various Codes are not defined in the VA Schedule for Rating Disabilities. Rather than apply a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although not an element of evidence 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. VA treatment records reflect the Veteran's history of two right total knee replacements and treatment for complaints of knee pain. The Veteran underwent a VA knee examination in March 2014. The VA examiner noted the Veteran's diagnosis of degenerative joint disease, left knee bursitis and arthralgia of the right knee. The Veteran reported that flare-ups of his bilateral knee condition impacted function of his knees in that his knee conditions are worse with climbing ladders, prolonged standing, squatting, and going up and down stairs. Range of motion of the right knee was flexion to 120 degrees, with objective evidence of painful motion beginning at 60 degrees, and extension to 0 degrees with no pain. Left knee range of motion was flexion to 135 degrees, with objective evidence of painful motion beginning at 65 degrees, and extension to 0 degrees with no pain. Ranges of motion remained unchanged after repetitive use testing. No additional limitation of range of motion or functional loss and/or functional impairment were noted after repetitive-use testing. Pain on palpation was present in both knees. Muscle strength testing was 5 out of 5 in both knees on both flexion and extension. Joint stability tests were normal, and there was no evidence of recurrent patellar subluxation/dislocation. The VA examiner noted the Veteran has had a meniscus condition in the past and underwent a meniscectomy. He also had a right knee replacement with residuals of intermediate degrees of residual weakness, pain, or limitation of motion. The Veteran occasionally used a brace and regularly used as cane to assist with ambulation. X-rays revealed degenerative arthritis in left knee and right knee replacement. Private medical records dated April 2014 for a six month follow up for the Veteran's status post right knee revision replacement noted the Veteran was doing very well and that he had reached a plateau in that he was stable. VA treatment records continue to reflect treatment for bilateral knee pain. The Veteran continued to attend physical therapy for his knees. The Veteran underwent a VA knee and lower leg examination in December 2015. The VA examiner noted the Veteran's diagnoses of degenerative arthritis, left knee and tendonitis/tendinosis, right knee. The Veteran reported experiencing left knee pain, especially on inclines going up/down. He stated that his left knee is the better knee and has to carry the work of mobility and of balancing because his right knee has considerable dysfunction. The Veteran stated that his right knee is the more dysfunctional knee. Prothesis was placed pre-military and eventually was replaced twice. The Veteran was wearing a hinged brace at the examination. He stated that his right knee is getting generally a "bit more sore and a bit more limiting; especially when walking up and down stairs" and from daily short walks. He cannot flex more than 100 degrees but can fully extend. The Veteran's reported that his "good knee" the left knee does not seem to flare under normal use. His "bad knee" the right knee distinctly can flare with use, and limits mobility to several hundred yards on the level, plus much shorter distances up/down ramps or stairs. Functional loss or functional impairment was described as limitation of flexion of the right knee to 100 degrees and absolute need of hinged brace for stability when walking. Range of motion of the right knee was from 0 to 100 degrees, extension was from 0 to 100 degrees. Range of motion of the right knee contributed to functional loss in that the Veteran cannot easily get into and out of vehicles and must use caution going up and down stairs. Pain was noted on examination in both flexion and extension and caused functional loss. Pain and tenderness medial posterior to knee joint prosthesis, and lateral to this prosthesis. Range of motion of the left knee was flexion from 0 to 135 degrees and extension from 135 to 0 degrees, no pain was noted on examination. No objective evidence of localized tenderness or pain on palpation of the left knee was noted. The Veteran was able to perform repetitive use testing on both knees which did not result in any additional functional loss or range of motion after three repetitions. An additional contributing factor of disability that impacts the right knee is instability of station without use of the hinged knee. Muscle strength test results were 4 out of 5 for right knee forward flexion and extension and 5 out of 5 form left knee forward flexion and extension. No muscle atrophy or ankylosis was present in either knee. No history of recurrent subluxation or history of lateral instability was noted. Joint stability test results were normal for left knee and were not able to be performed for right knee. The Veteran's total right knee replacements was noted to have intermediate degrees of residual weakness, pain, or limitation of motion. The VA examiner noted that since the installation of the Veteran's right knee prosthesis, he has arthralgias, limited flexion and pain in/around the prosthesis. In addition to the brace, the Veteran uses a cane to promote stability while walking. X-rays taken in August 2015 revealed right knee replacement, and minor varus deformity and degenerative joint disease on the left knee. The VA examiner noted that the left knee is vulnerable to changes because it is doing the "brunt work of mobility/propulsion, due to weakness and dysfunction of the right knee prosthesis." At his December 2018 hearing the Veteran testified that his left knee is painful and that he relies on it as his main support. He testified that his right knee is weak and gives out; he experiences severe instability and locking of the right knee. The Veteran underwent a VA knee and lower leg contract examination in October 2020. The VA examiner noted the Veteran's diagnosis of right knee tendonitis/tendinosis with prosthetic knee status post revision surgery and his diagnosis of degenerative joint disease left knee. Subjective complaints included pain in both knees and significant tightness in left knee. Flare-ups result in a decreased ability to walk and stand; functional loss or functional impairment was reported as a decreased ability to walk and stand. Range of motion of the right knee was flexion from 0 to 110 degrees and extension from 110 to 0 degrees. Range of motion contributed to functional loss in the Veteran's decreased ability to bend the right knee. Pain was noted on both flexion and extension. Objective evidence of localized tenderness or pain on palpation of joint was noted as "Diffuse right knee over joint; Moderate; Consistent with service-connected right knee tendinitis/tendinosis with prosthetic knee status post revision surgery." Evidence of pain with weight bearing was present, but there was no objective evidence of crepitus. Range of motion of the left knee was flexion from 0 to 120 degrees and extension from 120 to 0 degrees. Range of motion contributed to functional loss in the Veteran's decreased ability to bend the left knee. Pain was noted on both flexion and extension. Objective evidence of localized tenderness or pain on palpation of joint was noted as "Diffuse left knee over joint; Moderate; Consistent with service-connected left knee degenerative joint disease." Evidence of pain with weight bearing was present and there was objective evidence of crepitus. Repetitive use testing resulted in additional loss of range of motion of flexion from 0 to 105 degrees and extension from 105 degrees to 0 degrees right knee; and flexion from 0 to 115 degrees and extension from 115 degrees to 0 left knee. Additional functional loss due to pain in both knees was noted. Pain and lack of endurance were noted to significantly limit functional ability with repeated use over time and with flare-ups, bilaterally. Atrophy of disuse, right knee was noted to be an additional contributing factor of disability. Muscle strength test results were 4 out of 5 for the right knee and 5 out of 5 for the left knee. Muscle atrophy of right calf was present; right calf measured 31 cms, normal side was 33 cms. No ankylosis, no history of recurrent subluxation, no history of lateral instability and no history of recurrent effusion were noted. Joint stability testing was performed, and results were normal for both knees. The Veteran was noted to experience chronic pain and loss of motion of the right knee as residuals of his total knee replacement. The Veteran reported he still has pain from arthroplasty. The Veteran uses a right knee brace and a cane for assistance with ambulation. Objective evidence of pain in non-weight bearing was noted bilaterally and pain was present in passive motion in all planes, bilaterally. The Veteran is unable to walk or stand for more than 5 minutes without a break, and he experiences a decreased ability to walk without a cane or right knee brace. Left Knee The Veteran is seeking an increased initial evaluation in excess of 10 percent for his left knee degenerative arthritis. The Board has carefully considered all the evidence and potentially applicable diagnostic codes, including DeLuca factors, and finds the disability picture of the Veteran's left knee does not warrant a rating in excess of 10 percent. The evidence does not show, at any time during the appellate period, that the Veteran's symptoms meet the criteria for a 20 percent rating pursuant to Code 5260 because the flexion of the Veteran's left knee is not limited to 30 degrees. Even with consideration of the DeLuca factors, the Veteran's knee flexion is not limited to degrees in either knee. Range of motion was limited to 115 degrees, at most, with functional impairment due to pain and lack of endurance noted at the October 2020 VA examination. Therefore, the currently assigned 10 percent disability rating for the left knee contemplates the Veteran's diagnosed condition and functional limitations and compensates him for such. See DeLuca. The Board has considered evaluation under alternative Codes, but no additional compensation is warranted under such. Extension is repeatedly full and complete, and the joint is stable. Accordingly, entitlement to a rating in excess of 10 percent for the Veteran's degenerative joint disease, left knee is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. Thus, the Board finds that the evidence of record is consistent with the 10 percent disability evaluation previously assigned for the Veteran's left knee disability and adequately compensates him for his symptoms. Right Knee The Veteran is seeking an initial increased rating in excess of 30 percent for his right knee tendonitis/tendinosis with prosthetic knee. The Board has carefully considered all the evidence and potentially applicable diagnostic codes, including DeLuca factors, and finds the disability picture of the Veteran's right knee does not more nearly approximate the rating criteria of a higher disability level as the Veteran's symptoms do not reflect severe painful motion or weakness of the right knee. The March 2014 VA examination reflected unchanged ranges of motion of the right knee after repetitive use, with no additional functional loss or impairment. Pain on palpation was present; muscle strength test results were 5 out of 5 and joint stability tests were normal. The December 2015 VA examination revealed functional loss or functional impairment described as limitation of flexion of the right knee and the need of a hinged right knee brace for stability when walking. Pain was noted in both flexion and extension. Muscle strength test results were 4 out of 5 for the right knee; no muscle atrophy or ankylosis was present in the right knee; no history of recurrent subluxation or history of lateral instability was noted. The October 2020 VA contract examination revealed the Veteran was experiencing flare-ups which resulted in a decreased ability to walk and stand, and pain both flexion and extension. Objective evidence of localized tenderness or pain on palpation of joint, pain with weight-bearing and in nonweight-bearing, and pain in passive motion in all planes was noted. The Veteran continued to wear a right knee brace and use a cane for assistance with ambulation. The evidence of record does not show the Veteran's overall disability picture warrants the assignment of a 60 percent rating, pursuant to Code 5055 as the medical evidence of record does not indicate the Veteran was experiencing severe pain or weakness at any time during the appellate period. The Veteran was found to have intermediate degrees of residual weakness, pain or limitation of motion and chronic pain and loss of motion. The medical evidence of record does not indicate that the Veteran experienced frequent falls or required the use of a walker to assist in ambulation which would be indicative of severe weakness of the knee. The Veteran experienced pain in his right knee, but the pain did not even cause limitation of motion to a compensable degree under Code 5260 or 5261. Accordingly, entitlement to a rating in excess of 30 percent for the Veteran's right knee tendonitis/tendinosis status post right knee replacement is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. Thus, the Board finds that the evidence of record is consistent with the 30 percent disability evaluation previously assigned for the Veteran's right knee disability and adequately compensates him for his symptoms. TDIU The Veteran seeks entitlement to TDIU, on an extraschedular basis, prior to June 20, 2016. The Veteran asserts that his service-connected disabilities prevented him from securing and maintaining substantially gainful employment since March 2011. TDIU is granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disability or disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. TDIU may be granted under 38 C.F.R. § 4.16(a) if he meets certain schedular rating requirements, or under § 4.16(b) if he does not, so long as he is incapable of obtaining and maintaining substantially gainful employment on account of his service-connected disability or disabilities. Subsection 4.16(b) explains that it is the established VA policy 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. Therefore, rating boards should submit to the Director, Compensation Service, all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in subsection 4.16(a). 38 C.F.R. § 4.16(b). The Veteran's service-connected bilateral knee, back, right knee scar and right lower extremity radiculopathy disabilities have been rated 50 percent disabling from December 2014 to September 2015 and 60 percent disabling from September 2015 through June 20, 2016; rendering him ineligible for entitlement to a TDIU on a schedular basis. The Veteran filed an Application for Increased Compensation Based on Unemployability, VA Form 21-8940, in December 2015. He indicated that he had last worked full-time in 2011 and that his service-connected conditions prevented him from securing or following substantially gainful employment. The Veteran indicated that he had completed one year of college and that he had applied for VA Vocational Rehabilitation but was denied due to his service-connected conditions. The Veteran's file contains a Social Security Administration (SSA) decision dated November 2016 which reflects that the Veteran was granted disability benefits due to right knee pain, left knee pain and back pain. Beginning in 2014, VA treatment records reflect treatment from complaints of back pain and bilateral knee pain. A June 2014 Vocational Rehabilitation and Employment (VR&E) Services Counseling Record, VA Form 28-1902b, found the Veteran did ot have a serious employment handicap, was entitled to VR&E benefits, and that the achievement of a vocational goal was reasonably feasible because the Veteran's mental and physical conditions permit training for the goals to begin/complete and obtain employment within a reasonable time period; and that the Veteran possesses the educational skills and background to pursue the vocational goal or will be provided services to develop the necessary skills as part of the program. At a March 2014 VA spine examination, the Veteran reported his back condition was worse with prolonged sitting and standing, experiencing severe, constant back pain; worse for standing, bending and when he gets up in the morning and better for sitting, rest, avoidance of activities and prescription medication. The Veteran used a cane and was unable to walk more than a few yards. Range of motion was limited: flexion to 70 degrees, extension to 10 degrees, bilateral lateral flexion from 0 to 15 degrees, left lateral rotation from 0 to 15 degrees, right lateral rotation from 0 to 30 degrees. Objective evidence of pain on motion was noted on flexion and extension. VA examiner noted the Veteran's back disability impacted his ability to work in that it limited in his ability to perform physical and sedentary labor. A VA knee examination was also conducted in March 2014. The Veteran was noted to have flare-ups which impacted function of his knees with climbing ladders, prolonged standing, squatting, and going up and down stairs. Flexion of the right knee was limited to 120 degrees with objective evidence of pain at 60 degrees; flexion of the left knee was limited to 135 degrees with objective evidence of pain at 65 degrees. No limitation of extension was noted. Muscle strength was normal. The Veteran reported occasional use of a knee brace and regular use of a cane to assist with ambulation. The Veteran's bilateral knee conditions were noted to impact his ability to work in that he was limited in his ability to perform physical and sedentary activity. The Veteran underwent a VA back examination in December 2015. The Veteran reported experiencing a re-injury of his back due to a fall. Following the re-injury, he attended physical therapy, did exercises, acupuncture and had one injection. He reported no effective pain relief. He reported that he is being considered for surgery on his low back but was using a back corset and cane. The Veteran reported that he uses back support most of the time, which helps him get into motor vehicle and enables him to sit for sustained travel, it also helps with reduced low back pain when his is going for walks. Range of motion was limited: flexion to 45 degrees, extension to 10 degrees, bilateral lateral flexion from 0 to 15 degrees, left lateral rotation from 0 to 15 degrees, right lateral rotation from 0 to 20 degrees. Pain was noted on all ranges of motion and with weight bearing. The Veteran reported that activities which provoked pain in his back included carrying garbage out, vacuuming, getting in and out of vehicles, bending to put on shoes and socks and bending over to do dishes. The VA examiner stated that the Veteran's back condition impacted his ability to work in that his "low back pain and sensitivity to flares would prevent his return to his prior employment installing and servicing security equipment. His mobility is quite limited, and so is his ability to carry weighty objects. His LBP has been known to flare around the house, when he tries to carry wet laundry (heavy) or tries to help wife by carrying groceries." A VA knee examination was also conducted in December 2015. The Veteran reported pain in the knees that he experienced functional loss in that the range of motion of his knees was limited and he needed a hinged knee brace for stability when walking. d a was noted to have flare-ups which impacted function of his knees with climbing ladders, prolonged standing, squatting, and going up and down stairs. Flexion of the right knee was limited to 100 degrees with objective evidence of pain; flexion of the left knee was limited to 135 degrees with objective evidence of pain. No limitation of extension was noted. Muscle strength of the right knee was 4 out of 5, left knee was 5 out of 5. The Veteran reported occasional use of a knee brace and regular use of a cane to assist with ambulation. The Veteran's bilateral knee conditions were noted to impact his ability to work in that he was limited in his ability to perform physical and sedentary activity. In May 2020, the Board remanded the matter for referral to the Director of Compensation and Pension Service (C&P) for consideration of the Veteran's entitlement to a TDIU on an extraschedular basis, supported by a full statement of the Veteran's service-connected disabilities, educational and vocational attainment, and employment history and all other factors having a bearing on the issue in accordance with 38 C.F.R. § 4.16 (b). In January 2021, a determination was received from the Director of Compensation and Pension which found that the Veteran was not entitled to a TDIU on an extraschedular basis pursuant to the provisions of 38 C.F.R. § 4.16(b) prior to June 20, 2016. The Director noted that from May 31, 2013 to October 9, 2013 the Veteran's combined total disability evaluation was 50 percent for his low back, right knee tendonitis/tendinosis, left knee degenerative joint disease, right knee scar, and right lower extremity radiculopathy. From October 9, 2013 to November 30. 2014 he was in receipt of 100 percent disability due to his total right knee replacement. As of December 1, 2014, his total disability evaluation was 50 percent and as of September 8, 2015 it was 60 percent. In her determination, the Director acknowledges the Veteran's SSA records and SSA's grant of disability entitlement; noting that the medical evidence of record notes the Veteran is limited in his ability to ambulate and transfer from a seated to standing position as well as his ability to carry heavy objects. She stated that although it is conceded that the Veteran's service-connected conditions do cause functional limitations, the preponderance of the evidence does not show that the Veteran is unable to obtain of maintain gainful employment due to his service-connected conditions. The Director determined that the Veteran is not entitled to TDIU on an extraschedular basis. After a thorough review of the record, the Board concludes that the evidence does not demonstrate that the Veteran's service-connected knee and back disabilities prevented him from obtaining or maintaining substantially gainful employment. The medical evidence of record reveals no hospitalizations, surgeries, emergency room visits or intensive outpatient treatment for the Veteran's service-connected knee and back disabilities during the period on appeal from December 2015 to June 2016. The opinions of the VA examiners do not indicate the Veteran's knees and back precluded him from securing and following substantially gainful employment. The Board notes that all the examiners reach the same conclusion that the Veteran's service-connected disabilities impact his ability to work in that he was limited in his ability to perform physical and sedentary activity, but they did not find that the Veteran could not work at all. VA VR&E determined the achievement of a vocational goal was reasonably feasible for the Veteran. VA VR&E found that the Veteran's physical and mental conditions permitted training for the goals to begin/complete and obtain employment within a reasonable time period and that he possessed the educational skills and background to pursue the vocational goal or would be provided services by VA to develop such necessary skills as part of the program. However, the Veteran did not pursue vocational rehabilitation training. Thus, the Veteran does not meet the criteria for TDIU prior to June 20, 2016 as the evidence does not show that the Veteran is incapable of obtaining and maintaining gainful employment due to his service-connected disabilities prior to June 20, 2016. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. REASONS FOR REMAND The Veteran was provided a VA hearing loss and tinnitus examination in August 2019. The Veteran was diagnosed with bilateral sensorineural hearing loss and tinnitus. The VA examiner noted the Veteran's military occupational specialty as an electronics warfare tech and the moderate probability of the Veteran's in-service hazardous noise exposure. The VA examiner documented the Veteran's normal hearing at enlistment and at separation. The VA examiner determined that the Veteran's bilateral hearing loss was not related to service because there were no standard threshold shifts at any frequency 500 6KHz in either ear during active duty. The VA examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was caused by his time in service because there is no evidence of hearing loss or significant permanent threshold shifts occurring during active duty. The Board finds that this opinion is inadequate for adjudication purposes because service connection for hearing loss is not precluded where hearing was within normal limits on audiometric testing at separation from service. See Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). In other words, the examiner did not address the possibility of delayed onset, and simply offered a conclusory "no nexus" statement based on lack of onset in service. On remand, a new VA examination and opinion is required. Additionally, the VA examiner determined that it is at least as likely as not that the Veteran's tinnitus is related to his hearing loss. This issue is inextricably intertwined with the claim for entitlement to service connection for bilateral hearing loss which is being remanded for additional development. Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a hearing loss examination. The claims file must be reviewed in conjunction with the examination. The examiner must state whether or not it is at least as likely as not (50 percent or greater probability) that any currently diagnosed hearing loss is caused or aggravated by service, to include as due to his established acoustic trauma. Delayed onset hearing loss must be specifically addressed. A full and complete rationale for all opinions expressed must be provided. 2. Then, readjudicate the remanded issues. If the benefits sought remain denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Margaret M. Lunger 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.