Citation Nr: 21028260 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 14-17 685 DATE: May 10, 2021 ORDER Entitlement to an initial rating greater than 10 percent for degenerative disc disease and spondylosis of the cervical spine (neck condition); and in excess of 20 percent since October 13, 2016 is denied. Entitlement to an initial rating greater than 10 percent for low back strain with degenerative disc disease (back condition); and in excess of 20 percent since June 5, 2018 is denied. Entitlement to an initial rating greater than 10 percent for right knee patellofemoral syndrome with osteoarthritis is denied. Entitlement to an initial rating greater than 10 percent for left knee patellofemoral syndrome with osteoarthritis is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. Prior to October 13, 2016, the Veteran's neck condition manifested in painful limitation of motion, but without forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 2. Since October 13, 2016, the Veteran has had an abnormal spinal contour, but no greater limitation in his range of motion. 3. Prior to June 5, 2018, the Veteran had painful motion of his lumbar spine, but without forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 4. Since June 5, 2018, the Veteran has had an abnormal spinal contour, but no greater limitation in his range of motion. 5. The Veteran's right knee has manifested in painful motion but does not approximate limitation of motion equivalent to 30 degrees of flexion and/or 10 degrees of extension or less. 6. The Veteran's left knee has manifested in painful motion but does not approximate limitation of motion equivalent to 30 degrees of flexion and/or 10 degrees of extension or less. 7. The Veteran's service-connected disabilities have not prevented him from obtaining and maintaining employment consistent with his occupational and vocational experience. CONCLUSIONS OF LAW 1. The criteria an initial rating greater than 10 percent for a neck condition; and in excess of 20 percent since October 13, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242, 5243. 2. The criteria for an initial rating greater than 10 percent for a back condition; and in excess of 20 percent since June 5, 2018 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242, 5243. 3. The criteria for an initial rating of 10 percent for a right knee condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260. 4. The criteria for an initial rating of 10 percent for a left knee condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260. 5. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.10, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1983 to October 1989. By way of history, the Veteran initially applied for service connection for the claims on appeal on February 6, 2008. An October 2012 rating decision granted service connection for the claims on appeal. Thereafter, the Veteran appealed those initial ratings to the Board of Veterans Appeals (Board). Once on appeal, the Board remanded the Veteran's claims in March 2018 and April 2020. These claims have returned to the Board for adjudication. The Board also remanded the claim for a separate compensable rating for left lower extremity radiculopathy. Service connection for this disability was granted in an October 2020 rating decision. The Veteran had previously been granted service connection for radiculopathy of the right lower extremity in an October 2012 rating decision. The Board notes that as part of an increased rating claim, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, at Note 1. In this instance, the Board declines to assume jurisdiction over the ratings for the Veteran's radiculopathy disabilities in this appeal: radiculopathy of both the bilateral upper and lower extremities. The Veteran did not appeal the rating for his right lower extremity radiculopathy condition in the July 2013 notice of disagreement, but he did specifically appeal the other musculoskeletal issues. Further, the Veteran did not file a notice of disagreement with the rating assigned for the separate compensable rating for his left lower extremity. (While the Veteran's representative included the claim in the December 2020 brief to the Board, the representative listed the issue as "entitlement to service connection for left lower radiculopathy" which had already been granted). As for radiculopathy of the bilateral upper extremities, that matter was remanded separately for the issuance of a statement of the case (SOC) and the Veteran did not separately appeal that issue to the Board after the issuance of a May 2018 SOC. Therefore, the Board will not consider the ratings for the Veteran's radiculopathy disabilities in this decision. In the April 2020 Board Remand, the Remand instructions specifically directed the examiner as follows: "The examiner must note whether the Veteran demonstrates objective evidence of pain on motion and, if so, at what degree of motion he demonstrates such objective evidence." There are other similarly emphasized instructions in the Remand. The Board has reviewed the examinations in response to the Remand instructions. While the examination does not specifically follow the directives, the Board finds that there was substantial compliance with the instructions and no additional remand is required. See Stegall v. West, 11 Vet. App. 268 (1998). The Board interprets the previous remand instructions as an attempt to obtain a fuller picture of what the Veteran's pain levels were and his limitations during flares and repeated use, and functional loss related to the same. The Board finds the October 2020 examinations' descriptions to be sufficient because they attempted to ascertain that information. Increased Rating The Veteran contends that he should be entitled to higher ratings for his service-connected neck, back, and bilateral knee conditions. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In this case, separate evaluations are warranted as explained below. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Diagnostic Code 5003 provides that degenerative arthritis that is 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. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In addition to the general criteria for increased ratings claims, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Further, the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). At varying points in the record, the Veteran's neck and back disabilities include a diagnosis of intervertebral disc syndrome (IVDS). Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. The Board has considered the medical records and does not find evidence of incapacitating episodes. Further, the Veteran has contended that he has had such episodes. Thus, the Board will consider the Veteran's neck and back conditions under the General Rating Formula for Diseases and Injuries of the Spine. Further, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, at Note 1. However, aside of the radiculopathy disabilities discussed in the introduction, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his neck, back, and knee disabilities. 1. Initial rating greater than 10 percent for a neck condition; and in excess of 20 percent since October 13, 2016 The Veteran contends that he should be awarded higher ratings for his neck. In February 2008, the Veteran stated that he had constant pain in his neck. In May 2013, he reported pain and pain going into his right arm. In May 2014, he asserted that his neck condition had worsened. However, since that time, the Veteran has not submitted any lay statements about his condition. The remainder of the evidence consists of medical records. The Veteran was originally service-connected for his neck effective February 6, 2008 and awarded a 10 percent rating under Diagnostic Code 5242-5243. In a December 2016 rating decision, the Veteran's rating was increased to 20 percent effective October 13, 2016, the date the Veteran filed a "claim for increase," even though the Veteran's claim was on appeal. This increase appears to correlate with the November 2016 VA examination discussed below. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Evidence The Board finds the VA examinations to be the most probative evidence of record related to the Veteran's neck disability. While there are treatment records noting neck pain, there are no VA or private treatment records that provide a numerical equivalent to range of motion lost. Of those that do discuss range of motion, it is noted as full or within normal limits. The Veteran has been afforded several VA examinations during the period on appeal. The first came in April 2012. The Veteran complained of pain and that he had flare-ups once a month, that lasted 5-6 days, where he would have more pain and stiffness. The Veteran's forward flexion was 45 degrees, with a total painful range of motion at 225 degrees. The Veteran did not have additional range of motion lost after repetitions or repeated use. The examiner stated that the Veteran had functional loss in the form of painful and reduced movement. The remainder of the examination was within normal limits. The Veteran's second examination was in November 2016. He reported increased neck pain and that he had functional loss because he was limited to lifting 10 pounds and driving was difficult due to his reduced range of motion. He did not report flare-ups. Upon range of motion testing, the Veteran had forward flexion to 30 degrees, and total range of motion of 210 degrees. The Veteran had pain in his neck during passive range of motion and in all active ranges of motion. The Veteran did not have additional range of motion lost after repetitions or repeated use. He had muscle spasms resulting in an abnormal spinal contour due to guarding of his neck. The remainder of the examination was within normal limits. The next examination was in June 2018. He reported functional loss in that he had a limited ability to lift and twist his neck and look over his shoulder. He did not report flare-ups, but stated that his limitations were worse with repetitive use and during flares. Upon range of motion testing, the Veteran had forward flexion to 45 degrees and total range of motion of 205 degrees. During active range of motion, the examiner gave the estimation that the Veteran's total range of motion would be limited to 180 degrees, but his cervical flexion would not be more limited. The Veteran had pain in all ranges of motion. The Veteran did not perform repetitive use testing due to "pain and safety." He had muscle spasms resulting in an abnormal spinal contour due to guarding of his neck. The Board interprets the refusal to perform repetitive testing to be accounted for by the Veteran's guarding of his neck. The Veteran's most recent examination was in October 2020. The Veteran reported regular neck pain exacerbated by attempts at strenuous activities and was no longer able to run because of neck pain. The Veteran did not report flare-ups of neck pain. His initial range of motion was completely within normal limits, with pain in all motions, but the pain didn't cause functional loss. He had pain in non-weightbearing and during passive range of motion. After repetitions and repeated use, there would be no additional range of motion lost. The Veteran did not have guarding of his neck. The remaining examination was completely within normal limits. The examiner gave the opinion that due to his neck, he would limited in performing strenuous activities such as heavy lifting, pushing, or pulling. Analysis Given the above, the record does not substantiate that ratings in excess of those currently assigned are warranted. In order to warrant a higher initial rating, prior to October 13, 2016, the Veteran's neck would have to meet one of the following: forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. At most, the Veteran's forward flexion was 45 degrees and his total range of motion was 225 degrees. During this period, there was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour and the Veteran has not contended otherwise. After October 13, 2016, the Veteran had muscle spasms resulting in an abnormal gait or abnormal spinal contour. However, the Veteran did not have flexion of the cervical spine to 15 degrees or less or ankylosis. After October 13, 2016, at most the Veteran's forward flexion was limited to 30 degrees. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran only reported flare-ups at his first exam in April 2012, which was flare-ups of pain. While the Veteran reported pain, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. In this instance, the Veteran's statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher rating would be warranted The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's report of pain and limitation of function. Despite the Veteran's contention of a greater degree of limitation on his neck condition, the disability rating assigned herein indicates a significant impact on his functional ability. Such disability evaluations assigned by VA recognizes his painful motion. The critical question in this case, however, is whether the problems he has cited meet an even higher level under the rating criteria. For reasons cited above, the Board finds they do not. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for increased ratings for the Veteran's neck disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an initial rating greater than 10 percent for a back condition; and in excess of 20 percent since June 5, 2018 The Veteran contends that he should be awarded higher ratings for his back. In February 2008, the Veteran stated that he had constant pain in his back and with low back spasms. In May 2013, he reported that he has recurrent back spasms, limited motion, and trouble lifting. In May 2014, he asserted that his back condition had worsened. However, since that time, the Veteran has not submitted any lay statements about his condition. The remainder of the evidence consists of medical records. The Veteran was originally service-connected for his back from February 6, 2008 and awarded a 10 percent rating under Diagnostic Code 5243. In a May 2019 rating decision, the Veteran's rating was increased to 20 percent June 5, 2018. This correlates with the June 2018 VA examination discussed below. The Veteran's back disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5243. As discussed above, because there is no evidence of incapacitating episodes, the Veteran's disability will be rated under the General Rating Formula for Diseases and Injuries of the Spine. Under than formula, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Evidence The Board finds the VA examinations to be the most probative evidence of record related to the Veteran's back disability. While there are treatment records noting back pain, there are no VA or private treatment records that provide a numerical equivalent to range of motion lost. Of those that do discuss range of motion, virtually all note it as full or within normal limits. The Veteran's first VA examination was in April 2012. He reported pain since he exited service. He reported flare-ups of severe pain and stiffness, that occur once a month and last several days. Upon range of motion testing, the Veteran had forward flexion at 80 degrees and a total range of motion of 200 degrees. The Veteran did not perform repetitive testing due to pain and safety. The examiner gave the opinion that the Veteran did not have additionally limited range of motion after repeated use, but that he had functional loss to include pain and limited movement. The remainder of the examination was within normal limits, except for some scoliosis. The Veteran was functionally limited in standing and bending. The Veteran's next examination was in June 2018. The Veteran reported that his back would flare up a few times per year, with increased pain and stiffness, and severe restrictions in bending, lifting, and twisting. Upon range of motion testing, the Veteran's forward flexion was limited to 70 degrees and his total range of motion was limited to 165 degrees, with pain in all ranges of motion. His active range of motion was estimated to reduce his over range of motion to 140 degrees total. The Veteran did not perform repetitive use due to pain and safety. As for repeated use and during flare-ups, the examiner could not calculate an estimated range of motion lost after consulting with the Veteran. The Veteran had guarding that resulted in an abnormal gait, described as a slight limp and guarding during range of motion testing. The remaining examination was within normal limits. The Board interprets the refusal to perform repetitive testing to be accounted for by the Veteran's guarding of his back. The Veteran's most recent examination was in October 2020. The Veteran reported progressive intermittent back pain exacerbated by strenuous activities. He no longer enjoyed running because of lower back pain. He did not report flare-ups of back pain. Upon range of motion testing, he had forward flexion at 70 degrees and 170 degrees total, with pain upon retrieving items from the floor and pain in all ranges of motion. There was no additional range of motion lost after repetitive and repeated use. The Veteran had no guarding or muscle spasm and no additional functional loss. The examiner gave the opinion that due to his neck, he would limited in performing strenuous activities such as heavy lifting, pushing, or pulling. Analysis Given the above, the record does not substantiate that ratings in excess of those currently assigned are warranted. In order to warrant a higher initial rating, the Veteran's back would need to manifest in forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Here, the Board does not so find. At most, prior to June 2018, the Veteran's forward flexion was 80 degrees, with a combined range of motion of the thoracolumbar spine of 200 degrees. While the April 2012 examination noted some scoliosis, the examiner did not link it to muscle spasm or guarding severe enough to result in an abnormal spinal contour. Since June 5, 2018, the Veteran has had muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, but no greater degree of range of motion lost or ankyloses. The Board notes that the April 2012 examiner did not perform repetitive testing due to "pain and safety." However, the contemporaneous medical records do not reveal that there was an objective reason to not perform the testing. The Veteran had complaints of muscle spasms and tenderness, but the Veteran did not assert he felt unsafe doing lumbar movements. Further, there is no evidence of guarding resulting in an abnormal gait as found in the June 2018 examination. The Veteran reported flare-ups during the period at issue, but no examiner provided an estimate of range of motion lost during flare-ups or functional loss. Even so, the Board does not find that the Veteran's range of motion would be additionally limited, even considering the Veteran's pain on weightbearing and non-weightbearing, during passive range of motion, or considering functional loss. To approximate an initial 20 percent rating, the Veteran's range of motion would need to be limited by an additional 20 degrees (80 to 60) and his total range of motion would need to be limited by an additional 80 degrees (200 to 120). As for a rating in excess of 20 percent, the Veteran's forward flexion would need to be limited by an additional 40 degrees (70 to 30). The Board does not find these limitations to be approximated. While the Veteran reported pain, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. In this instance, the Veteran's statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher rating would be warranted The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's report of pain and limitation of function. Despite the Veteran's contention of a greater degree of limitation on his back condition, the disability rating assigned herein indicates a significant impact on his functional ability. Such disability evaluations assigned by VA recognizes his painful motion. The critical question in this case, however, is whether the problems he has cited meet an even higher level under the rating criteria. For reasons cited above, the Board finds they do not. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for increased ratings for his back disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an initial rating greater than 10 percent for right knee patellofemoral syndrome with osteoarthritis 4. Entitlement to an initial rating greater than 10 percent for left knee patellofemoral syndrome with osteoarthritis The Veteran contends that he should be awarded higher ratings for his knees. In February 2008, the Veteran stated that he had constant pain in his knees and his knees would give out and he would lose his balance. In May 2013, the Veteran asserted that he should have separate ratings for his arthritis and patellofemoral syndrome and he was going to get braces. However, since that time, the Veteran has not submitted any lay statements about his condition. The remainder of the evidence consists of medical records. The Board first turns to the Veteran's contention that he should have separate ratings for his arthritis and patellofemoral syndrome. The Veteran was granted initial 10 percent ratings for his knees under Diagnostic Code 5260. As explained in the October 2012 rating decision, while the Veteran's range of motion was not limited enough to meet the criteria for a compensable rating, the Veteran did have painful motion. Thus, a 10 percent rating was warranted under 38 C.F.R. § 4.59. The Veteran has not identified separate functional limitations related to two separate diagnoses and the Board could not identify the same. As the Veteran's knee limitations are appropriately addressed under Diagnostic Code 5260, there is no basis to award a separate rating. Further, to do so would violate the rule against pyramiding. 38 C.F.R. § 4.14. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. While the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant Diagnostic Codes for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, lateral instability and recurrent subluxation of the knee, and meniscal disabilities. The Board will explore all possibilities in this case. Standard range of knee motion is from zero degrees (on extension) to 140 degrees (on flexion). See 38 C.F.R. § 4.71, Plate II. When the limitation of motion is non-compensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint (such as the knee) or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a 0 percent (noncompensable) disability rating is assigned for flexion limited to 60 degrees, a 10 percent disability rating is assigned for flexion limited to 45 degrees, a 20 percent disability rating is assigned for flexion limited to 30 degrees, and a 30 percent disability rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 0 percent (noncompensable) disability rating is assigned for extension limited to 5 degrees, a 10 percent disability rating is assigned for extension limited to 10 degrees, a 20 percent disability rating is assigned for extension limited to 15 degrees, a 30 percent disability rating is assigned for extension limited to 20 degrees; a 40 percent disability rating is assigned for extension limited to 30 degrees; a 50 percent disability rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a. During the pendency of this appeal, VA amended the 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 5257, 5262), effective from February 7, 2021. However, no amendments are implicated in the Veteran's knee ratings. While the Veteran wears braces, instability was not found. Evidence The Board finds the VA examinations to be the most probative evidence of record related to the Veteran's knees. While there are treatment records noting knee pain, there are no VA or private treatment records that provide a numerical equivalent to range of motion (versus a percent a range of motion lost). Of those that do discuss range of motion, it is noted as full or within normal limits. The Veteran's first exam was in April 2012. He carried a diagnosis of osteoarthritis with patellofemoral syndrome. He reported severe flares with pain and stiffness, once a month, lasting a week. Upon range of motion testing, the Veteran's bilateral knees were 0-130 degrees. His functional loss was described as less movement than usual. The Veteran occasionally wore a brace. The examiner gave the opinion that the Veteran would be functionally limited in standing and squatting. The remainder of the examination was within normal limits. The Veteran's second examination was in June 2016. He reported that his knee condition had gotten more severe over time. The Veteran noted increased pain, present most of the time, that averaged 7-8/10 in intensity. He denied any swelling. While he reported he had fallen a few times, he did not think it was due to his knee giving out. He reported flare-ups of increased pain and had to extend his knees to reduce the pain. As for functional loss, he reported he could not run any more or perform prolonged standing, walking, or sitting. Upon range of motion testing, his right knee was 0-110 degrees and his left was 0-95 degrees. There was no pain noted on the examination, tenderness, or crepitus. After repetitive use, there was no additional changes. As for repeated use and during flare-ups of pain, the examiner could not say without mere speculation the degrees of range of motion lost during these episodes, but that the pain could significantly limit functional ability during these episodes. The examiner also stated that the knees would be additionally limited by reduced movement, weakened movement, and disturbance of locomotion, standing, and sitting. (The Board notes that in describing these "additional factors contributing to disability", the examiner suggested a greater level of disability, such as ankylosis and nerve injuries. However, the objective examination does not reveal such limitations and the Board gives these terms little probative weight). The Veteran regularly wore a brace for prolonged periods of walking. As for functional impact, the Veteran reported he could not perform work that would require him to be on his feet "for any length of time." The Veteran's next examination was June 2018. The Veteran reported difficulty with kneeling and squatting. He had flares on average three or four days a month and that when flares occur, his symptoms were worse than those at the examination. He would have increased pain and stiffness and severe restrictions. The examiner and the Veteran were unable to come up with an estimated range of motion lost during flares or repeated use. Upon range of motion testing, the Veteran's right knee was 0-130 degrees and his left was 0-125 degrees. Bilaterally, he had pain on flexion, but not during weightbearing, and there was no tenderness or pain upon palpation, but there was crepitus. The range of motion did not change after repetitive use. The Veteran wore a brace periodically. The remainder of the examination was within normal limits, except that pain was noted on passive range of motion and in non-weight bearing. The Veteran's most recent examination was in October 2020. The Veteran reported progressive, daily bilateral knee pain exacerbated prolonged weight-bearing. He no longer enjoyed running because of knee pain. He did not report flare-ups of his condition. Upon range of motion testing, his knees were bilaterally limited to 0-120 degrees, with pain on flexion and extension, and there was mild tenderness of his knees due to his knee condition. Kneeling and squatting would be affected by his lost range of motion. There was no additional range of motion lost after repetitive use or repeated use. The examiner gave the opinion that no additional factors would contribute to disability. As for a functional impact, the Veteran's knee pain would limit strenuous activities such as heavy lifting, kneeling, or crouching. His capacity for sedentary activities would not be limited. Analysis In order to warrant a higher initial rating, the Veteran's bilateral knee conditions would need to manifest in symptomology approximating a limitation of 30 degrees flexion or 15 degrees extension. Here, the Board finds that the evidence does not support this finding. The Veteran had four examinations on his bilateral knees. Over the eight years of examinations, the Veteran's right knee was limited to between 110 and 130 degrees of flexion and his extension was normal. As for the left knee, it was limited to between 95 and 130 degrees of flexion and his extension was normal. Thus, in order for the Veteran's knee conditions to warrant higher or separate ratings, his knees would have to approximate an additional 65 degrees of flexion lost (95 to 30) and an additional 15 degrees of extension lost (0 to 15). The evidence does not demonstrate such limitations. The examiners were not able to estimate a range of motion lost during flare-ups. The Veteran reported pain, functional loss, and a need to wear braces (for pain), but even considering those complaints, the Board does not find a degree of motion lost to result in a higher rating. While the Veteran reported pain, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. In this instance, the Veteran's statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher rating would be warranted The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's report of pain and limitation of function. Despite the Veteran's contention of a greater degree of limitation on his knee conditions, the disability rating assigned herein indicates a significant impact on his functional ability. Such disability evaluations assigned by VA recognizes his painful motion. The critical question in this case, however, is whether the problems he has cited meet an even higher level under the rating criteria. For reasons cited above, the Board finds they do not. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for his knee conditions. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. TDIU 5. Entitlement to a TDIU The Veteran contends that his service-connected disabilities preclude employment. See Notice of Disagreement, received October 13, 2016. Therefore, a TDIU has been raised by the record in the context of his increased rating claim for tremors. See Rice v. Shinseki, 22 Vet. App. 447, 456 (2009) (holding that a claim for a TDIU is part of an increased rating claim when expressly raised by the Veteran or reasonably raised by the record). The law provides that a total disability rating may be assigned where the schedular rating is less than total 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 are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16 (a). When considering whether the Veteran's disabilities meet this requirement, disabilities affecting a single body system will be considered as one disability. Id. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. See Moore v. Derwinski, 1 Vet. App. 356 (1991). Factors to be considered in determining whether unemployability exists are the Veteran's education, employment history, and loss of work-related functions due to pain. Ferraro v. Derwinski, 1 Vet. App. 326, 330, 332 (1991). Consideration may not be given to the veteran's age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The ultimate question is whether the veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board notes that after entitlement to a TDIU was remanded, the AOJ requested the Veteran submit information to assist his claim, to include the completion of VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. The AOJ sent a second request for information. However, the Veteran did not submit any additional information regarding his education or work history. For the entire period on appeal, the Veteran's ratings have, at most, combined to a 60 percent rating. As such, the Veteran does not meet the schedular requirements for a TDIU set forth in 38 C.F.R. § 4.16(a) at any point during the period on appeal. However, a TDIU evaluation can still be awarded if it is established by the evidence of record that service-connected disabilities have rendered the Veteran unable to secure and follow substantially gainful employment. The Board does not so find. The Veteran's disabilities are solely physical, he does not have any service-connected cognitive or psychological disabilities. While the Veteran may have pain that affects his sleep and concentration, the Veteran is not otherwise limited in regards to his social interaction, memory, and ability to follow instructions. Therefore, the Board does not find that jobs that allow sitting or a sit-stand option to be precluded by the Veteran's service-connected disabilities. While the Veteran did not identify his vocational and educational profile, it is clear from a review of the file that the Veteran was pursuing vocational rehabilitation during the period on appeal and believed himself capable of such rehabilitation to perform work or get additional training. Therefore, he is not unemployable; his service-connected disabilities have not rendered him unable to secure or follow substantially gainful employment. See 38 C.F.R. § 4.16 (a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013) (in a claim for TDIU, the ultimate question of whether a Veteran is capable of substantially gainful employment is not a medical one; that determination is for the adjudicator); see also Gilbert, supra. Therefore, the entitlement to a TDIU is denied. K. ANDERSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. M. Hitchcock 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.