Citation Nr: 21028955 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 18-37 633 DATE: May 12, 2021 ORDER Service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is denied. A disability rating of 40 percent for gout is granted. A disability rating in excess of 10 percent prior to December 3, 2019, and 20 percent thereafter, for thoracolumbar spondylosis of L5 with degenerative disc disease is denied. A disability rating in excess of 10 percent prior to October 18, 2016, in excess of 10 percent from February 1, 2017 to August 3, 2018 for left knee degenerative joint disease and in excess of 30 percent from October 1, 2019 for left total knee replacement is denied. A disability rating in excess of 10 percent prior to October 1, 2015, and in excess of 10 percent from February 1, 2016 to August 7, 2019 for residuals, internal derangement and degenerative joint disease, status post arthroscopic debridement and repair, right knee, and in excess of 30 percent from October 1, 2020, for right knee total replacement, is denied. A separate rating of 10 percent, but no higher, for instability of the right knee is granted. A total rating based on individual unemployability due to service-connected disabilities (TDIU) is granted effective October 1, 2020. REMANDED Entitlement to service connection for a herniated cervical disc and radiculopathy is remanded. Entitlement to TDIU, prior to October 1, 2020, on an extraschedular basis, is remanded. FINDINGS OF FACT 1. At no time during the pendency of the claim does the Veteran have a current disability of any psychiatric disorder, and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. 2. The Veteran's gout manifestations more closely approximate incapacitating exacerbations occurring three or more times a year. 3. Prior to December 3, 2019, the Veteran's thoracolumbar spondylosis of L5 with degenerative disc disease was manifested by forward flexion greater than 60 degrees and a combined range of motion greater than 120 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, ankylosis, incapacitating episodes due to intervertebral disc syndrome (IVDS), or associated objective neurological abnormalities. 4. After December 3, 2019, the Veteran's thoracolumbar spondylosis of L5 with degenerative disc disease did not manifest in forward flexion limited to 30 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as result of repetitive motion and/or flare-ups, ankylosis, incapacitating episodes due to IVDS, or associated objective neurological abnormalities. 5. Prior to October 1, 2019 and exclusive of periods of total temporary ratings, the Veteran's left knee disability is productive of flexion limited to, at worst, 100 degrees with painful motion; flexion limited to 30 degrees has not been shown at any time. 6. As of October 1, 2019, the Veteran's left knee disability results in no worse than intermediate degrees of residual weakness, pain, or limitation of motion, without chronic residuals consisting of severe painful motion or weakness in the affected extremity. 7. Prior to October 1, 2020 and exclusive of periods of total temporary ratings, the Veteran's right knee disability is productive of flexion limited to, at worst, 90 degrees with painful motion; flexion limited to 30 degrees has not been shown at any time. 8. As of October 1, 2020, the Veteran's right knee disability results in no worse than intermediate degrees of residual weakness, pain, or limitation of motion, without chronic residuals consisting of severe painful motion or weakness in the affected extremity. 9. The evidence shows slight instability due to the Veteran's right knee disability. 10. The probative evidence of record shows that it is at least as likely as not that the Veteran is unable to secure or follow substantially gainful employment due solely to his service-connected disabilities from October 1, 2020. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 C.F.R. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for a 40 percent rating, but no higher, for gout are met throughout the appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5002, 5017. 3. Prior to December 3, 2019 criteria for a disability rating in excess of 10 percent for thoracolumbar spondylosis of L5 with degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5239. 4. Subsequent to December 3, 2019 criteria for a disability rating in excess of 20 percent for thoracolumbar spondylosis of L5 with degenerative disc disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 5. The criteria for entitlement to an initial rating in excess of 10 percent, prior to October 1, 2019, for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. 6. The criteria for entitlement to a disability rating in excess of 30 percent, subsequent to October 1, 2019, for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 7. The criteria for entitlement to a disability rating in excess of 10 percent, prior to October 1, 2020, for a right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. 8. The criteria for entitlement to a disability rating in excess of 30 percent, subsequent to October 1, 2019, for a right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 9. The criteria for a separate rating of 10 percent for instability of the right knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 5003-5257. 10. The criteria for a TDIU are met from October 1, 2020. 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 served on active duty in the United States Navy from June 1985 to March 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in December 2013, April 2015, March 2017 and August 2016 by a Department of Veterans Affairs (VA) Regional Office. The claims other than entitlement to service connection for a herniated cervical disc and radiculopathy were previously before the Board in November 2019. At that time, the Board remanded all but the claim for an increased disability rating for gout, which it denied. The Veteran appealed that denial to the United States Court of Appeals for Veterans Claims (Court). In a December 2020 Joint Motion for Partial Remand (JMPR), the parties agreed that the Board erred in its November 2019 decision when it failed to set forth an adequate statement of reasons or bases regarding whether the Veteran's gout caused incapacitating exacerbations occurring three or more times per year, thus warranting a higher evaluation. The Court then vacated and remanded that part of the decision which addressed an increased disability rating for gout to the Board. Finally, the Board notes that in December 2020 and January 2021, the Veteran's attorney submitted requests to have the appeal regarding the thoracolumbar spondylosis of L5 with degenerative disc disease claim reviewed under the Appeals Modernization Act (AMA), and specifically requested higher level review. However, as explained in January 2021 and March 2021 correspondence, the Veteran was ineligible to transfer his appeal into AMA, as his appeal had already been activated by the Board. The appeal was subsequently remanded by the Board under the legacy appellate process. Service Connection Acquired Psychiatric Disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). For PTSD, service connection requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § § 4.125 (a), a link, established by medical evidence between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). An award of service connection requires a finding of a current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability"). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. The Veteran contends he currently has PTSD due to service; specifically, he asserts that sleeping in enclosed, small racks while at sea, and having planes land over his sleeping quarters, caused him to develop PTSD. However, the Board finds determinative the absence of competent evidence of a current disability of an acquired psychiatric disorder, to include PTSD, during the pendency of the appeal, to include the period proximate to receipt of his claim. In this regard, in January 2020, the Veteran underwent a VA psychological examination in connection with his claim. In pertinent part, the VA psychiatrist found the Veteran's symptoms did not meet the diagnostic criteria for a mental disorder, to include PTSD, under DSM-5 criteria. She noted that the Veteran's service treatment records and post-service VA and private treatment records did not show any mental health treatment, symptoms or concerns. Multiple depression screens were negative. Social Security Administration records showed no psychiatric diagnoses. The psychiatrist acknowledged the Veteran's claims that his sleeping assignment caused PTSD; however, she determined such a situation did not rise to the level of a stressor for the condition. She concluded that based on her examination he did not meet the criteria, in fact, for any psychiatric condition. The Board affords great probative weight to the January 2020 VA examiner's opinion as such considered all of the pertinent evidence of record, to include the statements of the Veteran and his relevant medical and military history, and provided a complete rationale, relying on and citing to the evidence reviewed. Moreover, the evidence does not contain a competent medical opinion to the contrary. In this regard, although the Veteran claims he has a current acquired psychiatric disorder, to include PTSD, which is related to service, it is well established that a layperson without medical training is not qualified to render a medical diagnosis or medical opinion of certain disorders. See 38 C.F.R. § 3.159 (a)(1). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, as the diagnosis of an acquired disorder is not a simple question that can be determined based on mere personal observations by a lay person, the Veteran's lay testimony is not competent to establish a medical diagnosis. See Jandreau, 492 F.3d at 1376-77; see also Davidson, 581 F.3d at 1316. Here, it is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer such a diagnosis. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Therefore, the Board affords his statements regarding the presence of a current acquired psychiatric disorder no probative weight. Moreover, the January 2020 VA psychiatrist's determination is supported by the Veteran's VA treatment records, which are negative for any complaints, treatment, or diagnosis of an acquired psychiatric disorder, to include PTSD. Consequently, the Board finds the evidence does not establish a disability of an acquired psychiatric disorder during the pendency of the appeal or prior to the Veteran's filing of a claim. Furthermore, as noted at the VA examination, there was no functional impairment associated with such alleged disorder. Therefore, service connection for an acquired psychiatric disorder must be denied. Watson, supra; Brammer, supra; Rabideau, supra. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. As such, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The claim is denied. Increased Disability Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). 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, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Gout The Veteran asserts that he is entitled to a higher disability rating for his gout because the severity of his symptoms is worse than contemplated by the currently assigned rating. His service-connected gout is currently rated at 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5017, which directs VA to rate gout under the criteria for rheumatoid arthritis. Under that criteria, 38 C.F.R. § 4.71a, Diagnostic Code 5002, disability ratings are assigned based on whether gout is an active process or manifested by chronic residuals. For an active process, a 100 percent rating is assigned for constitutional manifestations associated with active joint involvement, totally incapacitating. A 60 percent rating is assigned where manifestations less than commensurate with criteria for a 100 percent but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. A 40 percent rating is assigned with symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. The current 20 percent rating is assigned for one or two exacerbations a year in a well-established diagnosis. For chronic residuals, Diagnostic Code 5002 permits evaluation based on limitation of motion or ankylosis, favorable or unfavorable, of specific joints affected consistent with applicable diagnostic codes. Where the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, is to be combined, not added, under Diagnostic Code 5002. Such limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A Note to the Code provides that the rating for active process cannot be combined with that for residuals based on limitation of motion or ankylosis; the higher rating is to be assigned. Turning to the evidence, of record is a June 2016 lay statement submitted by the Veteran. In that statement, the Veteran affirmed that his gout affected his ability to work. He stated that when his gout flared up, he could not put his shoes on due to the swelling and pain in his legs. He stated the flare-ups occurred about once a month, and he could not walk during a flare-up. He stated he also experienced gout on his hands, resulting in irritation of scars and an inability to use his hand. At a January 2017 VA examination, the Veteran reported continued intermittent flare-ups a "few times" a year that required medication for treatment. He stated that during flare-ups, he had pain in the foot and ankle, which he treated with medication. The Veteran did not require continuous use of medication for his gout. He had not lost weight or have anemia as a result of his gout. No joint pain, limitation of joint movement, or joint deformities were shown to exist as a result of gout. The Veteran was not shown to have exacerbations which were not incapacitating or incapacitating, and his gout was not manifested by constitutional manifestations associated with active joint involvement that were totally incapacitating. The Veteran's gout was not manifested by weight loss and anemia productive of severe impairment of health, or by severely incapacitating exacerbations occurring 4 or more times a year, or a lesser number over prolonged periods. There was no indication that the disability was manifested by symptom combinations productive of definite impairment of health objectively supported by examination findings. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to his gout. Importantly, the examiner noted that the Veteran was asymptomatic at the time of the examination. Based on the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds that there is objective evidence indicating that he has experienced incapacitating exacerbations occurring 3 or more times a year. As noted in the JMPR, the Veteran explained in the June 2016 statement that he experienced flare-ups of gout so painful that he was unable to put his shoes on, with pain and swelling. These happened approximately once a month, preventing him from walking on the occasion that it occurred in both feet. Clearly, the disability picture presented is best approximated by a rating of 40 percent. A higher rating of 60 percent disabled is only applicable if the Veteran has experienced anemia and weight loss productive of severe impairment of health attributable to gout, or if he has experienced severely incapacitating exacerbations occurring four or more times per year or fewer than four severely incapacitating exacerbations over prolonged periods. The Veteran has not described such, and the January 2017 examiner did not find evidence of severe impairment of health due to anemia or weight loss. Nor have severely incapacitating episodes of gout been demonstrated at any time. Accordingly, a higher rating of 60 percent disabled is not warranted. In granting the increased rating based on incapacitating episodes, the Board acknowledges that the January 2017 VA examiner found that the Veteran did not have exacerbations which were not incapacitating or incapacitating, or manifestations associated with active joint involvement that were totally incapacitating. However, as noted at the time, the January 2017 examination was undertaken at a point where the Veteran's gout was asymptomatic. The Board finds no reason to doubt the Veteran's competent, credible reports of his symptoms, their severity, and their frequency. See Layno v. Brown, 6 Vet. App. 465 (1994). Thus, the Board concludes that the criteria for a rating of 40 percent, but not higher, for gout have been met throughout the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Codes 5002, 5017. To this extent, the claim is granted. Thoracolumbar spondylosis of L5 with degenerative disc disease The Veteran's thoracolumbar spondylosis of L5 with degenerative disc disease (hereinafter, "back disability") is rated at 10 percent disabling under Diagnostic Code 5003-5239, prior to December 3, 2019, and 20 percent disabling under Diagnostic Code 5242 thereafter. Under these codes, degenerative arthritis is evaluated under the General Rating Formula for Disease and Injuries of the Spine (General Rating Formula). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Such provides for a 20 percent rating where there is 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. Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Note (1): Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. Effective February 7, 2021, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38 C.F.R. § 4.71a). When 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. VAOPGCPREC 3-2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021. Hence, VA has made clear that its intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The rating criteria for Diagnostic Codes 5239 and the general rating formula for diseases and injuries of the spine were not revised. The changes effective February 7, 2021 under 38 C.F.R. § 4.71a, Diagnostic Code 5242 was not to the rating schedule itself but added instruction to classify disabilities associated with all non-IVDS intervertebral disc disabilities under Diagnostic Code 5242. As such, Diagnostic Code 5242 now reflects "Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either [Diagnostic Code] 5003 or 5010)." As such, the changes do not impact the general rating formula and evaluation of the Veteran's disability under the pre- and post-February 7, 2021 regulations is not required. As an initial matter, the Board notes that the record does not show, and the Veteran does not contend, that he ever had IVDS, to include incapacitating episodes thereof. Therefore, the IVDS Rating Formula would not allow for higher ratings for the Veteran's back disability at any point pertinent to the appeal period. In January 2017, the Veteran underwent a VA back examination. At that time, he reported pain in the lower back, which was treated with over the counter and prescription medication. He denied experiencing flare-ups, and did not use assistive devices such as a cane or wheelchair. Range of motion testing showed forward flexion to 80 degrees, and extension, bilateral lateral flexion, and bilateral lateral rotation all at 20 degrees. Range of motion was abnormal, but did not contribute to functional loss. No pain was noted on examination. The Veteran was able to perform repetitive-use testing with at least three repetitions, without additional loss of function or range of motion. Guarding and muscle spasm were absent, as were radiculopathy, ankylosis, neurologic abnormalities, and IVDS. The examiner concluded there was no functional impact resulting from the Veteran's back disability. In December 2019, the Veteran underwent an additional VA back examination. At that time, he reported back pain and stiffness which worsened after prolonged activity. He occasionally used a cane to walk. The Veteran experienced flare-ups, which were precipitated by activities such as bending and lifting, or prolonged sitting, standing or walking. He treated his symptoms with prescription medication, a heating pad, and a TENS unit. Range of motion testing showed forward flexion to 60 degrees, with extension to 10. Right lateral flexion was 20 degrees, with left to 25. Right lateral rotation was 20 degrees, and left lateral rotation was 25. The Veteran's decreased range of motion interfered with bending, lifting, and stooping, as well as prolonged sitting, standing and walking. The Veteran's back pain resulted in functional loss, on all planes. Localized tenderness or pain on palpation was noted. The Veteran was able to perform repetitive use testing, with some additional loss of motion due to pain. Although the examination was not conducted during a flare-up, it was medically consistent with the Veteran's statements describing functional loss during a flare-up. The examiner estimated there would be some loss of range of motion during a flare up: forward flexion would be 50 degrees, extension to 5, right lateral flexion and rotation to 10 each, and left lateral flexion and rotation to 15 each. The Veteran had muscle spasm resulting in abnormal gait or abnormal spine contour. There was less movement than normal, as evidenced by decreased range of motion. Ankylosis, muscle atrophy, radiculopathy, neurologic abnormalities and IVDS were all absent. Based on this evidence, the Board finds that a disability rating in excess of 10 percent, prior to December 3, 2019, is not warranted. As noted above, to warrant a 20 percent disability rating under the General Rating Formula, forward flexion of the thoracolumbar spine must be limited to at least 60 degrees; the combined range of motion must be limited to at least 120 degrees; or muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. However, review of the evidence does not reveal symptomatology consistent with a 20 percent rating for this period. Specifically, range of motion testing conducted during the January 2017 VA examination revealed forward flexion to 80 degrees and a combined range of motion of 180 degrees. Notably, the examiner did not document pain on motion and there was no additional limitation of motion upon repetitive use testing. Thus, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, such measurements do not more nearly approximate those required for a rating in excess of 10 percent under the General Rating Formula. Additionally, the evidence does not indicate that the Veteran had muscle spasms or guarding severe enough to result in abnormal gait or abnormal spine contour such as scoliosis, reversed lordosis, or abnormal kyphosis at any point prior to December 3, 2019. The January 2017 examination report showed that the Veteran's back disability did not result in muscle spasms or guarding severe enough to result in abnormal gait or abnormal spine contour. Therefore, a rating in excess of 10 percent for the Veteran's back disability prior to December 3, 2019, on such basis is not warranted. Turning to the period subsequent to December 3, 2019, the Board finds that a rating in excess of 20 percent is not warranted under the General Rating Formula. As referenced above, in order to warrant the next higher rating of 40 percent, the evidence must reflect that the Veteran's back disability results in forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. However, the range of lumbar motion recorded during the appeal period fails to reveal the requisite limitation of lumbar flexion or any spinal ankylosis, or otherwise suggest that the Veteran's back disability produces an impairment analogous to such limitation of motion during a flare-up or upon repetitive or repeated use over time. Specifically, the Veteran demonstrated 60 degrees of forward flexion during his December 2019 VA examination, and the examiner stated that the Veteran's thoracolumbar spine was not ankylosed, either favorably or unfavorably. Even when estimating the range of motion during a flare-up, the examiner determined that the Veteran's forward flexion would be limited to 50 degrees, far more than the 30 degrees which would warrant a higher, 40 percent rating. Therefore, a rating in excess of 20 percent for the Veteran's back disability, as of December 3, 2019, is not warranted. The Board has also considered whether separate ratings for associated objective neurological abnormalities are warranted at any time throughout the appeal period, pursuant to Note (1) of the General Rating Formula. However, the Veteran does not contend, and the evidence does not show, that there are associated objective neurological abnormalities, to include radiculopathy, or bladder or bowel impairment, associated with his back disability. Consequently, the Board finds that separate ratings for associated objective neurologic abnormalities are not warranted. In reaching the foregoing determinations, the Board recognizes the Veteran's sincerely held belief that his back disability is more severe than as reflected by the currently assigned ratings, and notes he is competent to describe his symptoms and their effects on his daily life and occupation. See Jandreau, supra; Layno supra; Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds instead that the medical evidence in which professionals with medical expertise examined the Veteran, completed necessary testing, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria is more persuasive than his own reports regarding the severity of such conditions. The Board has also considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran's service-connected back disability; however, the Board finds that his symptomatology has been stable throughout each appeal period. Therefore, the Board finds that increased ratings for the Veteran's back disability are not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. The claims are denied. Knees Prior to October 18, 2016, and from February 1, 2017 to August 3, 2018, the Veteran's left knee disability was characterized as left knee degenerative joint disease and rated under Diagnostic Code 5003-5260. (During the periods between October 18, 2016 and February 1, 2017, and from August 3, 2018 to October 1, 2019, the Veteran was in receipt of a temporary total rating for post-surgical convalescence.) Similarly, prior to October 1, 2015, and from February 1, 2016 to August 7, 2019, the Veteran's right knee disability was characterized as residuals, internal derangement and degenerative joint disease, status post arthroscopic debridement and repair, and rated under Diagnostic Code 5003-5260. (During the periods between October 1, 2015 and February 1, 2016, and from August 7, 2019 to October 1, 2020, the Veteran was in receipt of a temporary total rating for post-surgical convalescence.) At the outset, the Board notes that hyphenated diagnostic codes are used when a rating under one code requires use of an additional code to identify the basis for the rating assigned. See 38 C.F.R. § 4.27. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a. As the Veteran's left knee disability manifests by limitation of motion, the disability will be rated based on the diagnostic codes concerning limitation of motion of the knee. The Board's analysis will begin with Diagnostic Code 5260, which contemplates the criteria for limitation of flexion of the knee, but all potentially applicable rating criteria will also be considered. Under Diagnostic Code 5260, in relevant part, flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a maximum 30 percent rating. 38 C.F.R. § 4.71a. The Board notes that separate ratings under Diagnostic Code 5260 (limitation of flexion) and Diagnostic Code 5261 (limitation of extension) may be assigned for disability of the same joint. See VAOPGCPREC 9-04 (September 17, 2004). As such, Diagnostic Code 5261 may potentially be for application here. Under Diagnostic Code 5261, extension limited to 5 degrees is noncompensable. Extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Finally, where extension is limited to 45 degrees, a maximum 50 percent rating may be assigned. 38 C.F.R. § 4.71a. For reference, normal range of motion of the knee is 140 degrees of flexion and zero degrees of extension. See id. at Plate II. In addition to the ratings based on limitation of motion, a separate rating may also be assigned for instability of the knee. See VAOPGCPREC 23-97 (July 1, 1997). Under Diagnostic Code 5257, other knee impairment with slight recurrent subluxation or lateral instability warrants a 10 percent rating. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A maximum 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Finally, the Board notes that although the portion of the rating schedule that addresses the musculoskeletal system was revised effective February 7, 2021, Diagnostic Code 5003-5260 was not changed. Turning to the relevant evidence of record, the Board initially notes that VA treatment records show that the Veteran has consistently reported and sought treatment for chronic bilateral knee pain throughout the duration of the periods on appeal. In June 2013, the Veteran underwent a VA knee and lower leg conditions examination. He reported sharp pain in the right knee. His right knee would buckle and he would lose balance. He reported flare-ups which were caused by bending, squatting, standing and climbing stairs, and treated with rest, ice, heat and time. Pain in the left knee was intermittent, but sharp. Flare-ups of the left knee were brought on by overuse, bending and squatting. Range of motion testing at that time showed right knee flexion to 115 degrees, without limitation of extension or evidence of painful motion. Left knee flexion was measured to 120 degrees, without limitation of extension or evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions, bilaterally, without any additional loss of range of motion. Functional loss was characterized as less movement than normal, and pain on movement, bilaterally. Flexion was normal and both knees were found to be stable. There was no evidence or history of recurrent patellar subluxation or dislocation, or any tibial and/or fibular impairment. The Veteran had a meniscal tear and frequent episodes of joint pain. He had a meniscectomy, bilaterally, with residual symptoms of pain and giving way. The Veteran used a brace on a regular basis. Imaging studies showed arthritis, bilaterally. A VA treatment note from October 2013 showed the Veteran's right knee flexion to be to 120 degrees, with intermittent instability and swelling. Flexion was tested during visits in November and December of that year, and found to be 120 degrees as well. A May 2014 VA treatment note showed that, when tested, the Veteran had full range of motion of the both knees. A July 2014 note showed bilateral flexion to 120 degrees. An October 2014 VA treatment note showed right knee flexion to 120 degrees. In December 2014, right knee flexion was at 120 degrees, with locking and instability. There was no evidence of significant abnormalities at that time. In a July 2016 VA treatment note, the Veteran's left knee flexion was measured to 120 degrees, with pain on deep flexion. MRI testing showed a possible meniscus tear. In January 2017, the Veteran underwent another VA knee and lower leg conditions examination. At that time, the Veteran reported using knee braces as needed, and that he treated recurrent mild to moderate knee pain with prescription medication. Range of motion testing showed right knee flexion to 120 degrees, with extension to 0. Left knee flexion was 120 degrees, with extension to 0. Repetitive use testing resulted in no additional loss of function or range. The Veteran denied experiencing flare-ups at the visit. Ankylosis was absent. Joint stability testing showed no instability, bilaterally. The examiner noted a history of surgery to treat meniscal tears, bilaterally, noting subsequent right knee pain and discomfort with prolonged standing, kneeling or climbing, and left knee continued pain with kneeling or climbing. The Veteran denied the use of any assistive devices. In an April 2017 VA treatment note, the Veteran reported pain in the left knee. Range of motion testing at that time was normal. Similarly, testing in January, April and June 2018 at VA showed limited range of motion, with pain upon testing. A December 2018 VA treatment note showed reports of right knee instability, and giving out. In December 2019, in response to the Board's remand, the Veteran underwent a VA knee and lower leg conditions examination. At that time, the total knee replacement with limited extension and flexion were noted, bilaterally. He reported experiencing pain and stiffness, with right knee weakness. Symptoms worsened with squatting, walking up or down stairs, sitting for longer than 15 minutes, and walking short distances. He used a cane intermittently and treated his symptoms with prescription medication. The Veteran reported flare-ups, bilaterally, which were caused by squatting, sitting and walking. The Veteran noted decreased range of motion in the bilateral knees. Range of motion testing showed right knee flexion to 90 degrees, with extension to 5. Pain noted on examination caused functional loss on flexion and extension. Left knee testing showed flexion to 100 degrees, and extension to 5. Similarly, functional loss was caused by pain on flexion and extension. Repetitive use testing resulted in some loss of range of motion, with right knee flexion to 85 and extension to 5. Left knee flexion was 95 after testing, and extension to 5. The examiner estimated that, during flare-ups, due to pain, right knee flexion would be 80 degrees, and extension 5; left knee flexion would be 90 degrees and extension also 5. It was noted that there was less, and weakened, movement, a disturbance of locomotion, and interference with standing, bilaterally, with swelling evident in the left knee. Ankylosis was absent and joint stability testing showed no instability. Based on the foregoing evidence of record, the Board finds that an increased rating based on limitation of flexion is not warranted for either the left or right knee disabilities at any time. As noted above, the next higher rating of 20 percent under Diagnostic Code 5260 requires flexion of the knee limited to 30 degrees. However, as outlined above, the objective medical evidence demonstrates that the Veteran's left knee flexion was limited to, at most, 100 degrees, and his right knee flexion was limited at most to 90 degrees. During the relevant appeal periods, the evidence does not suggest at any time that the Veteran's left and right knee disabilities manifested by, or more closely approximated, flexion limited to 30 degrees. In making this determination, the Board has fully considered whether higher ratings can be assigned based on consideration of the factors addressed in 38 C.F.R. §§ 4.40, 4.45, and DeLuca, 8 Vet. App. at 204-07. The evidence shows that the Veteran has consistently reported experiencing pain and painful motion, with some swelling and weakness in his bilateral knees, especially after increased activity. Moreover, he has, at times, described experiencing periods of flare-up and functional loss due to increased pain with prolonged walking, standing, sitting, and climbing stairs. The Veteran is competent to report these symptoms. Layno, supra. While the Board acknowledges that the Veteran may experience additional functional loss due to factors such as pain during periods of flare-up or after repeated use over time, as indicated on the December 2019 VA examination report, this functional loss would only result in, at most, an additional loss of 5 degrees of flexion in both knees. The Board finds that, even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, as well as the Veteran's reports of increased pain and functional impairment during periods of flare-up, there is no evidence to conclude that the Veteran's functional losses equate to the criteria required for a 20 percent or greater rating for either the left or right knee. See 38 C.F.R. §§ 4.40, 4.45; DeLuca at 204-07; see also Sharp v. Shulkin, 29 Vet. App. 26 (2017). Moreover, as the Veteran's subjective reports of pain, painful motion, and swelling are already contemplated by his currently-assigned 10 percent ratings, higher ratings under DeLuca are not warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59. The Board has also considered whether separate compensable ratings are warranted for either knee based on limitation of extension and recurrent subluxation and/or lateral instability. However, the Board notes that testing showed the Veteran consistently had extension to zero degrees, or full extension, in both knees throughout this appeal period. There is no subjective or clinical evidence to suggest that the Veteran had limitation of extension in either knee at any time (the December 2019 VA examination showed some limitation of extension, which is discussed below). Therefore, separate ratings under Diagnostic Code 5261 for limitation of extension of the knee are not warranted. With regard to subluxation or instability, under Diagnostic Code 5257, a 10 percent evaluation is warranted for slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. A 20 percent evaluation is warranted for moderate recurrent subluxation or lateral instability. Id. A 30 percent evaluation, which is the maximum available under this diagnostic code, is warranted for severe subluxation or lateral instability. Id. The Board notes that the terms "slight," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. A review of the medical evidence shows that the Veteran's VA examinations throughout the entire period on appeal do not reflect any findings of left or right knee instability. However, the Veteran's VA treatment records has consistently noted that he uses a cane occasionally, and a knee brace regularly, as a normal mode of locomotion. In addition, the Veteran has consistently reported instability, with occasional falls. The Veteran reported at the June 2013 VA examination that his knee gave way, and VA treatment records from as early as October 2013 show reports of instability. Throughout the appeal period, the Veteran has consistently reported that his right knee is unstable. Based on such evidence, the Board finds that the Veteran's right knee disability exhibits slight instability. As such, a separate 10 percent disability rating for the right knee is warranted under Diagnostic Code 5257. Although his knee disability warrants a 10 percent rating for slight instability, the Board finds that higher evaluations for "moderate" or "severe" instability are not warranted based upon the evidence of record. Aside from the Veteran's reports of falling and using a cane and knee brace as a normal mode of locomotion, the VA examinations contain testing results which show that posterior, medial, and lateral instability were all normal. He also did not have recurrent subluxation or dislocation. As such, the evidence does not suggest moderate instability. Finally, the Board has also considered whether the Veteran is eligible for a separate rating under any other potentially applicable diagnostic code. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In this regard, the Board notes that as there is no evidence during the periods on appeal of ankylosis, dislocated or removed semilunar cartilage, tibia and fibula impairment, or genu recurvatum in either knee, higher or separate ratings are not warranted under Diagnostic Codes 5256, 5258, 5262, or 5263. Diagnostic Code 5055 As of October 1, 2019, the Veteran's left knee disability was recharacterized as a left knee total replacement and rated at 30 percent under Diagnostic Code 5055. A year later, as of October 1, 2020, the Veteran's right knee disability was recharacterized as a right knee total replacement and rated at 30 percent under Diagnostic Code 5055. Diagnostic Code 5055 provides the rating for total knee replacements. As noted above, the rating criteria under Diagnostic Code 5055 changed on February 7, 2021. As such, the Board must consider the Veteran's current rating of 30 percent under the new and old rating criteria. Under the old rating criteria, for one year following implantation of a knee prosthesis for a service-connected knee disability, a 100 percent rating is assigned. Thereafter, a 60 percent rating is assigned when there are chronic residuals consisting of severe painful motion or weakness in the affected extremity; otherwise, a minimum 30 percent rating is assigned. 38 C.F.R. § 4.71a. Diagnostic Code 5055 specifies that a minimum 30 percent rating is assigned, but when there are intermediate degrees of residual weakness, pain, or limitation of motion, the disability is to be rated by analogy under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 (knee ankylosis), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula) if applicable. However, no such rating by analogy is applied when there is evidence of chronic residuals consisting of severe painful motion or weakness in the affected extremity as that is provided in the maximum 60 percent rating under Diagnostic Code 5055. Diagnostic Codes 5256, 5261, and 5262 do not provide for any higher ratings; the maximum ratings available under these codes are 60 percent, 50 percent, and 40 percent, respectively. Under the new rating criteria, Diagnostic Code 5055 provides a 100 percent rating for the four months following implantation of a knee prosthesis for a service-connected knee disability. Thereafter, the rating criteria remains the same with the exception that a separate evaluation for resurfacing after the conclusion of the 100 percent evaluation period may be warranted. Here, there is no evidence the Veteran's knees have undergone resurfacing during the appeal period. Thus, as it pertains to this specific Veteran, the old and new rating criteria are the same. The Board finds that ratings in excess of 30 percent for the bilateral knees following the total replacement surgeries are not warranted. There is no evidence throughout the respective appeal periods of ankylosis, limitation of extension to 30 degrees or more, or of nonunion of the tibia and fibula with loose motion requiring a brace or analogous symptomology in either knee. As such, a rating in excess of 30 percent rated by analogy under Diagnostic Codes 5256, 5261, or 5262 is not established. Further, the Veteran's symptom presentation does not rise to the level of severe painful motion or weakness. Although the December 2019 examination demonstrated continued painful limitation of motion, post-surgery, the examiner determined that the Veteran's bilateral knees did not have chronic residuals of severe painful motion or weakness. Finally, the Veteran is not entitled to a separate rating under Diagnostic Codes 5256, 5261, or 5262. The record does not reflect the Veteran ever had ankylosis or nonunion of the tibia and fibula during the appeal period. Although the December 2019 VA examiner found the Veteran's bilateral extension was limited to 5 degrees, this would only provide a noncompensable rating under Diagnostic Code 5261. Thus, as the currently-assigned 30 percent is a higher rating than 0 percent, the Veteran will maintain his 30 percent rating under Diagnostic Code 5055. In addition, the Board finds that the Veteran's symptoms of painful limitation of motion and mild weakness are already contemplated under Diagnostic Code 5055 and additional ratings under other diagnostic codes encompassing such symptomology would constitute pyramiding. Accordingly, a rating in excess of 30 percent for left knee replacement residuals as of October 1, 2019 and in excess of 30 percent for right knee replacement residuals from October 1, 2020, is not warranted. In reaching the above conclusions regarding each of the Veteran's knee claims, the Board acknowledges his sincerely-held belief that his symptoms are more severe than contemplated by the currently-assigned ratings for his left and right knee disabilities. The Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of pain and other symptomatology. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); see also Layno, 6 Vet. App. at 469-71. While the Board has considered the lay statements of record, and has given them appropriate weight where they are consistent with the objective medical evidence of record, the Board has accorded greater probative weight to the objective evidence of record as VA clinicians and examiners have the requisite medical training and expertise to make complex medical determinations. Therefore, the medical evidence is more probative regarding the current level of severity of the Veteran's knee disabilities, and the most probative medical evidence has shown that the Veteran's left and right knee disabilities are no more than 10 and 30 percent disabling under the applicable criteria, for their respective time periods. The Board has considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran's service-connected knee disabilities; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Thus, assigning staged ratings for such disabilities is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent for a left knee disability and a rating in excess of 10 percent for a right knee disability prior to October 1, 2019 and October 1, 2020, respectively, and against the assignment of a disability rating in excess of 30 percent for each knee subsequent to these dates. Therefore, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. To this extent, the claims are denied. TDIU Subsequent to October 1, 2020 Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran 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, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient disability to bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident, or disabilities affecting a single body system, will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16 (a). Consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his or her age or to impairment cause by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Substantially gainful employment is defined as work that is more than marginal and that permits the individual to earn a living wage. See Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment shall not be considered substantially gainful employment. The determination of whether a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability is a factual determination rather than a medical question. Therefore, responsibility for the ultimate determination of whether a veteran is capable of securing or following substantially gainful employment is placed on the VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); see also 38 C.F.R. § 4.16; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). During the period starting October 1, 2020, service connection is in effect for a right knee disability, rated as 30 percent disabling; a left knee disability, rated at 30 percent disabling; gout, at 20 percent; back disability, 20 percent; bilateral knee scars, 10 percent each; and a residual laceration of left hand, a right knee scar sub patella, and left knee medical scar, each rated as noncompensable. Thus, his combined disability rating is 80 percent, and he meets the schedular criteria for TDIU. The Board has addressed the period prior to October 1, 2020 in the Remand section of this decision. As such, the Board must determine whether the Veteran was able to secure or follow a substantially gainful occupation as of that date. The record shows the Veteran is a high school graduate with some college credit. He last worked in 2014, for a year, doing general construction work as a laborer. Prior to that, he worked in maintenance. In a June 2016 statement, the Veteran described the impact that his service-connected disabilities had on his ability to work. He indicated that he regularly missed work due to them, and that he would be physically unable to do his previous jobs due to the strain. He described problems with falling due to his knees, and an inability to sit for long periods of time. His back sometimes made it impossible for him to stand, and the medication he took to treat the condition made him drowsy. His service-connected gout made work impossible during flare-ups. In October 2016, the Veteran's attorney submitted a September 2016 report from a private vocational expert. In that report, the examiner concluded that the Veteran was precluded from securing and following a substantially gainful occupation due to his service-connected disabilities. The examiner based this conclusion on consideration of the Veteran's education, work history, and such disabilities. He noted that the Veteran attempted to re-enter the workforce by taking the 2014 construction job, but had to quit due to the physical demands. He had no experience or skills that would transfer to sedentary work. Even if he was able to, the Veteran would not be able to attend to any job on a consistent enough basis to be able to maintain the position, due to his back and knee disabilities. In addition, he was not able to perform physical labor due to these disabilities. The examiner determined that there was no job in the local or national economy for which the Veteran would be able to perform due to his service-connected back and knee disabilities. He went on to wholly deny the validity of any statement made by any clinician who indicated that, despite his disabilities, the Veteran would be able to work. To that end, in a January 2017 back examination report, a VA physician who examined the Veteran concluded there would be no functional impact on his ability to work, due to his back disability. That same examiner, in addressing the Veteran's knees, indicated that there would be some impact due to discomfort with prolonged standing, climbing and kneeling. The examiner further concluded that there would be no impact from the Veteran's gout. In the December 2019 VA report of back examination, the examiner concluded that there would be a functional impact on the Veteran's ability to work, due to the impact of the Veteran's back on his ability to bend, lift and stoop, and his inability to sit, stand or walk for extended periods of time. A December 2019 VA knee examiner came to similar conclusions, finding that the Veteran's ability to bend, squat, kneel and crawl, and inability to sit, stand or walk for periods longer than 30 minutes, would impact his ability to work. Based on this evidence, the Board must find that the Veteran is significantly limited in his ability to work due his service-connected disabilities. The entirety of the Veteran's work history involved physically demanding positions which were labor intensive, which the evidence clearly shows would no longer be possible, due to service-connected disabilities. Given the combined effects of the Veteran's back and knee disabilities, as well as his reported limitations due to gout, the Board finds that the probative evidence of record shows that it is at least as likely as not that he has been unable to secure or follow substantially gainful employment due solely to his service-connected disabilities as of October 1, 2020. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. Thus, TDIU is granted from that date. REASONS FOR REMAND Herniated cervical disc and radiculopathy In its January 2020 remand, the Board requested the Veteran be provided with an examination regarding the etiology of his herniated cervical disc and radiculopathy (hereinafter, "neck condition"). He underwent such the following month, at which time it was determined that it was less likely than not that the condition was due to his military service, to include an in-service motor vehicle accident, and it was not aggravated by his service-connected disabilities. Subsequently, in a May 2020 letter from his attorney, the Veteran asserted for the first time that his neck symptoms might be due to his service in the Persian Gulf. The Veteran's DD Form 214 and service personnel records confirm that he served on active duty during the Persian Gulf War era, including on a ship (USS Nimitz), but they do not confirm that such service included time in the Southwest Asia theater of operations. Thus, the Board finds that a remand is warranted, during which an attempt should be made to verify whether the Veteran had qualifying service in the Southwest Asia theater of operations. The Board further notes that if the Veteran is determined to have served in Southwest Asia, an examination should be obtained to address whether or not his neck symptoms are due to that service. The examiner should consider that joint pain is one of the signs or symptoms that are contemplated under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 (b) with respect to undiagnosed illnesses and medically unexplained chronic multisymptom illness. TDIU prior to October 1, 2020 The Board found above that the Veteran was unable to secure or follow substantially gainful employment due solely to his service-connected disabilities as of October 1, 2020. However, it based these findings on evidence that included the period of time prior to that date, whereexclusive of periods of temporary total disabilitythe Veteran did not meet the schedular criteria for TDIU. Where a veteran fails to meet the disability rating threshold under 38 C.F.R. § 4.16 (a), an extraschedular disability rating for TDIU may nevertheless be warranted where the veteran is unemployable due to service-connected disabilities. 38 C.F.R. § 4.16 (b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Should the Board discern a plausible basis for an extraschedular TDIU, it must refer the matter to the Director of Compensation Service for an initial decision before the Board may decide the issue. See Wages v. McDonald, 27 Vet. App. 233, 236 (2015). Here, there is clearly an indication from the record that the Veteran was unable to work due to his service-connected disabilities prior to October 1, 2020. As the Board is prohibited from awarding an extraschedular TDIU in the first instance, a remand is required to refer consideration of extraschedular TDIU, to the Director of the Compensation Service. The matters are REMANDED for the following action: 1. Complete any development necessary to determine whether the USS Nimitz was in the Southwest Asia theater of operations, as defined in 38C.F.R. §3.317 (e), while the Veteran was aboard from September 1995 to at least April 1996. All efforts to verify this service should be documented in the claims file. 2. If the Veteran is determined to have served in Southwest Asia, schedule him for a Gulf War examination. The examiner is asked to opine whether it is at least as likely as not that the Veteran's reported neck condition constitute signs or symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness, with an appropriate and detailed rationale. 3. Refer this case to the Director of Compensation Service for consideration of a TDIU prior to October 1, 2020, on an extra-schedular basis pursuant to 38 C.F.R. § 4.16 (b). R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeremy J. Olsen, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.