Citation Nr: 21030244 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-16 100 DATE: May 18, 2021 ORDER Entitlement to service connection for obstructive sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is denied. Entitlement to an initial evaluation in excess of 10 percent for right knee patellofemoral syndrome is denied. Entitlement to an initial evaluation in excess of 10 percent for right knee instability from October 13, 2020, through February 6, 2021, is denied, Entitlement to an initial 20 percent evaluation but no more, for right knee instability from February 7, 2021, is granted. Entitlement to an initial evaluation in excess of 10 percent prior to October 13, 2020, and in excess of 20 percent from that date, for left shoulder dyskinesis is denied. Entitlement to an initial evaluation in excess of 10 percent for traumatic brain injury (TBI)/post-concussion syndrome with insomnia, is denied. Entitlement to specially adapted housing is denied. REMANDED Entitlement to a total rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's sleep apnea did not have its onset in service, is not otherwise the result of a disease or injury incurred in service, and was not caused or aggravated by PTSD. 2. The Veteran's right knee patellofemoral syndrome is characterized by flexion to 125 degrees and extension to 0 degrees. 3. From October 13, 2020, the right knee patellar instability has been characterized by slight instability and use of a brace. 4. Prior to October 13, 2020, the Veteran's left shoulder dyskinesis was characterized by flexion to 170 degrees and abduction to 170 degrees. 5. From October 13, 2020, the Veteran's left shoulder dyskinesis has been characterized by flexion to 115 degrees and abduction to 180 degrees. 6. The Veteran's TBI/post-concussion syndrome, with insomnia, is characterized by difficulty sleeping and headaches. 7. The Veteran's service-connected disabilities do not result in a loss or loss of use of a lower extremity; loss or loss of use of both upper extremities; permanent impairment of the vision of both eyes; full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; amyotrophic lateral sclerosis; or ankylosis of a knee or hip. CONCLUSIONS OF LAW 1. The criteria for service connection for obstructive sleep apnea, to include as secondary to PTSD, have not been met. 38 U.S.C. §§ 1110, 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for an initial evaluation in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 3. The criteria for an initial evaluation in excess of 10 percent for right knee instability from October 13, 2020, through February 6, 2021 have not been met, and from February 7, 2021 the criteria for an evaluation of 20 percent have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257; 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). 4. The criteria for an initial evaluation in excess of 10 percent prior to October 13, 2020, and in excess of 20 percent from that date, for left shoulder dyskinesis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003-5201; 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). 5. The criteria for an initial evaluation in excess of 10 percent for TBI/post-concussion syndrome with insomnia, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8045. 6. The criteria for specially adapted housing have not been met. 38 U.S.C. §§ 2101, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.809. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 2000 to January 2010. This appeal was previously before the Board in January 2019, at which time the Board remanded it for additional development. The requested development has been completed, and the claim is properly before the Board for appellate consideration. 1. Entitlement to service connection for obstructive sleep apnea, to include as secondary to PTSD Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In addition to the elements of direct service connection and presumptive service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The service treatment records (STRs) show that, in April 2004, the Veteran was noted to have anxiety with occasional anxiety attacks that lead to shortness of breath. He also had insomnia and nightmares. In May 2004 the Veteran reported trouble falling asleep with nightmares, and he was noted to have insomnia. He complained of insomnia and difficulty falling asleep in May 2005, and was prescribed Ambien. In March 2006 the Veteran was again prescribed Ambien for insomnia. The Veteran had a VA examination in January 2012 at which he was diagnosed with obstructive sleep apnea. He reported that he was told he may have sleep apnea when he was treated for insomnia during service. In May 2019 the Veteran had a VA examination, and the examiner noted that the service treatment records are negative for a diagnosis or treatment of sleep apnea. The diagnosis was established two years after service. It was also noted that a diagnosis requires symptoms and a supportive polysomnogram. It was less likely than not that the sleep apnea was directly related to military service, including environmental hazards during the Gulf War. The examiner cited a study showing that an increased risk of obstructive sleep apnea is not associated with service in the Gulf War, including exposure to environmental hazards. Furthermore, the examiner wrote that PTSD is not a recognized risk factor for the development of obstructive sleep apnea. The Veteran was obese, with a body mass index of 34.6. Obesity and being male were the most likely etiologies of his obstructive sleep apnea. In September 2019 the VA examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was caused or aggravated by the service-connected PTSD. The rationale was that PTSD is not a recognized risk factor for the development or aggravation of obstructive sleep apnea. A study was cited that discussed various risk factors. In October 2019 the Veteran's representative submitted medical literature on sleep apnea and PTSD. The Veteran was provided a VA examination in October 2020, and the examiner opined that the Veteran's sleep apnea is less likely than not related to service or proximately due to or the result of PTSD, and was not aggravated by PTSD. The examiner noted that the Veteran was diagnosed two years after service. It was noted that there was a study from 2015 showing that younger veterans with PTSD had a higher risk of screening positive for obstructive sleep apnea. Another study did not find higher incidence of obstructive sleep apnea in veterans with combat related PTSD. The findings showed that obstructive sleep apnea made PTSD worse, but not the other way around. Further studies were needed to understand the relationship between the conditions. The examiner also cited a physician who reviewed medical literature and felt that the weight of the current medical literature did not support a clear relationship between the increased prevalence of obstructive sleep apnea and PTSD. There was no well defined causal link between sleep apnea and PTSD. Medical literature discussing obesity, aging, being male, and airway abnormalities being risk factors for sleep apnea was cited. The Veteran's major risk factors were being male and obesity. The Board acknowledges that, while service connection is not available for obesity itself, obesity caused or aggravated by a service-connected disability may nevertheless be an "intermediate step" for secondary service connection for any compensable disabilities caused or aggravated by obesity. Walsh v. Wilkie, 32 Vet. App. 300 (2020). However, the record for review is devoid competent evidence, to include from the Veteran, that his obesity is due to one or more of his service-connected disabilities. Probative value is given to the opinion of the October 2020 examiner because it was based on a review of the record and consideration of the disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("...[M]ost of the probative value of a medical opinion comes from its reasoning" and the Board "must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion."). The examiner considered and discussed the medical literature submitted by the Veteran's representative in October 2019 as well as other medical literature about sleep apnea and its relationship to PTSD and other disabilities and risk factors. Furthermore, the Veteran's history regarding sleep apnea was considered. There are no competent opinions of record indicating a relationship between the sleep apnea and the Veteran's service or a service-connected disability, including PTSD. Because the evidence preponderates against the claim of service connection for sleep apnea, to include as secondary to PTSD, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. Increased Rating Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, consideration also must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not specifically contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 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 no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 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. 2. Entitlement to an initial evaluation in excess of 10 percent for right knee patellofemoral syndrome 3. Entitlement to an initial evaluation in excess of 10 percent for right knee instability from October 13, 2020 Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When X-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. During the pendency of the appeal, the criteria under Diagnostic Code 5257 were amended, effective February 7, 2021. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). When a law or regulation changes during the course of a claim, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under both the old and new rating criteria, and the criteria that is more favorable to the Veteran will be applied. If the new criteria are more favorable, they will only be applied from February 7, 2021, when the regulations became effective. Under the rating criteria in effect prior to February 7, 2021, Diagnostic Code 5257 provided ratings for impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee was rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee was rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee was rated 30 percent disabling. 38 C.F.R. § 4.71a. Under the rating criteria in effect since February 7, 2021, Diagnostic Code 5257 provides ratings for recurrent subluxation or instability and patellar instability. Recurrent subluxation manifested by a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation, is rated 10 percent. A sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation, is rated 20 percent. An unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation, is rated 30 percent. 85 Fed. Reg. at 76463. Patellar instability involving a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker, is rated 10 percent. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker, is rated 20 percent. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker, is rated 30 percent. Note (1) states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). 85 Fed. Reg. at 76463. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. The Veteran has a separate evaluation for shin splints under Diagnostic Code 5262 that is not on appeal and will therefore not be discussed herein. The Veteran had a VA examination in June 2010 at which he reported that his right knee got painful on long drives and after standing for long periods of time. On examination there was parapatellar tenderness in the right knee. Range of motion was flexion to 130 degrees and extension to 0 degrees. There was no objective evidence of pain on active motion or after three repetitions of motion. In addition, there were not additional limitations of motion after repetitive motion. The examiner felt that there was not an effect on occupational activities or activities of daily living. At March 2012 VA treatment right knee flexion was to 130 degrees and extension was to 0 degrees. There was constant crepitus, and the knee was painful. Ligament stability tests were positive for the anterior drawer, and were otherwise negative. Meniscus injury tests were negative. The assessment was that there were signs and symptoms suggestive of bilateral knee arthralgia, chondromalacia patella, and anterior instability of the right knee. The Veteran had a VA examination in August 2014 at which it was noted that he had knee popping and grinding, and the right knee occasionally gave out. Flare-ups occurred with increased physical activity, and were manifested by increased pain and crepitance. Range of motion was flexion to 140 degrees or greater and extension to 0 degrees. There was no objective evidence of painful motion or reduced motion with repetitive testing. The knee had pain on palpation. Muscle strength testing was normal and there was no evidence of recurrent patellar subluxation or dislocation. X-rays were normal. At January 2015 VA treatment the Veteran reported that his knees were getting worse. The knee braces had helped, but the pain was worsening. The Veteran had an examination arranged through VA in October 2020 at which he was diagnosed with right knee instability. The reported functional impairment was limits on exercising and activities such as running. Lifting heavy pallets at his job put strain on his knees. Constantly getting up and down and standing in one spot for too long after 30 minutes also put a strain on his legs and knees. On examination, range of motion was flexion to 125 degrees and extension to 0 degrees. There was pain on motion that caused functional loss. On repetitive use testing there was not additional loss of motion. The examiner estimated that with repeated use over time flexion was to 120 degrees and extension to 0 degrees, and with flare-ups flexion was to 115 degrees and extension to 0 degrees. The additional functional loss was due to pain. The Veteran did not have pain on passive motion. There was slight lateral instability and no history of recurrent subluxation. A Lachman test showed anterior instability, while posterior instability, medial instability, and lateral instability tests were normal. The Veteran used a brace on a regular basis. The record does not show right knee ankylosis, dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion, or symptomatic removal of the semilunar cartilage. Therefore, Diagnostic Codes 5256, 5258, and 5259 are not applicable. See 38 C.F.R. § 4.71a. While there were signs of anterior instability noted at the March 2012 VA treatment, the August 2014 examiner noted that there was no recurrent patellar subluxation or dislocation. The record does not otherwise shoe recurrent patellar subluxation or dislocation prior to October 13, 2020. Therefore, the Veteran does not qualify for a separate compensable evaluation under Diagnostic Code 5257 prior to October 13, 2020. See 38 C.F.R. § 4.71a. A rating of 10 percent has been assigned under Diagnostic Code 5257 from October 13, 2020. Under the rating criteria in effect prior to February 7, 2021, the Veteran does not qualify for an evaluation in excess of 10 percent under Diagnostic Code 5257 because the record does not show moderate recurrent subluxation or lateral instability of the right knee. See 38 C.F.R. § 4.71a. At the October 2020 examination, there was slight lateral instability and no history of recurrent subluxation. A Lachman test showed anterior instability, while posterior instability, medial instability, and lateral instability tests were normal Under the rating criteria in effect from February 7, 2021, the Veteran qualifies for a 20 percent rating under Diagnostic Code 5257 for patellar instability due to his use of a knee brace. See 85 Fed. Reg. at 76463. He does not qualify for a 30 percent rating for patellar instability because the record does not show he was prescribed a brace and either a cane or a walker. See id. The Veteran does not qualify for a separate 10 percent rating for recurrent subluxation or instability under the new version of Diagnostic Code 5257 because the record does not show a sprain, incomplete ligament tear, or complete ligament tear caused persistent instability. See id. The Veteran does not qualify for an evaluation in excess of 10 percent for right leg patellofemoral syndrome based on limitation of flexion because flexion has not been limited to 30 degrees, as is required for a 20 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Flexion was to 130 degrees at the March 2012 examination, to 140 degrees at the August 2014 examination, and to 125 degrees at the October 2020 examination. The Veteran does not qualify for a compensable evaluation for right knee extension because the record does not show that extension is limited to 10 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Extension was to 0 degrees at the March 2012, August 2014, and October 2020 examinations. Under 38 C.F.R. §§ 4.40 and 4.45, and the decision in DeLuca, the Board is required to consider the Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate disability evaluation for a disability using the limitation of motion diagnostic codes. At the June 2010 examination, there was no objective evidence of pain on active motion or after three repetitions of motion. In addition, there were not additional limitations of motion after repetitive motion. At the August 2014 examination, there was no objective evidence of painful motion or reduced motion with repetitive testing. However, the knee had pain on palpation. The October 2020 examiner estimated that flexion was limited to 120 degrees with repeated use over time and 115 with flare-ups. Extension was estimated to be to 0 degrees. The pain and the additional loss of flexion are contemplated in the currently assigned 10 percent rating, and the Board notes that the additional loss of flexion did not limit it to 30 degrees. Therefore, the Veteran does not qualify for an increased rating based on 38 C.F.R. §§ 4.40 and 4.45, and the decision in DeLuca. Finally, in light of the holding in Fenderson, supra, the Board has considered whether the Veteran is entitled to "staged" ratings for his service-connected right knee patellofemoral syndrome, or to additional "staged" ratings for right knee instability, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period has the disability on appeal been more disabling than as currently rated under the present decision of the Board. Because the evidence preponderates against the claim for an evaluation in excess of 10 percent for right knee patellofemoral syndrome based on limitation of flexion, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 55-57. 4. Entitlement to an initial evaluation in excess of 10 percent prior to October 13, 2020, and in excess of 20 percent from that date, for left shoulder dyskinesis Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees. 38 C.F.R. § 4.71, Plate I. It is noted that the record shows that the Veteran is right-handed. During the pendency of the appeal, the criteria under Diagnostic Code 5201 were amended, effective February 7, 2021. 85 Fed. Reg. at 76463. Under the criteria in effect prior to February 7, 2021, Diagnostic Code 5201 provided that limitation of motion of the arm at the shoulder level is rated 20 percent for the major shoulder and 20 percent for the minor shoulder; limitation of motion of the arm midway between the side and shoulder level is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder; and limitation of motion of the arm to 25 degrees from the side is rated as 40 percent for the major shoulder and 30 percent for the minor shoulder. 38 C.F.R. § 4.71a. Under the criteria in effect from February 7, 2021, at the shoulder level is defined as flexion and/or abduction being limited to 90 degrees. Midway between the side and shoulder level is defined as flexion and/or abduction limited to 45 degrees. 85 Fed. Reg. at 76463. The rating criteria are otherwise unchanged. The criteria under Diagnostic Code 5202 were also amended, effective February 7, 2021. 85 Fed. Reg. at 76463. Under the criteria in effect prior to February 7, 2021, Diagnostic Code 5202 provided ratings for other impairment of the humerus. Malunion of the humerus with moderate deformity is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; malunion of the humerus with marked deformity is rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Recurrent dislocations of the humerus at the scapulohumeral joint, with infrequent episodes, and guarding of movement only at the shoulder level, are rated as 20 percent for the major shoulder and 20 percent for the minor shoulder; recurrent dislocations of the humerus at the scapulohumeral joint, with frequent episodes and guarding of all arm movements, are rated as 30 percent for the major shoulder and 20 percent for the minor shoulder. Fibrous union of the humerus is rated as 50 percent for the major shoulder and 40 percent for the minor shoulder. Nonunion of humerus (false flail joint) is rated as 60 percent for the major shoulder and 50 percent for the minor shoulder. Loss of head of the humerus (flail shoulder) is rated as 80 percent for the major shoulder and 70 percent for the minor shoulder. 38 C.F.R. § 4.71a. Under the criteria in effect from February 7, 2021 for Diagnostic Code 5202, infrequent episodes and guarding of movement only at the shoulder level (flexion and/or abduction) for the major and minor shoulder are rated 20 percent. 85 Fed. Reg. at 76463. The rating criteria for Diagnostic Code 5202 are otherwise unchanged. Diagnostic Code 5203 provides ratings for other impairment of the clavicle or scapula. Nonunion of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Dislocation of the clavicle or scapula with loose movement is rated as 20 percent for the major shoulder and 20 percent for the minor shoulder. Diagnostic Code 5203 provides an alternative rating based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a. At a June 2010 VA examination the Veteran said he felt like he had a pinched nerve in the shoulder blade. On examination, range of motion was flexion to 170 degrees, abduction to 170 degrees, internal rotation to 80 degrees, and external rotation to 80 degrees. There was no objective evidence of pain on active motion or after three repetitions of motion. In addition, there were not additional limitations of motion after repetitive motion. The examiner felt that there was not an effect on occupational activities or activities of daily living. At May 2012 VA treatment the Veteran said that his myofascial shoulder pain had improved slightly. The Veteran had a VA examination in August 2014. It was noted that he is right hand dominant. Range of motion of the left shoulder was flexion to 180 degrees and abduction to 180 degrees. There was not pain on either motion or reduction of motion on repetitive use testing. Left shoulder internal and external rotation were both performed to 90 degrees. The examiner noted that the Veteran denied any problems with the left shoulder and that the left shoulder was stable. The Veteran had an examination arranged through VA in October 2020. He reported instant pain that he rated as seven or eight out of ten if he lifted the arm above shoulder level. The pain increased to ten out of ten with repeated motion. On examination left shoulder range of motion was flexion to 115 degrees, abduction to 130 degrees, external rotation to 65 degrees, and internal rotation to 70 degrees. Pain was noted on all motions, and it caused functional loss. There was not additional loss of motion after three repetitions. The examiner estimated that with repeated use over time flexion was to 110 degrees, abduction to 125 degrees, external rotation to 60 degrees, and internal rotation to 65 degrees. It was estimated that during flare-ups, flexion was to 105 degrees, abduction to 120 degrees, external rotation to 55 degrees, and internal rotation to 60 degrees. There was no objective evidence of pain on passive motion or when the joint was used on non weight bearing. Muscle strength testing was normal, and there was no shoulder instability, dislocation, or labral pathology. A clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition was not suspected. In an October 2020 examination report addendum, the examiner wrote that there was no palpable tenderness of the left shoulder joint. The examiner wrote in February 2021 that the left shoulder scapula condition was left shoulder dyskinesis. The severity was mild to moderate. The Veteran does not qualify for an evaluation in excess of 10 percent prior to October 23, 2020 for the left shoulder because the examinations and treatment records do not show that limitation of motion was limited to shoulder level, as required for a 20 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. At the June 2010 examination flexion and abduction were to 170 degrees, and at the August 2014 examination flexion and abduction were to 180 degrees, which is a normal range of motion. For the period from October 23, 2020, the Veteran does not qualify for an evaluation in excess of 20 percent because the record does not show that motion has been limited to 25 degrees from the side, as required for a 30 percent rating for the minor side under the old criteria and the new criteria effective February 7, 2021. See 38 C.F.R. § 4.71a, Diagnostic Code 5201; 85 Fed. Reg. at 76463. At the October 2020 examination flexion was to 115 degrees and abduction was to 130 degrees. Diagnostic Codes 5202 and 5203 are not applicable for the entire period on appeal because the record does not show other impairment of the humerus or impairment of the clavicle or scapula. See 38 C.F.R. § 4.71a. Under 38 C.F.R. §§ 4.40 and 4.45, and the decision in DeLuca, the Board is required to consider the Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate disability evaluation for a disability using the limitation of motion diagnostic codes. At the June 2010 VA examination there was no objective evidence of pain on active motion or after three repetitions of motion. In addition, there were not additional limitations of motion after repetitive motion. At the August 2014 VA examination there was not pain on either motion or reduction of motion on repetitive use testing. The October 2020 examiner estimated that there was 5 degree reduction of flexion and abduction with repeated use over time and a 10 degree reduction of flexion and abduction during flare-ups. It was also noted at the examination that there was no evidence of pain on passive motion testing. Therefore, the Veteran does not qualify for increased ratings based on 38 C.F.R. §§ 4.40 and 4.45, and the decision in DeLuca. Finally, in light of the holding in Fenderson, supra, the Board has considered whether the Veteran is entitled to additional "staged" ratings for his service-connected left shoulder dyskinesis, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period has the disability on appeal been more disabling than as currently rated under the present decision of the Board. Because the evidence preponderates against the claim for an evaluation in excess of 10 percent prior to October 13, 2020, and in excess of 20 percent from that date, for left shoulder dyskinesis and right knee instability, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 55-57. 5. Entitlement to an initial evaluation in excess of 10 percent for TBI/post-concussion syndrome with insomnia The Veteran is seeking an evaluation in excess of 10 percent for TBI/post-concussion syndrome with insomnia. Diagnostic Code 8045 provides for the evaluation of TBI. 38 C.F.R. § 4.124a. There are three main areas of dysfunction listed that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. They are evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" whether or not they are part of cognitive impairment. However, a rater is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another Diagnostic Code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Emotional/behavioral dysfunction is evaluated under § 4.130 (Schedule of ratings--mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Physical (including neurological) dysfunction is evaluated based on the following list, under an appropriate Diagnostic Code: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. Residuals not listed above that are reported on an examination are evaluated under the most appropriate Diagnostic Code. Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The need for special monthly compensation is considered for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100-percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. Note (1) to Diagnostic Code 8045 states: There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified'" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2) to Diagnostic Code 8045 states: Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3) to Diagnostic Code 8045 states: "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4) to Diagnostic Code 8045 states: The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. 38 C.F.R. § 4.124a. The evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The Veteran had a VA examination for TBI in June 2010 at which the cognitive complaints were decreased memory, problems with attention, distractibility, reduced thinking efficiency, problems with multitasking, and difficulties with reasoning and problem-solving. The physical complaints included severe headaches and chronic back pain. He reported a history of mood and personality changes since the injuries. On examination the Veteran was fully oriented. It was noted that at time he appeared to have difficulty organizing his thoughts and putting them into words. Overall thought processes were logical and coherent with no evidence of hallucinations or delusions. Recent and remote memory were impaired. Visual memory functioning was moderately to severely impaired. Language and communication skills were intact and ranged from average to low average. Visuospatial processing was intact and fell within the average to above average range. Deductive reasoning and problem-solving skills were intact, and testing was within low average limits. The self-reported psychiatric symptoms were consistent with severe clinical depression. At a June 2010 VA general medicine examination, the Veteran reported that there were times when he would be up for 48 hours straight and then would sleep for only two hours. Ambien had worked when he was in the military. The insomnia had gotten progressively worse and caused memory loss, decreased concentration, and lack of stamina. The Veteran reported persistent daytime hypersomnolence at the January 2012 VA examination for sleep apnea. At May 2012 VA TBI treatment the Veteran reported that he continued to have memory complaints and was easily forgetful. His sleep was improved with trazodone, and migraine headaches were improved with Motrin. At a July 2019 psychological examination, the Veteran reported chronic sleep disturbance. The Veteran had an examination arranged through VA in October 2020. The examiner wrote that the Veteran had mild memory loss and difficulty recalling conversations, remembering names, and misplacing items. Judgement, social interaction, motor activity, visual spatial orientation, and consciousness were normal. The Veteran was always oriented to person, time, place, and situation. The examiner noted that the Veteran had subjective symptoms that do not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. There were no neurobehavioral effects from TBI, and the Veteran was able to communicate by and comprehend spoken and written language. The examiner noted that headaches were the only listed residual of TBI. A neuropsychological test was invalid due to poor effort by the Veteran. The examiner was unable to differentiate the symptoms of TBI with mental health disorders without resorting to speculation, and noted that symptoms of TBI and mental health often overlap. With regards to the appropriate rating under the TBI facets, a level of 1 is assigned for memory, attention, and executive functions. Memory was impaired at the June 2010 examination, and the Veteran had difficulty organizing his thoughts. At May 2012 treatment the Veteran reported problems with his memory. The Veteran has also reported difficulty sleeping. The October 2020 VA TBI examiner felt there was mild memory loss and difficulty recalling conversations, remembering names, and misplacing items. This corresponds to a level 1 of impairment. See 38 C.F.R. § 4.71a, Diagnostic Code 8045. The assignment of a level 1 of impairment is consistent with the current 10 percent rating for TBI. Judgement, social interaction, orientation motor activity, visual spatial orientation, and consciousness have been normal. The record does not show neurobehavioral effects from TBI, and the Veteran is able to communicate by and comprehend spoken and written language. Therefore, there is no impairment in these areas for the purposes of the rating for TBI. See 38 C.F.R. § 4.71A, Diagnostic Code 8045. The October 2020 examiner opined that the Veteran has subjective symptoms that do not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. This corresponds with a level of impairment of 0. See id. The October 2020 examiner noted that the Veteran's headaches area residual of TBI. The Veteran currently has separate noncompensable ratings for migraine headaches and headaches. He reported headaches at the June 2010 VA examination. At May 2012 treatment the Veteran reported improvement in his migraine headaches. He had an October 2020 examination for headaches at which he reported constant head pain, pulsating or throbbing head pain, and pain on both sides on the head. The Veteran did not have characteristic prostrating attacks of migraine or non-migraine headaches. In addition, there was not very prostrating and prolonged attacks of migraines or non-migraine pain production of severe economic inadaptability. The Veteran does not qualify for a separate compensable evaluation for headaches because there are not characteristic prostrating attacks averaging one in two months over the last several months. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. Thus, a preponderance of the competent and credible evidence shows that TBI/concussion syndrome with insomnia is not manifested by at least a level of 2 in any of the specially enumerated criteria listed in the table entitled Evaluations Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified found at Diagnostic Code 8045 at any time during the time frame on appeal. The highest his level of severity is 1. Therefore, the Board finds that the Veteran does not meet the criteria for a rating in excess of 10 percent under Diagnostic Code 8045. Finally, in light of the holding in Fenderson, supra, the Board has considered whether the Veteran is entitled to "staged" ratings for his service-connected TBI/concussion syndrome with insomnia, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time during the claims period has the disability on appeal been more disabling than as currently rated under the present decision of the Board. Because the evidence preponderates against the claim for an evaluation in excess of 10 percent for TBI/concussion syndrome with insomnia, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 55-57. Specially Adapted Housing 6. Entitlement to specially adapted housing Specially adapted housing is available to a veteran who is entitled to compensation for permanent and total disability due to: (1) amyotrophic lateral sclerosis rated as 100 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8017; (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; (3) full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk; or (4) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbows. Specially adapted housing is additionally available to a veteran with a permanent and total disability that precludes locomotion without the aids of braces, crutches, canes, or a wheelchair due to: (5) the loss, or loss of use, of both lower extremities, such as to preclude locomotion; (6) the loss or loss of use of one lower extremity, together with residuals of organic disease or injury which affect the functions of balance and propulsion; or, (7) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which affect the functions of balance or propulsion as to preclude unaided locomotion. 38 U.S.C. § 2101(a); 38 C.F.R. § 3.809. "Loss of use" is not specifically defined under 38 C.F.R. § 3.809 or 3.809a. Regulations pertaining to special monthly compensation for loss of use of a hand or foot state that loss of use is held to exist when no effective function remains other than that which would be equally well-served by an amputation with use of a suitable prosthetic appliance. The determination should be made on the basis of the actual remaining function, such as the ability to grasp, manipulate objects, balance, or propel oneself forward. See 38 C.F.R. §§ 3.350(a)(2), 4.63. The Court of Appeals for Veterans Claims has found that a "loss of use" exists when there is "deprivation of the ability to avail oneself" of that extremity, and functional impairment caused by pain, weakness, or incoordination should be taken into account when making that determination. See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). Service connection is in effect for PTSD, rated 50 percent; left shoulder left shoulder dyskinesis, rated 20 percent; right knee instability, rated 20 percent; a lumbosacral spine disability, rated 10 percent; right knee patellofemoral syndrome, rated 10 percent; tinnitus, rated 10 percent; TBI/concussion syndrome with insomnia, rated 10 percent; GERD, rated 10 percent; bilateral shin splints, rated noncompensable; left ear hearing loss, rated noncompensable; migraine headaches, rated noncompensable; and headaches, rated noncompensable. The combined rating in 80 percent. In April 2015 the Veteran's representative wrote that the Veteran required home adaption due to his service-connected disabilities. His left shoulder, right knee, and TBI made home adaption necessary. The October 2020 knee examiner noted that the Veteran's right knee disabilities, left knee strain, and bilateral shin splints limited exercise and activities such as running. The Veteran said that knee braces restrict his movement. It was noted at the October 2020 shoulder examination that the bilateral shoulder disabilities limited heavy repetitive lifting and strenuous activities. The Board notes that service connection is not in effect for left knee and right shoulder disabilities. Furthermore, the record does not show loss of use of both lower extremities; loss of use of one lower extremity, together with residuals of organic disease or injury which affect the functions of balance and propulsion; or the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which affect the functions of balance or propulsion due to service-connected disability. See 38 C.F.R. § 3.809. The other criteria applicable to entitlement to specially adapted housing are not applicable in this case. Specifically, the Veteran is not service connected for amyotrophic lateral sclerosis, for a disability that results in blindness in both eyes, or full thickness or subdermal burns. See 38 C.F.R. § 3.809. In summary, the weight of the competent and probative medical evidence preponderates against finding that the Veteran's service-connected disabilities meet any of the criteria under 38 C.F.R. § 3.809 for specially adapted housing. While the Board is sympathetic to the Veteran, since the evidence preponderates against the claim for specially adapted housing, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. REASONS FOR REMAND Entitlement to a TDIU is remanded. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim of entitlement to a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. At a July 2019 examination for PTSD, the Veteran reported having been at his job for five or six months. The Veteran said at the October 2020 shoulder and knee examinations that he left his job due to heavy repetitive lifting of 45 pound pallets that strained his shoulders and knees. At the knee examination he said he had not worked since the end of 2019. Additional development regarding the Veteran's employment history is needed before the entitlement to a TDIU can be decided on the merits. The matters are REMANDED for the following action: 1. The AOJ must issue and ask the Veteran to complete VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to include his complete employment history since 2010. 2. Thereafter, the AOJ must undertake any development necessary to adjudicate the issue of entitlement to a TDIU from January 18, 2010, to include verifying the Veteran's complete educational and occupational histories or obtaining an assessment from a vocational expert. 3. Thereafter, the AOJ must readjudicate the Veteran's appeal seeking a TDIU from January 18, 2010, to the present in light of the totality of the record. If the benefit sought is not granted to the fullest extent, the Veteran and his private attorney must be provided a copy of the readjudication and afforded an appropriate time to respond. . SCOTT W. DALE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Scott Shoreman, 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.