Citation Nr: 21030842 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 12-09 798 DATE: May 19, 2021 ORDER An evaluation in excess of 10 percent disabling for limitation of motion of the left knee for the period prior to October 12, 2011 is denied. A rating of 50 percent disabling, but no greater, for limitation of extension of the left knee for the period from October 12, 2011 to May 1, 2013 is granted. A rating in excess of 30 percent disabling for prosthetic replacement of the left knee for the period from July 1, 2014 to November 19, 2014 is denied. A rating in excess of 30 percent disabling for prosthetic replacement of the left knee for the period from March 1, 2015 to December 15, 2015 is denied. A rating in excess of 60 percent disabling for prosthetic replacement of the left knee for the period since December 15, 2015 is denied. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period from October 1, 2014 to November 20, 2014 and the period from March 1, 2015 to May 8, 2015 is granted. REMANDED Service connection for a left hip disability is remanded. FINDINGS OF FACT 1. For the period prior to May 1, 2013, the Veteran's left knee disability symptoms most nearly approximated documented arthritis of the left knee with painful motion, resulting in functional loss. 2. For the period from October 12, 2011 to May 1, 2013, the Veteran's left knee disability symptoms most nearly approximated limitation of extension to 45 degrees. 3. For the period from July 1, 2014 to November 20, 2014, the Veteran's left knee disability symptoms most nearly approximated prosthetic replacement of the left knee. 4. For the period from March 1, 2015 to December 15, 2015, the Veteran's left knee disability symptoms most nearly approximated prosthetic replacement of the left knee. 5. For the period since December 15, 2015, the Veteran's left knee disability symptoms most nearly approximated prosthetic replacement of the left knee with chronic residuals consisting of severe painful motion or weakness in the affected extremity. 6. Resolving all reasonable doubt in favor of the Veteran, her service-connected disabilities rendered her unable to obtain and maintain substantially gainful employment for the period from October 1, 2014 to November 20, 2014 and the period from March 1, 2015 to December 15, 2015. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent disabling for limitation of motion of the left knee for the period prior to October 12, 2011 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5010. 2. The criteria for a rating of 50 percent disabling, but no greater, for limitation of extension of the left knee for the period from October 12, 2011 to May 1, 2013 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5261. 3. The criteria for a rating in excess of 30 percent disabling for the period from July 1, 2014 to November 19, 2014 for prosthetic replacement of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 4. The criteria for a rating in excess of 30 percent disabling for the period from March 1, 2015 to December 15, 2015 for prosthetic replacement of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 5. The criteria for a rating in excess of 60 percent disabling for the period since December 15, 2015 for prosthetic replacement of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 6. The criteria for a TDIU for the period from October 1, 2014 to November 20, 2014 and the period from March 1, 2015 to December 15, 2015 have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training (ACDUTRA) from May 1982 to August 1982 and May 1983 to August 1983, and on active duty from February 2003 to May 2004 in the United States Army Reserves. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July 2010 and August 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office. The issues on appeal were previously before the Board in October 2020, when they were remanded to the Agency of Original Jurisdiction (AOJ) for additional development. The AOJ issued an October 2020 rating decision enacting the Board's grant of service connection for the Veteran's right ankle condition and, after taking further action, confirmed and continued the prior denial of the remaining issues on appeal in a February 2021 Supplemental Statement of the Case (SSOC) and returned the case to the Board. The record does not reflect that the Veteran disagreed with the October 2020 rating decision and, as such, the issue of service connection for a right ankle disability is no longer in appellate status. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of an appeal, a second notice of disagreement must thereafter be timely filed in order to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of the award of service connection). In the October 2020 remand, the Board directed the AOJ to obtain any outstanding VA and/or private treatment records relevant to the Veteran's left hip and left knee conditions that were not already of record, and to notify the Veteran if any such records were not obtainable. The AOJ was further directed to a medical opinion from a qualified clinician regarding the nature and etiology of the Veteran's left hip condition. The AOJ was finally directed to schedule the Veteran for an examination regarding the severity of her left knee condition. The claims file reflects that the AOJ requested the appropriate medical opinion and examination; however, it does not appear that the examiner who offered the medical opinion regarding the Veteran's left hip condition answered each specific question posed by the Board in the October 2020 remand directives Therefore, there has not been substantial compliance with all of the Board's remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Increased Ratings Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In considering the severity of a disability, it is essential to trace the medical history. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider a veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). When adjudicating an increased rating claim, the relevant time period for consideration begins one year before the claim was filed. See 38 C.F.R. § 3.400(o); Hart, 21 Vet. App. at 509. The record reflects that VA received the Veteran's claim for the issues currently under review on December 22, 2010. The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. These provisions thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206 07 (1995). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable Diagnostic Code(s) pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In determining if a higher rating is warranted on this basis, pain itself does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in §§ 4.40 and 4.45. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The intent of the Rating Schedule is to recognize actually painful, unstable or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. As such, painful motion should be considered to determine whether a higher rating is warranted on such basis, whether or not arthritis is present. See Burton v. Shinseki, 25 Vet. App. 1. Accordingly, the Board will analyze the evidence of record to determine the Veteran's current levels of disability. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the claims. 1. Entitlement to increased evaluations for a left knee disability. The Veteran contends, in essence, that she is entitled to increased evaluations for her left knee disability throughout the period on appeal, as her symptoms related to the condition more nearly approximated the criteria for higher ratings during the relevant timeframes. She is currently rated under Diagnostic Code 5055-5003 as 10 percent disabled for the period on appeal prior to May 1, 2013, as 30 percent disabled for the period from July 1, 2014 to November 20, 2014, as 30 percent disabled for the period from March 1, 2015 to December 15, 2015, and as 60 percent disabled since December 15, 2015. She is also rated as 100 percent disabled for the period from May 1, 2013 to July 1, 2014 and the period from November 20, 2014 to March 1, 2015, but, as 100 percent is the maximum evaluation available for her left knee disability, those periods will not be addressed at length herein. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code determines its rating based on a residual condition, with the number following the hyphen representing the residual. 38 C.F.R. § 4.27. Diagnostic Code 5055 sets out the rating criteria for a knee replacement. While the record indicates that the evaluation assigned for the Veteran's left knee disability for the period prior to May 1, 2013 includes consideration of a knee replacement during that time, the Board notes that the Veteran did not undergo replacement of her left knee until May 1, 2013. Therefore, the rating criteria for Diagnostic Code 5055 are not applicable during the period prior to May 1, 2013 in evaluating the left knee disability. The Board notes that, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. The Veteran's left knee disability was rated under Diagnostic Code 5055 for the period dating from the effective date of the revised rating schedule (February 7, 2021). While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the changes to DC 5055 do not avail the Veteran. In VAOPGCPREC 23-97, the VA General Counsel interpreted that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that, if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. The General Counsel has also directed that separate ratings are available if a particular knee disability causes both compensable (10 percent) limitation of extension (Diagnostic Code 5261) and compensable limitation of flexion (Diagnostic Code 5260) of the same joint. Specifically, where a veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04. Under Diagnostic Code 5003, degenerative arthritis 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. 38 C.F.R. § 4.71a. When, however, the limitation of motion is non-compensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. Id. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, x-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, x-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings will not be combined with ratings based on limitation of motion. Id. Under Diagnostic Code 5055, a 30 percent minimum rating is warranted for prosthetic replacement of the knee. Id. A 60 percent rating is warranted for prosthetic replacement of the knee with chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. Prosthetic replacement of the knee with intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. Id. A 100 percent rating is warranted for one year following implantation of the prosthesis. Id. Under Diagnostic Code 5256, a 30 percent rating is warranted for ankylosis of the knee in a favorable angle in full extension, or in slight flexion between zero degrees and 10 degrees, a 40 percent rating is warranted for ankylosis of the knee in flexion between 10 degrees and 20 degrees, a 50 percent rating is warranted for ankylosis of the knee in flexion between 20 degrees and 45 degrees, and a 60 percent rating is warranted for extremely unfavorable ankylosis of the knee in flexion at an angle of 45 degrees or more. Id. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. Id. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Id. Under Diagnostic Code 5259, a 10 percent rating is warranted for symptomatic removal of the semilunar cartilage. Id. Under Diagnostic Code 5260, a 10 percent rating is warranted if flexion is limited to 45 degrees, a 20 percent rating is warranted if flexion is limited to 30 degrees, and the maximum 30 percent rating is warranted if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Normal range of motion of the knee is up to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Id. Under Diagnostic Code 5261, a 10 percent rating is warranted if extension is limited to 10 degrees, a 20 percent rating is warranted if extension is limited to 15 degrees, a 30 percent rating is warranted if extension is limited to 20 degrees, a 40 percent rating is warranted if extension is limited to 30 degrees, and a 50 percent rating is warranted if extension is limited to 45 degrees. Id. Under Diagnostic Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability, a 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability, a 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability, and a 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion, requiring a brace. Id. Under Diagnostic Code 5263, a 10 percent rating is warranted for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Id. A. Entitlement to an evaluation in excess of 10 percent disabling for the period prior to May 1, 2013. In a March 2010 VA examination, the Veteran reported that she experienced constant sharp pain in the lateral aspect of her left knee, with constant swelling. She noted that she had occasional buckling of her knee, but no locking. She indicated that she experienced flare-ups of her symptoms resulting in stiffness on a daily basis, and stated that the flare-ups were brought on by climbing more than five stairs at a time, standing for more than five minutes at a time, or walking more than 100 feet at a time. She claimed that the flare-ups subsided in approximately 10 minutes after she sat down, elevated her left leg, and iced her left knee. The examiner indicated that the Veteran was independent with all activities of daily living without adaptive equipment and independent with ambulation, although she sometimes used a cane due to her left knee condition. The examiner noted that she worked full-time as a secretary, but she indicated that her work efficiency decreased due to her left knee condition and her foot condition. She reported that she frequently needed the assistance of coworkers to walk to retrieve records and was also slow to walk to greet clients at the reception window. The examiner indicated that the Veteran's range of motion for her left knee was from zero to 105 degrees, with evidence of pain beginning at 75 degrees. The examiner noted that her range of motion decreased to zero to 90 degrees after repetitive motion testing. The examiner stated that there was no ligamentous instability. The examiner indicated that she had a mildly antalgic gait, with decreased weight-shifting onto the left leg. The examiner concluded that during a flare-up of her symptoms, the Veteran could have an increase in pain and further limitation of motion of her left knee that affected her functional capacity. In an August 2010 statement, the Veteran claimed that her left knee was swollen and very sore, and noted that it hurt and popped with any type of ambulation. A September 2010 VA orthopedic surgery consultation note indicated that the Veteran reported increasing left knee pain, and the treating clinician observed that she was limping severely on her left side. In an October 2011 VA examination, the examiner noted that the Veteran was scheduled for a left knee total arthroplasty in October 2011, but had to cancel the operation because her mother was sick. The examiner documented a range of motion for the Veteran's left knee of 90 degrees of flexion, with painful motion beginning at 90 degrees, and limitation to 20 degrees of extension, with painful motion at 20 degrees. After repetitive use testing, her range of motion of her left knee was listed as 90 degrees of flexion and limitation to 45 degrees or greater for extension. The examiner indicated that the limitation of motion of her left knee did not result in functional loss of her left lower extremity. The examiner noted that she was limited to sedentary work due to her left knee disability, and would not be able to maintain employment that involved physical activity or prolonged standing. Based on the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran's left knee disability symptoms more nearly approximated the criteria for a rating in excess of 10 percent disabling based on limitation of flexion of the joint for the period prior to October 12, 2011. Although the medical evidence reflects that the Veteran experienced functional loss associated with her left knee disability symptoms, at no time prior to May 1, 2013 did the limitation of flexion of her left knee reach a compensable level, even when considering the point at which there was evidence of painful motion. Additionally, there is otherwise no indication that the Veteran experienced symptoms which would entitle her to an evaluation in excess of 10 percent disabling under a different Diagnostic Code. However, the evidence does indicate that the Veteran exhibited a compensable level of limitation of extension of her left knee at the time of the October 2011 VA examination. The examiner documented that the extension of her left knee was initially limited to 20 degrees, and that the severity increased limitation to 45 degrees or more after repetitive use testing. There is no indication that her symptoms improved prior to her left knee replacement operation in May 2013. Therefore, resolving all reasonable doubt in favor of the Veteran, the preponderance of the evidence is in favor of a finding that her left knee disability symptoms most nearly approximated limitation of extension to 45 degrees or more since October 12, 2011, and a 50 percent rating is warranted as of that date. The Board notes that prior to October 12, 2011, the 10 percent rating assigned to the Veteran is based on the criteria for Diagnostic Code 5003. As discussed above, the 10 percent rating allowable under Diagnostic Code 5003 is only applicable where the limitation of motion of a joint is otherwise not compensable. Therefore, she is not eligible for a 10 percent rating under Diagnostic Code 5003 for any additional limitation of motion (e.g., flexion) of her left knee that is not itself at a compensable level as of that date. In summation, entitlement to an evaluation in excess of 10 percent disabling for limitation of motion of the Veteran's left knee is not warranted for the period prior to October 12, 2011. However, entitlement to an evaluation of 50 percent disabling for limitation of extension is warranted from October 12, 2011 to May 1, 2013, which also nullifies the previously assigned 10 percent rating under Diagnostic Code 5003 during that time period. B. Entitlement to a rating in excess of 30 percent disabling for the period from July 1, 2014 to November 20, 2014. In an August 2014 private physical therapy progress note, the treating clinician stated that the Veteran had a range of flexion for her left knee of 90 degrees when she completed physical therapy after her left knee replacement surgery. In a September 2014 VA orthopedic surgery consultation note, the Veteran reported experiencing pain in her left knee of a severity of five out of 10. The treating clinician noted that she walked with an abnormal gait and listed a range of motion for her left knee from zero to 45 degrees. The clinician stated that the Veteran's left knee was well-aligned and showed no gross abnormality. An October 2014 private treatment record stated that the Veteran's range of motion for her left knee had regressed from 90 degrees after completing physical therapy to only 60 degrees. The treating clinician noted that she struggled to gain strength and range of motion after her knee replacement surgery. A November 2014 private treatment record noted that the Veteran had approximately 80 degrees of flexion in her left knee, with full extension and no effusion. The clinician recommended arthroscopic debridement of adhesions, scar tissue, and closed manipulation. Accordingly, the Board finds that the preponderance of the evidence is against a finding that the Veteran's left knee symptoms more nearly approximated the criteria for a rating in excess of 30 percent disabling for the period from July 1, 2014 to November 20, 2014. Although the record indicates that she did experience residuals after her left knee replacement operation, the medical evidence reflects that the residuals did not consist of severe painful motion or weakness of her left lower extremity. While she reported experiencing pain in her left knee and weakness was documented in her private treatment records, she quantified the severity of her pain as five out of 10 in September 2014, when she exhibited the greatest limitation of flexion of her knee. Additionally, there is no indication that she continued to experience limitation of extension of her left knee as she did before her knee replacement operation in May 2013. Thus, the limitation of motion of the Veteran's left knee would, itself only warrant a 10 percent evaluation under Diagnostic Code 5260, and the minimum 30 percent evaluation under Diagnostic Code 5055 represents the maximum evaluation warranted for the period from July 1, 2014 to November 20, 2014. C. Entitlement to an evaluation in excess of 30 percent disabling for the period from March 1, 2015 to December 15, 2015. In a January 2015 VA examination, the examiner documented a range of motion for the Veteran's left knee of negative 10 to 70 degrees. The examiner noted pain on examination in flexion and extension, which resulted in functional loss. Her range of motion for her left knee remained the same after repetitive use testing, but the examiner indicated that there was additional functional loss due to pain, fatigue, and weakness. The examiner further indicated that pain, fatigue, and weakness would result in functional loss during a flare-up, although the examiner documented that such functional loss would still result in a range of motion of negative 10 degrees to 70 degrees. The examiner documented a reduction of strength in her left knee to a level of three out of five in both flexion and extension, with no muscle atrophy. The examiner stated that there was no history of recurrent subluxation or recurrent effusion, but noted a history of slight lateral instability of the left knee. The examiner indicated that the Veteran had residual signs or symptoms after arthroscopic surgery including pain, weakness, and instability. The examiner listed functional impairment impacting her ability to perform occupational tasks including that she was unable to walk long distances, had pain in her knees with "up and down motion," she was unable to stand for any period of time, she could not "get down to bend on her knees" and had difficulty picking up computer equipment. The examiner concluded that the Veteran was unable to perform any physical or sedentary work as a result of post-operative surgery on her left knee. Although there is limited evidence regarding the severity of the Veteran's left knee disability symptoms during the period from March 1, 2015 to December 15, 2015, the Board finds that the preponderance of the evidence is against a finding that the her left knee disability symptoms more nearly approximated the criteria for an evaluation in excess of 30 percent disabling during that time. The January 2015 examiner documented a limitation of flexion at a noncompensable level and a limitation of extension at a level which would entitle the Veteran to a 10 percent evaluation, along with slight instability which would warrant an additional 10 percent evaluation. These evaluations would still fail to eclipse the minimum 30 percent rating assigned for a prosthetic knee replacement. Therefore, an evaluation in excess of 30 percent disabling would not be available based on intermediate degrees of residual weakness, pain, or limitation of motion. Further, the Board finds that the preponderance of the evidence is against a finding that the Veteran's prosthetic knee replacement residuals more nearly approximated chronic residuals consisting of severe painful motion or weakness in her left lower extremity. Again, the evidence indicates that the Veteran experienced pain and weakness as a result of her left knee disability; however, in the January 2015 examination report, the examiner did not note that the residuals related to her left knee were severe. This is highlighted by the fact that the examiner did document in the same examination report that the Veteran's residuals related to her right knee prosthetic replacement were severe. Thus, entitlement to a rating in excess of 30 percent disabling is not warranted for the Veteran's left knee disability for the period from March 1, 2015 to December 15, 2015. D. Entitlement to a rating in excess of 60 percent disabling for the period since December 15, 2015. The Board notes that, with the exception of the one-year period after implantation of a prosthesis during a knee replacement operation, there is no schedular evaluation in excess of 60 disabling available under the Diagnostic Codes applicable to knee disabilities. See 38 C.F.R. § 4.71a. The record indicates that the Veteran's left knee replacement operation took place more than one year prior to December 15, 2015, and there is also no indication from the record that the Veteran's left knee disability resulted in a unique or exceptional disability pattern during the period since December 15, 2015. Accordingly, entitlement to a rating in excess of 60 percent disabling is not warranted for that period of time. 2. Entitlement to a TDIU prior to December 15, 2015 The Veteran asserts, in essence, that she has been unable to obtain and maintain substantially gainful employment as a result of her service-connected disabilities since October 1, 2014. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. A total disability rating may be assigned where the combined rating for the Veteran's service-connected disabilities is less than total if the disabled Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purpose of defining a disability of either 60 percent or 40 percent under 38 C.F.R. § 4.16(a), the following will be considered one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single incident; (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple injuries incurred as a prisoner of war. 38 C.F.R. § 4.16(a). In exceptional cases, an extra-schedular rating may be assigned on the basis of a showing of unemployability alone. See 38 C.F.R. § 4.16(b). The Board notes that the Veteran is already assigned a TDIU for the period beginning December 15, 2015. The record reflects that the Veteran retired from full-time work on September 30, 2014 due to a reduction in staffing. As previously discussed by the Board, the Veteran does not meet the schedular requirements for a TDIU for the period prior to December 15, 2015. Thus, the primary question before the Board is whether her service-connected disabilities rendered her unable to obtain and maintain substantially gainful employment for the period from October 1, 2014 to December 15, 2015 on an extraschedular basis. The claims file reflects that an opinion regarding entitlement to a TDIU on an extraschedular basis by the Director of the Compensation Service is of record, and the Board may properly consider the issue. See Bowling v. Principi, 15 Vet. App. 1 (2001) (A claim for entitlement to a TDIU on an extraschedular basis must first be referred to the Director of the Compensation Service for initial consideration before the Board can render a decision on the issue). A TDIU rating is contingent on the schedular rating being less than total. 38 C.F.R. § 4.16(a). However, in Bradley v. Peake, 22 Vet. App. 280 (2008), the United States Court of Appeals for Veterans Claims (Court) held that the issue of entitlement to a TDIU may not be moot based on the assignment of a total schedular rating under certain circumstances, in particular where special monthly compensation (SMC) could be awarded based on the consideration of a TDIU rating under 38 U.S.C. § 1114(s). See also Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2011). Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis of an award of SMC. 38 U.S.C. § 1114(s), in relevant part, states that if a Veteran has a service-connected disability rated as total, and has an additional service-connected disability or disabilities individually ratable at 60 percent or more, the Veteran shall be entitled to monthly compensation. In this instance, the Veteran is rated as 100 percent disabled for her left knee disability for the periods from May 1, 2013 to July 1, 2014 and from November 20, 2014 to March 1, 2015; however, the Veteran does not have an additional service-connected disability individually ratable at 60 percent or more. Thus, entitlement to a TDIU is moot for those periods. The lack of an additional service-connected disability individually ratable at 60 percent or more also renders the question of whether the Veteran's left knee disability, by itself, warrants entitlement to a TDIU moot, as SMC would likewise not be available under 38 U.S.C. § 1114(s) even if her left knee disability was found to result in total disability based on individual unemployability at any time during the period on appeal. Essentially, the Veteran' is therefore seeking entitlement to a TDIU for the periods from October 1, 2014 to November 20, 2014 and from March 1, 2015 to May 1, 2015. In her December 2014 Application for Increased Compensation Based on Unemployability, the Veteran indicated that she was unable to secure or follow a substantially gainful employment due to her left and right knee disabilities. She stated that she became too disabled to work on September 30, 2014. In a January 2015 VA examination, the Veteran reported that she was unable to walk long distances, that she had pain in her knees "with up and down motion," that she was unable to stand for any period of time, that she was unable to "get down to bend on her knees," and that she could not pick up computer equipment. The examiner noted that the Veteran was under the care of an orthopedic surgeon associated with a November 2014 left knee surgery, and was unable to work due to the surgery. The examiner stated that she was unable to perform any physical or sedentary work duties due to recent post-operative surgery of her left knee. In a February 2015 communication, the Veteran's former employer indicated that she performed secretarial work, but was laid off on September 30, 2014. In a July 2017 letter, the Veteran indicated that her supervisors at her previous job worked with her and were not restrictive when it came to taking time off of work due to her service-connected disabilities. She noted that she was permitted to work at her own pace and allowed to "come to work a little late and leave a little early if [she] deemed it necessary." She noted that she frequently took off work to attend medical appointments and physical therapy sessions for her conditions. In an April 2018 decision by the Social Security Administration (SSA), received by VA in July 2018, the SSA granted the Veteran disability benefits. The SSA indicated that the Veteran had been disabled since November 20, 2014. In an August 2019 opinion, the Director of the Compensation Service stated that a review of the evidentiary record did not demonstrate that the Veteran was unable to secure or follow substantially gainful employment due to her service-connected bilateral knee condition from September 30, 2014 to December 15, 2015. The Director noted that the Veteran previously worked as an executive secretary, with job duties including typing letters, sitting in on meetings, and keeping her supervisor's itinerary. The Director further noted that she missed work due to her service-connected disabilities, but stated that her supervisor accommodated the numerous appointments associated with her disabilities. Although the record indicates that the Veteran did not stop working in September 2014 as a direct result of her service-connected disabilities, the relevant evidence indicates that she had significantly limited mobility due to her bilateral knee disabilities, and required accomodation from her previous employer due to the symptoms and necessary treatment of her disabilities. The Board further notes that the Veteran underwent a total knee replacement operation on her left knee less than two months after being laid off from her job, and it is unlikely that she could have found gainful employment during that timeframe, which would allow for the necessary prolonged period of convalescence following her operation. Additionally, the January 2015 VA examiner stated that the Veteran was unable to perform any physical or sedentary work duties due to her recovery from a November 2014 surgery. The record indicates, based on the Veteran's combined disability rating, that the severity of her service connected disabilities, including the severity of her left knee disability, increased after the January 2015 VA examination and, resolving all reasonable doubt in favor of the Veteran, the Board finds that her service connected disabilities more likely than not precluded her from working for the roughly nine month period from March 2015 to December 2015. Based on the foregoing, the preponderance of the evidence indicates that the Veteran was unable to obtain and maintain substantially gainful employment due to her service-connected disabilities for the period from October 1, 2014 to November 20, 2014 and the period from March 1, 2015 to December 15, 2015. Accordingly, entitlement to a TDIU on an extraschedular basis is warranted for each period. REASONS FOR REMAND 1. Service connection for a left hip disability is remanded. The Veteran contends, in essence, that she is entitled to service connection for a left hip disability on the basis that the condition is due to her service-connected disabilities. In the Board's October 2020 remand, the AOJ was directed to obtain an opinion from a qualified clinician to determine the nature and etiology of the Veteran's left hip condition. The Board noted that a July 1982 service treatment record reflected the Veteran had left hip pain due to a fall, and that a July 2010 VA treatment record noted that she was seen for left hip pain. The Board asked the clinician providing the opinion to address whether it was at least as likely as not that the Veteran's left hip condition was caused or aggravated by her bilateral pes planus, her left knee conditions, her right knee conditions, and/or her right ankle condition. The AOJ obtained the requested opinion in February 2021. The clinician providing the opinion stated that it was less likely than not that the Veteran's left hip condition was related to her right ankle condition, pes planus, right knee condition, or left knee condition. The examiner documented that there was no credible evidence to suggest that an injury or disease of one lower extremity joint would have any significant impact on another lower extremity joint, unless such a condition resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or shortening of the injured lower extremity resulting in a limb length discrepancy of more than four or five centimeters so that the individual's gait patter has been altered to the extent that clinically there is an obvious lurching type gait (a significant limp). The clinician further claimed that there was no mechanism to support aggravation of the Veteran's left hip condition by her service-connected disabilities. The clinician additionally indicated that the Veteran's service treatment records did not show complaints or injury to the hips during active duty service, and that post-service medical records noted pain in 2015, which was 11 years after separation from service. Thus, it is clear that the February 2021 clinician failed to comply with the terms of the Board's October 2020 remand. The clinician did not address the record of left hip pain during the Veteran's ACDUTA period in 1982, and incorrectly indicated that the first note of left hip pain after her separation from service was in 2015. Further, the Board notes that the Veteran is already service-connected for a right knee disability on the basis that the condition was caused by her left knee disability, contradicting the theory of the clinician's opinion that there was "no mechanism" to support aggravation of the Veteran's left hip condition by her service-connected disabilities and that no injury or disease of a lower extremity joint would have any significant impact on another lower extremity joint. In an October 2011 VA examination, which served as the basis of the grant of service connection for the Veteran's right knee disability, the examiner stated that she favored her right side with ambulation due to her left knee pain that could result in progressive osteoarthritis. Her VA treatment records also note that she had an abnormal gait due to her knee disabilities on multiple occasions. Based on the foregoing, the Board finds that the examining clinician's February 2021 opinion is inadequate, and an addendum opinion is necessary which addresses all relevant evidence of record and clarifies the apparent contradiction between the previously conceded fact that the Veteran's right knee disability was due to compensation for her left knee disability and the clinician's basis for a negative nexus opinion that she did not have symptoms related to her service-connected disabilities which could result in additional disability of her lower extremities. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate); see also D'Aries, supra. The matters are REMANDED for the following action: Make arrangements to provide the record on appeal to an appropriately qualified clinician for purposes of obtaining a medical opinion as to the nature and etiology of any left hip condition the Veteran may have had during the period on appeal. (1). After reviewing the record, the clinician should provide an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that any such left hip condition diagnosed during the period on appeal was related to the Veteran's military service. (2). If not, is it at least as likely as not that a diagnosed left hip condition was caused by a service-connected disability? (3). If not, is it at least as likely as not that the Veteran's diagnosed left hip condition is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability? If the Veteran's claimed left hip condition is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In doing so, the examiner should specifically discuss the July 1982 service treatment record detailing complaints of left hip pain, as well as the Veteran's VA treatment records noting left hip pain as early as 2010. The examiner should also clarify the discrepancy between the negative nexus opinions based on the fact that the Veteran does not have symptoms related to her service-connected disabilities which could result in an additional lower extremity disability (e.g., a significant limp) and the Board's service connection of her right knee disability on the basis that it was due to compensation for her left knee disability. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries observable to a layperson. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The examiner is also reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Thus, the examiner is to consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran's statements asserting symptomatology. The examiner must provide a comprehensive rationale for all opinions expressed. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. Specifically, the examiner must indicate whether there was a further need for information or testing, or whether an opinion could not be rendered due to limitations of knowledge in the medical community at large. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Ferguson, 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.