Citation Nr: 21032087 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 08-19 670A DATE: May 25, 2021 ORDER Entitlement to a rating in excess of 20 percent for low back strain with degenerative joint disease (DJD) is denied. Entitlement to total disability based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. For all periods relevant to this appeal, the Veteran's low back strain with degenerative joint disease has been manifested primarily by pain, stiffness, fatigue, weakness, periodic flare-ups after activity, and thoracolumbar spine flexion to no less than 42 degrees. 2. The Veteran's service-connected disabilities have rendered him incapable of securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for low back strain with degenerative joint disease (DJD) have not been met. 48 U.S.C. §§ 1155, 5103, 5103A, 4107 (2012); 38 U.S.C. §§ 3.159, 4.1, 4.3, 4.71a, Diagnostic Codes 5235-5242. 2. The criteria to establish TDIU have been met. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.16. 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1973 to July 1973. These matters come before the Board of Veterans' Appeals (Board) on appeal of an August 2007 rating decision from a Department of Veterans Affairs (VA) regional Office (RO). In May 2011 and July 2014, the Board remanded the claim of entitlement to an increased rating for lumbar spine disability. In February 2015 the Board remanded the Veteran's claims of entitlement to an increased rating for low back strain and entitlement to TDIU for further development. In a May 2018 decision, the Board denied the above-mentioned claims, and the Veteran timely appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In August 2019, the Court granted the parties Joint Motion for Remand (JMR), vacating the Board's decision and remanding the issues back to the Board. The Board remanded these issues in April 2020 in order to obtain a new VA examination that was in compliance with the Court's order and the JMR. During the pendency of this appeal, the Veteran was awarded service connection and a 10 percent rating for left lower extremity radiculopathy in a December 2020 rating decision. The Veteran has not appealed this rating as of the date of this decision, and therefore the Board will not take jurisdiction over this issue. 1. Entitlement to a rating in excess of 20 percent for low back strain with degenerative joint disease (DJD) is denied. The Veteran's low back strain with DJD is currently rated as 20 percent disabling throughout the entirety of the appeal period. The Veteran's low back strain with DJD is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5292-5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded VA examinations in March 2008, July 2011, November 2014, September 2016, and December 2020. The March 2008 examiner noted the Veteran's initial range of motion was 0 to 60 degrees for active forward flexion, with pain beginning at 60 degrees. The range of motion for passive forward flexion was 0 to 80 degrees, with pain beginning at 80 degrees. No additional loss was noted with repetitive-use testing. The Veteran reported experiencing flare-ups which he described as severe, occurred weekly and lasting for hours and usually followed walking, sitting too long, standing, or sleeping flat on his back. No estimate of loss of range of motion was provided for the Veteran's flare-ups. The examiner noted muscle spasms, guarding, and pain with movement but no atrophy, weakness, ankylosis, or IVDS. In the July 2011 examination, the Veteran reported dull, achy, and sharp pains in his low back, depending on what he was doing, which even occurs while he is sitting down. He also indicated his pain radiated down both legs and hips. The Veteran reported having flare-ups, but stated this pain was all the time, being a 5 out of 10. The Veteran took naproxen and, tramadol, and hydrocodone to help manage his pain, although he reported his pain continues to worsen. His initial range of motion for forward flexion was 78 degrees, which improved to 83 degrees after repetitive-use testing, Pain was noted during range of motion testing, but no weakness, fatiguability, or incoordination was noted. The examiner did not address whether IVDS was present. In the November 2014 examination, the Veteran reported daily pain between a 5 and an 8 out of 10. He also reported sharp and dull mid- and lower lumbar pain. He reported no recent muscle spasms, noting they had been very rare as of that time. He also reported intermittent daily pain, tingling, and numbness starting in his feet and hands. The Veteran reported having flare-ups, noting they occur weekly for about a day and are brought on by cold or wet weather, sudden "wrong" movements, increased activity and bending, and driving. These flare-ups cause the Veteran to quit whatever he was doing at the time because the pain is so bad, he has to "stop and wait it out." They are alleviated by rest, stretching, and medication. The examiner noted the Veteran's pain during his flare-ups caused decreased movement, especially bending, with the Veteran describing only being able to bend about half of his normal range of motion during a flare-up. The Veteran reported having a flare-up during the examination due to driving. The November 2014 examiner noted the Veteran's initial range of motion for forward flexion was from 0 to 85 degrees, with pain noted at 75 degrees. There was no additional loss in range of motion after repetitive-use testing. Functional loss was noted due to pain, weakness, and lack of endurance. Mild tenderness on palpation was noted on the L2-L5 midline. The Veteran had normal muscle strength but no atrophy, muscle spasms or guarding was noted. His knee reflexes were normal, while his ankle reflexes were hypoactive, and all sensation tests showed decreased sensation. No radiculopathy or ankylosis was noted. As for IVDS, the examiner indicated the Veteran had IVDS but noted no incapacitating episodes over the past 12 months due to IVDS. During the September 2016 examination, the Veteran reported that his back pain had worsened, and he was prescribed tramadol and hydrocodone to help with his pain. He described his pain as being between a 5 and 8 out of 10 on a daily basis, with sharp and dull mid-to lower lumbar pain. The Veteran reported experiencing flare-ups, having last experienced one about two months prior to the examination that was caused by overuse. The Veteran treated his flare-up with pain medication and rest and sitting straight up helped with his pain. He also reported having functional loss due to increased back pain with lifting, stooping, and reaching, as well as pain and stiffness daily. Rest and changing positions seem to help. The Veteran's initial range of motion for forward flexion was from 0 to 75 degrees, with the examiner noting this range of motion was normal for a 65-year old, although pain was noted during the exam and caused functional loss. No additional loss was noted after repetitive-use testing. While the examiner noted the Veteran experienced flare-ups but was not experiencing one during the examination, the examiner failed to opine on whether the Veteran's flare-ups would cause additional loss in range of motion. The Veteran's muscle strength and sensation testing were noted as normal, although both his knee and ankle reflexes were hypoactive. No atrophy, ankylosis, radiculopathy, or IVDS were noted. In the December 2020 examination, the Veteran reported having constant dull and aching pains, along with a sharp stabbing pain, decreased range of motion, stiffness, fatigue, weakness, lack of endurance, and incoordination due to his back condition. He also mentioned he has numbness, prickling, or tingling sensations in his lower extremities, along with sharp, jabbing, throbbing, and burning pain and extreme sensitivity to touch in his lower extremities. The Veteran also reported experiencing flare-ups when doing any strenuous work involving his back, stating they occurred about 2 to 3 times a week, last a couple of hours to a couple of days, and are severe in nature. He further reported experiencing functional loss due to his back pain, mainly with limitations in bending, stooping, pushing, pulling, carrying, and lifting moderate objects over 10 pounds. The December 2020 examiner noted the Veteran's initial range of motion for forward flexion was from 0 to 70 degrees, which decreased to 60 degrees after repetitive-use testing, and pain was noted during all movements. The examiner stated the Veteran's range of motion contributed to his functional loss regarding bending, stooping, pushing, pulling, carrying, and lifting moderate objects over 10 pounds. Pain, fatigue, weakness, and lack of endurance contribute to the Veteran's functional loss both during repetitive use testing as well as during flare-ups. The examiner opined the Veteran's range of motion was decreased to a forward flexion of 0 to 60 degrees during his flare-ups. The examiner also noted muscle spasms that result in abnormal gait or spine contour. The Veteran's muscle strength was normal except for his right knee, which was 4/5, hypoactive reflexes in both knees, and he had decreased sensation in both thighs/knees. Radiculopathy was noted in both lower extremities, but the Veteran had no ankylosis or IVDS. The Veteran's VA treatment records also have range of motion measurements for his thoracolumbar spine. However, the Veteran has, throughout the appeal period, maintained at least 42 degrees of forward flexion, which was noted in relation to the Veteran's initial physical therapy treatment visit in December 2016. Retesting in February 2017 showed the Veteran's forward flexion had improved to 55 degrees at that time. Additionally, the Veteran provided lay statements in support of his worsening low back disability. In a June 2016 statement from his friend K.L., she describes her observations that the Veteran had decreased mobility due to his pain, noting he appeared to have difficulty performing housework and sitting for long periods of time. The Veteran's own June 2016 statement described how he had difficulty with climbing and lifting, which affected his work as a carpenter. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for low back strain with DJD. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, lack of endurance, pain during flare-ups, and pain during repetitive use over time. With respect to his flare-ups, the Veteran stated on the March 2008 examination that his flare-ups lasted for hours and usually followed walking, sitting too long, standing, or sleeping flat on his back; statements in the July 2011 examination that his pain during flare-ups was typically a 5 out of 10 and occurred constantly; statements during the November 2014 examination that his flare-ups occurred weekly for about a day, causing him to quit whatever he was doing in order to wait it out because the pain was so bad; statements in the September 2016 examination that his flare-ups were caused by overuse and were manageable with pain medication, rest, and sitting up straight; and statements in the December 2020 examination that his flare-ups were brought on by strenuous work, occurred about 2 to 3 times a week, and lasted a couple of hours to a couple of days. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the above statements about his flare-ups would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. While the Board empathizes with the Veteran's pain and restricted ranges of motion due to his low back disability, he has retained forward flexion in the record of at least 42 degrees throughout the appeal period, well above the maximum 30 degrees allowed under a 40 percent rating. There is also no evidence of record that the Veteran's activities of daily living have been greatly impacted by his reduced thoracolumbar forward flexion. Although the Veteran's June 2016 statement describes his difficulty with climbing and lifting, and the June 2016 statement from K.L. notes the Veteran appears to have difficulty with housework and sitting for long periods of time, these alone do not indicate that his activities of daily living have been greatly impacted. Additionally, the most recent VA examination shows the Veteran maintains forward flexion of at least 60 degrees, even when considering his flare-ups. Furthermore, 38 C.F.R. §§ 4.40 and 4.45 permit consideration of a higher evaluation to be awarded where there is additional functional loss and/or limitation of motion due to factors such as pain, weakened movement, excess fatigability, and incoordination during flare-ups and/or after repeated use over time.). See Mitchell v. Shinseki, 25 Vet. App. 32, 36-37 (2011); see also Deluca v. Brown, 8 Vet. App. 202, 205-06 (1995). This additional loss can be considered under the general Rating Formula of an evaluation based on ankylosis if a claimant's functional loss is consistent with the loss contemplated by ankylosis, or if the Veteran's range of motion is functionally equivalent to ankylosis. See Chavis v. McDonough, No. 18-2928, 2012 LEXIS 660 (Vet. App. April 16, 2021. However, the evidence of record shows the Veteran had, at the very least, 42 degrees of forward flexion, and his most recent VA examination shows he has 60 degrees of forward flexion during flare-ups. This range of motion, along with the evidence that the Veteran can perform his activities of daily living, show the Veteran does not have functional loss that is functionally equivalent to ankylosis. Thus, a higher rating of 40 percent for favorable ankylosis of the thoracolumbar spine or 50 percent for unfavorable ankylosis of the thoracolumbar spine utilizing §§ 4.40 and 4.45 are not warranted. The Board notes that during the pendency of this appeal, minor amendments were made to the language of DC 5242 effective February 7, 2021. These amendments did not change the criteria for compensation based on limitation of motion of the thoracolumbar spine under the general rating criteria and are therefore not relevant to this appeal. 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020) (to be codified at 38C.F.R. §4.71a, DC 5242). Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. The November 2014 examiner opined that the Veteran's low back disability was productive of IVDS; however, the examiner does not point to any findings from the examination or elsewhere in the record to support that conclusion. Additionally, the November 2014 examiner's findings of IVDS are contradicted directly by other opinions the record, including the September 2016 VA examination and the December 2020 VA examination, both of which note the Veteran does not have IVDS. Further, the Veteran's private and VA treatment records have no findings or treatment related to IVDS. And, although the Veteran testified during the February 2011 hearing that he had what he referred to as "incapacitating episodes" he was never diagnosed with IVDS or prescribed bed rest by a physician. While the Veteran is competent and credible to report symptoms he experienced, he is not competent to provide a diagnosis of IVDS because these issues are medically complex and require specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4. Based on the evidence of record, the Board finds that the Veteran's low back disability has not been productive of IVDS, and therefore Diagnostic Code 5243 does not apply. The Board has also considered whether a higher rating would be warranted under the amended rating criteria (effective February 7, 2021) for DC 5243. The evidence does not reflect that the Veteran's lumbar spine disability has symptoms of disc herniation with compression and/or irritation of the adjacent nerve root. Consequently, consideration of a potentially higher rating under DC 5243 from February 7, 2021 onwards is not warranted. 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020) (to be codified at 38C.F.R. § 4.71a, DC 5243). Regarding neurological impairment, the Veteran has already been granted service connection for right and left lower extremity radiculopathy and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Additionally, no issues concerning the evaluation of the right lower extremity radiculopathy has been preserved for appeal, and the left lower extremity radiculopathy has not been appealed as of this decision. As such, the Board will not take jurisdiction here as to any issues concerning the right or left lower extremity radiculopathies. Based on the foregoing, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for low back strain with DJD. Accordingly, the Board finds that the preponderance of the evidence is against finding that a disability rating in excess of 20 percent, for the Veteran's low back strain with DJD is warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990), 2. Entitlement to total disability based on individual unemployability (TDIU) is granted. The Veteran's claim for TDIU was raised implicitly by the evidence of record pertaining to the issues brought on appeal and, as such, stems from the Veteran's March 2007 claim for increased disability ratings for his lower back, right hip, and left knee. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3)disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table). The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., their history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether they are capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has the following disabilities that are service connected: low back strain, rated at 20 percent from June 2001; left patella chondromalacia, rated at 10 percent from June 2001; left hip strain, rated at 10 percent, from May 2003; right knee patellofemoral degenerative arthritis (rated previously as right knee strain), rated at 10 percent from May 2003; right and left hip strain, rated at 10 percent each from May 2003; right lower extremity radiculopathy, rated at 10 percent from August 2003; and left lower extremity radiculopathy, rated at 10 percent from December 2020. The Veteran's bilateral hip and knee disabilities are subject to the bilateral factor and, moreover, arise out of a common etiology. Therefore, these disabilities are treated as a single disability and, in combination with the Veteran's low back disability, result in a 60 percent rating for one system, the orthopedic system, over the entire appeal period. 38 C.F.R. §§ 4.16(a) and 4.25. Based on the forgoing, the Veteran has one disability rated 60 percent or more. Accordingly, the Board may consider the claim for a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). For the reasons that follow, the Board finds that a TDIU is warranted from December 22, 2020. The Veteran contends that his general symptoms of pain, weakness, fatigability, and lack of endurance associated with his service-connected disabilities render him incapable of working a full eight-hour day. In his June 2016 statement, he described having difficulties with climbing and lifting due to his disabilities. The June 2016 statement from his friend K.L. notes the Veteran appeared to have decreased mobility as well as difficulty performing housework. The Veteran also indicated in his June 2016 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, that he last worked fulltime as a carpenter in May 2010 and was too disabled to work in June 2012. He also reports education through three years of high school as well as occupational experience as a carpenter In his March 2008 examination, the Veteran reported having been a carpenter for over 20 years and was working part-time as of the examination. The examiner noted the Veteran had decreased mobility, manual dexterity, decreased strength in his lower extremities, and issues with lifting and carrying due to his low back. The examiner further noted the Veteran's hip and knee disabilities did not have any significant occupational effects. The Veteran did not report losing any time from work due to his disabilities, and the examiner did not opine that the Veteran was unable to obtain or follow gainful employment. In his July 2011 examination, the Veteran reported he reduced his workday to 5 hours due to his back, knee, and hip pain. He also described avoiding climbing ladders for work, instead hiring help for any jobs that required climbing ladders. The November 2014 examiner opined that the Veteran's low back disability impacted his ability to work, resulting in such restrictions as avoidance of prolonged standing or sitting, lifting, carrying, bending, and twisting during episodes of pain. The Veteran also required pain medication to help with his pain, which could impact his dexterity and alertness, and thus workplace safety. While his ability to exercise was mildly impacted by his low back disability, no other activities of daily living were impacted. In an April 2015 examination, the Veteran reported having daily knee pain and occasional episodes of locking and giving way. The Veteran also reported pain and stiffness in both his hips, and tenderness on palpation was noted in both hips. The examiner further opined while the Veteran's low back, knee, and hip disabilities on their own all impacted his ability to work in heavy duty occupations, none of these conditions on their own prevented him from being gainfully employed in a light duty or desk-job occupation. Additionally, even when looking at the combined effects of his low back, hip, and knee disabilities, the Veteran could still be gainfully employed in a light duty or desk-job occupation. In a July 2015 VA treatment record, the Veteran reported pain and locking in his knees, stating these symptoms were aggravated by prolonged sitting and climbing ladders. He also reported the pain in his hips was aggravated by prolonged sitting and climbing ladders. At the September 2016 examination, the Veteran reported that he stopped working fulltime in 2012 due to his back and knee pain, although he currently worked about 8 hours a week doing handyman work. He also collected Social Security retirement benefits and VA disability benefits. The Veteran reported increased knee pain that was aggravated by climbing, lifting, squatting, and walking for more than 10 minutes. In his hip examination, the Veteran reported difficulty walking, climbing stairs, and standing for long periods in one position due to pain. The examiner opined the Veteran's low back disability impacted his ability to work due to his avoidance of prolonged standing or sitting, lifting, carrying, bending, and twisting during episodes of pain. He also used pain medication to manage his low back disability, which could affect his dexterity and alertness. The Veteran's hip disabilities impacted his ability to work because he required assistive devices for ambulation, frequent rest periods and should avoid prolonged periods of standing or sitting without breaks as well as high-risk activities likely to cause reinjury. His knee disabilities also impacted his ability to work, with the examiner noting long-term use of a protective knee brace may be recommended, and the Veteran should avoid activities requiring squatting, jumping, and abrupt turning or twisting. However, the examiner opined that while the Veteran's service-connected back, knee, and hip disabilities prevent him from being gainfully employed in heavy duty occupations, he can still be gainfully employed in light duty or desk-job occupations. The December 2020 examiner opined the Veteran was unable to perform any sedentary work due to his limitations in bending, stooping, pushing, pulling, carrying, and lifting moderate objects over 10 pounds because of the pain and discomfort caused by his low back disability. Having carefully considered the record, the Board concludes that TDIU is warranted for the entire period of the Veteran's appeal. As early as 2008, the Veteran reported that he worked part time, and he was noted to experience decreased mobility, manual dexterity, decreased strength in his lower extremities, and issues with lifting and carrying due to his low back symptoms. He reported similar limitations in 2011. In 2014, an examiner opined that the Veteran's low back disability resulted in such restrictions as avoidance of prolonged standing or sitting, lifting, carrying, bending, and twisting during episodes of pain. This examiner also noted that the Veteran's pain medication could impact his dexterity and alertness, and thus workplace safety. An April 2015 VA examiner opined that the Veteran's low back, knee, and hip disabilities on their own all impacted his ability to work in heavy duty occupations. The 2016 examiner also noted that heavy duty occupations were essentially precluded. Finally, the 2020 examiner opined that sedentary work was also precluded. The Board has also considered the Veteran's credible statements describing the impact of his service-connected disabilities on his occupational functioning. In weighing the lay and medical evidence of record, the Board finds that there is an approximate balance as to whether the Veteran is rendered unable to obtain and maintain a substantially gainful occupation as the result of his service-connected disabilities for the period of this appeal. As such, entitlement to TDIU is warranted. J.K. Barone Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, Associate 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.