Citation Nr: 21040135 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-54 320 DATE: July 2, 2021 ORDER Entitlement to a rating in excess of 20 percent for service-connected right knee limitation of flexion (formerly right knee patellofemoral pain syndrome) is denied. Entitlement to a rating in excess of 20 percent for service-connected left knee limitation of flexion (formerly left knee patellofemoral pain syndrome) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. FINDINGS OF FACT 1. The Veteran's service-connected right knee limitation of flexion (formerly right knee patellofemoral pain syndrome) is manifested by pain and limitation of motion; ankylosis, tibia or fibula impairment, a semilunar cartilage condition, or genu recurvatum are not present. 2. The Veteran's service-connected left knee limitation of flexion (formerly left knee patellofemoral pain syndrome) is manifested by pain and limitation of motion; ankylosis, tibia or fibula impairment, a semilunar cartilage condition, or genu recurvatum are not present. 3. The Veteran's service-connected disabilities do not preclude him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 20 percent for service-connected right knee limitation of flexion (formerly right knee patellofemoral pain syndrome) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Code 5260. 2. The criteria for entitlement to a rating in excess of 20 percent for service-connected left knee limitation of flexion (formerly left knee patellofemoral pain syndrome) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Code 5260. 3. The criteria for entitlement to a TDIU due to service-connected disabilities have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1994 to June 1997 and from October 2000 to February 2004, including almost four years of sea service. This matter is before the Board of Veterans' Appeal (Board) on appeal from an August 2012 rating decision issued by a Department of Veteran Affairs (VA) Regional Office (RO). In February 2017, the Veteran testified at a hearing at the RO before a Veterans Law Judge (VLJ). A transcript of the hearing is of record. The VLJ who conducted the February 2017 hearing is no longer employed with the Board. In a June 2020 letter, the Veteran was informed that the VLJ who held the February 2017 hearing is no longer employed at the Board and was offered the opportunity to have another hearing by a VLJ who would adjudicate the appeal. No response to that letter was received. Therefore, the Board has determined that a further hearing is not warranted. The Board remanded the issues on January 2018 and June 2020 for further development. All development actions having been completed (including obtaining treatment records and new examinations, providing the Veteran with a formal claim for a TDIU, and readjudication of his case), the Board finds substantial compliance with its remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating 1. Entitlement to a rating in excess of 20 percent for service-connected right knee limitation of flexion (formerly right knee patellofemoral pain syndrome). 2. Entitlement to a rating in excess of 20 percent for service-connected left knee limitation of flexion (formerly left knee patellofemoral pain syndrome). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In rating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or maligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Importantly, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71(a) 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. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. This change only effects the Veteran's claims for increase involving instability and malunion of the tibia and fibula, and the changes are discussed in greater detail below. The Veteran is service-connected for the following knee disabilities: (1) right knee limitation of flexion (formerly right knee patellofemoral pain syndrome) rated at 10 percent from February 11, 2004, and 20 percent from May 4, 2010 under 38 C.F.R. § 4.71(a), Diagnostic Code 5260; and (2) left knee limitation of flexion (formerly left knee patellofemoral pain syndrome) rated at 10 percent from February 11, 2004, and 20 percent from May 4, 2010 under 38 C.F.R. § 4.71(a), Diagnostic Code 5260. Increased ratings are not warranted for the Veteran's service-connected knee disabilities. Diagnostic Code 5256 pertains to ankylosis of the knee. 38 C.F.R. § 4.71(a). The previous version of Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, or a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. 38 C.F.R. § 4.71(a). The new version of Diagnostic Code 5257 retains ratings for recurrent subluxation or instability, providing a 30 percent rating for such instability with 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. A 20 percent rating is assigned for either 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 for an 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. A 10 percent rating is assigned for 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. The revised Diagnostic Code 5257 also created a new rating for patellar instability; importantly, each of those ratings requires a diagnosed condition of patellar instability for application. Diagnostic Code 5258 provides for assignment of a 20 percent rating with semilunar cartilage dislocated with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71(a). Diagnostic Code 5259 provides for assignment of a 10 percent rating for removal of symptomatic semilunar cartilage. 38 C.F.R. § 4.71(a). Diagnostic Code 5260 provides for a 10 percent rating when flexion of the leg is limited to 45 degrees; a 20 percent rating when flexion is limited to 30 degrees; and a 30 percent rating when flexion is limited to 15 degrees. 38 C.F.R. § 4.71(a). Diagnostic Code 5261 provides for a 10 percent rating when extension is limited to 10 degrees; a 20 percent rating with extension limited to 15 degrees; a 30 percent rating with extension limited to 20 degrees; a 40 percent rating with extension limited to 30 degrees; and a 50 percent rating is assigned with extension limited to 45 degrees. 38 C.F.R. § 4.71(a). Diagnostic Code 5262 provides ratings for impairment of the tibia and fibula. A 40 percent rating is assigned for nonunion with loose motion requiring a knee brace; a 30 percent rating is assigned for malunion with marked knee or ankle disability; a 20 percent rating is assigned for malunion with moderate ankle or knee disability; and a 10 percent rating is assigned for malunion with slight knee or ankle disability. 38 C.F.R. § 4.71(a). Diagnostic Code 5263 provides for a 10 percent rating for genu recurvatum, acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated. 38 C.F.R. § 4.71(a). Diagnostic Code 5010 provides that arthritis, due to trauma, substantiated by X-ray findings should be rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71(a). Diagnostic Code 5003 provides that 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 (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application 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. In the absence of limitation of motion, it is rated as the following: 20 percent is assigned 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 is assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1): 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): The 20 percent and 10 percent ratings based on X-ray findings, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. In June 2010, the Veteran had a VA examination for his service-connected bilateral knee disorder. He was diagnosed with bilateral patellofemoral pain syndrome. The Veteran's symptoms included pain, weakness, giving away, and fatigability. He did not have to use any ambulatory aids. Upon physical examination, it was noted that the Veteran did not have ankylosis of the knee joints. Initial range of motion testing of the left knee revealed flexion from 0 to 120 degrees and extension to 0 degrees. Initial range of motion testing of the right knee revealed flexion from 0 to 120 degrees and extension to 0 degrees. The Veteran had painful motion in the right and left knees. The Veteran's bilateral knee disorder had a mild effect on daily activities. In July 2011, the Veteran was afforded a VA examination for his bilateral knees. The Veteran was diagnosed with bilateral patellofemoral pain syndrome. The Veteran reported that his symptoms included pain, locking, and popping. He did not need any ambulatory aids. Initial range of motion testing in the right knee revealed flexion from 0 to 120 degrees and extension to 0 degrees. Initial range of motion testing of the left knee revealed flexion from 0 to 130 degrees and extension to 0 degrees. There was no additional loss of range of motion after repetitive use testing in the right or left knee. The VA examiner concluded that the effect of the Veteran's bilateral patellofemoral pain syndrome was minimal on his usual occupation and daily activities. In January 2012, the Veteran was afforded a VA examination for his knees. The Veteran was diagnosed with stable bilateral patellofemoral syndrome. Flare-ups did not impact the function of the knee and/or leg. Initial range of motion testing in the right knee revealed flexion from 0 to 135 degrees with no objective evidence of painful motion and extension ending on 0 degrees or any degree of hyperextension with no objective evidence of painful motion. Initial range of motion testing of the left knee revealed flexion from 0 to 140 degrees or greater with no objective evidence of painful motion and extension ending at 0 degrees or any degree of hyperextension with no objective evidence of painful motion. Range of motion testing in the right and left knees after repetitive use testing (three repetitions) did not show any additional functional loss or loss of range of motion. The Veteran did not have tenderness or pain to palpation for joint line or soft tissues of either knee. He did not have a reduction in muscle strength or joint instability in either of his knees. The Veteran did not have patellar subluxation/dislocation. He also did not have shin splints, stress fractures, chronic exertional compartment syndrome, and/or any other tibial and/or fibular impairment. He also did not have a meniscus (semilunar cartilage) condition. The Veteran did not need any assistive devices as a normal mode of locomotion. The VA examiner concluded that the Veteran's bilateral knee condition impacted his ability to work in that the Veteran stated he had 5 to 10 days of lost time; however, he did not seek medical attention. The Veteran continued to work full-time at a distribution center. In April 2016, the Veteran was afforded a VA examination for his knee conditions. The Veteran was diagnosed with bilateral patellofemoral pain syndrome. The Veteran reported that he could not stand on his knees for more than an hour before they started to ache. He could not squat comfortably or sit for long periods of time. He could run but not walk very far. Initial range of motion testing in the right knee revealed flexion from 0 to 130 degrees and extension from 130 to 0 degrees. There was no evidence of pain with weight bearing in the right knee. He had mild right knee tenderness to the lateral/medial joint line and inferior patella area. The right knee also had crepitus. Initial range of motion testing of the left knee revealed flexion from 0 to 120 degrees and extension from 120 to 0 degrees. There was no evidence of pain with weight bearing, but the Veteran had crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions, but there was no additional function loss after three repetitions in the right and left knees. The Veteran was not examined immediately after repetitive use over time in the right and left knees. There was no reduction in muscle strength in the left or right knees. He did not have muscle atrophy or ankylosis in the right or left knees. The Veteran did not have recurrent subluxation, lateral instability, or recurrent effusion in the right or left knees. There was no evidence of recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran never had a meniscus (semilunar cartilage) condition. The examiner concluded that the Veteran's bilateral knee condition impacted the Veteran's ability to work. Specifically, the examiner stated that the Veteran should refrain from activities requiring repeated squatting, jumping, and abrupt turning or twisting. Pain medications at times might include prescription painkillers (opioid analgesics), which could affect dexterity and alertness, which also could pose a safety-sensitive hazard. However, it did not affect his activities of daily living. The examiner further opined that based on a review of the Veteran's records and findings, including functional effect on occupational and activities of daily living, the Veteran's bilateral knee conditions were unlikely to render the Veteran incapable of employment in heavy duty or light duty occupations, even though some work restrictions or accommodations might be required in some occupations. In October 2016, the Veteran was afforded a VA examination for his knees. The Veteran reported that he could not stand on his knees for more than an hour before they started to ache. He could not squat comfortably or run very far. Both knees were about the same in symptoms and limitations. He could not sit for long periods of time. Initial range of motion testing of the right knee revealed flexion from 0 to 130 degrees and extension from 130 to 0 degrees. There was no evidence of pain with weight bearing; however, there was objective evidence of right knee tenderness to a mild degree. There was objective evidence of crepitus. Initial range of motion testing of the left knee revealed flexion from 0 to 120 degrees and extension from 120 to 0 degrees. The Veteran did not have pain with weight bearing in the left knee. However, he had left knee tenderness to a mild degree and crepitus. There was no additional functional loss or range of motion after three repetitions in the right knee or left knee. The Veteran was not examined immediately after repetitive use over a period of time with the left knee or right knee. The Veteran's bilateral knee disability caused disturbance of locomotion, interference with sitting, and interference with standing. There was no reduction in muscle strength in the left knee or right knee. He did not have muscle atrophy or ankylosis. Joint stability testing did not reveal any recurrent subluxation, lateral instability, or recurrent effusion. The examiner concluded that the Veteran's bilateral knee disability impacted his ability to work. The Veteran had to refrain from activities requiring repeated squatting, jumping, and abrupt turning or twisting. Pain medications at times could affect dexterity and alertness and might pose a safety-sensitive hazard. The VA examiner explained that these restrictions would need to be accommodated. During the Veteran's February 2017 hearing, the Veteran testified to having extreme and constant pain at all times. He reported that he had been issued braces and had constant pain. His knee popped and cracked. The Veteran said that he could not stand longer than 15 minutes or keep them in a bent position for longer than 5 minutes. The Veteran reported at the most previous VA examination that he could not walk an excessive amount. He reported flares that prevented all activity for a few hours at a time. He said that he took cortisone shots, but they did not work. In July 2018, the Veteran was afforded a VA examination for his knees. The Veteran was diagnosed with bilateral patellofemoral pain syndrome. The Veteran had popping, locking, pain, and grinding in his knees. He described the pain as feeling like a "Charlie horse." The pain was a burning, cramping sensation that went under the kneecap and around the whole joint; the pain shot down his legs. The Veteran took Meloxicam. Rest and straightening his legs also helped. The Veteran reported flare-ups of his knees. He would have flare-ups on cold days. He also had flare-ups if he turned his knees wrong or if he moved them in the wrong direction. He also had flare-ups when he sat with his knees bent. He could not stand for a long period of time. He had burning, tingling, numbing, and throbbing sensations. Initial range of motion testing of the right knee revealed flexion from 0 to 110 degrees and extension from 110 to 0 degrees. There was mild pain noted in the right knee and objective evidence of localized tenderness or pain on palpation of the joint. There was no evidence of pain with weight bearing in the right knee, but there was evidence of crepitus. Initial range of motion testing of the left knee revealed flexion from 0 to 120 degrees and extension from 120 to 0 degrees. Pain was noted in flexion. There was objective evidence of localized tenderness or pain on palpation of the left knee to a mild degree. The Veteran did not have pain in the left knee with weight bearing, but there was objective evidence of crepitus. There was no additional loss of function or range of motion in the left knee or right knee with repetitive-use testing with at least three repetitions. The Veteran was not immediately examined after repetitive use over time with respect to the right knee, and pain, weakness, fatigability, or incoordination did not significantly limit function ability with repeated use over a period of time. The VA examiner estimated that the range of motion with repeated use over a period of time for the right knee was 0 to 110 degrees flexion and 110 to 0 degrees extension. With respect to the left knee, the Veteran was not examined immediately after repetitive use over time, and pain, weakness, fatigability, or incoordination did not significantly limit function ability with repeated use over a period of time. The VA examiner estimated that the range of motion with repeated use over a period of time for the left knee was 0 to 120 degrees flexion and 120 to 0 degrees extension. The Veteran was not being examined in the right or left knees during flare-ups. There was no additional functional loss. With respect to the right knee, the examiner estimated the range of motion during flare-ups was 0 to 110 degrees flexion and 110 to 0 degrees extension. With respect to the left knee, the examiner estimated the range of motion during flare-ups was 0 to 120 degrees flexion and 120 to 0 degrees extension. There was no reduction in muscle strength, and the Veteran did not have muscle atrophy. The VA examiner reported that the Veteran did not have ankylosis in his right knee or left knee. The Veteran did not have recurrent subluxation, lateral instability, or recurrent effusion. The VA examiner concluded that the Veteran's right knee and left knee disability did not impact his ability to work. When taken together as a whole and with consideration of the other medical evidence of record, the Board finds the June 2010, July 2011, January 2012, April 2016, October 2016, and July 2018 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, medical expertise, adequate findings, sufficient rationales, and proper consideration of the Veteran's lay statements. After a thorough review of the Veteran's medical evidence and lay statements, the Board concludes that a rating in excess of 20 percent is not warranted for the Veteran's service-connected bilateral knee disorders. The Veteran's bilateral patellofemoral pain syndrome is characterized by symptoms of pain, aches, popping, locking, tenderness, and mild crepitus. The Veteran complained that he could not stand for more than an hour. He could not squat comfortably or sit for long periods of time. He could run but not walk very far. The Veteran's VA examinations and treatment records showed that the Veteran's extension and flexion were not limited to such a degree as to warrant a higher evaluation under Diagnostic Codes 5260 and 5261, to include after repetitive-use and repetitive use over a period of time and during flare-ups. Under Diagnostic Code 5257, a separate rating is not warranted either as the Veteran's bilateral knee disabilities have not demonstrated instability throughout the appeal period. Absent objective signs or symptoms noted on examination, however, a separate rating is not warranted under the old Diagnostic Code 5257. A separate rating is also not warranted under the revised Diagnostic Code 5257. For a separate rating to be warranted, evidence would have to show recurrent instability (with or without surgical repair) that does not require a prescription for a medical provider for a brace, cane, or walker. Objective testing has not revealed instability (there are also no complaints from the Veteran about this), so it cannot be said that there is recurrent instability. Therefore, a separate rating is precluded under the revised version of Diagnostic Code 5257. A higher rating is not warranted under Diagnostic Code 5003 because there is no X-ray evidence of degenerative arthritis involving 2 or more major or minor joints with occasional incapacitating exacerbations. The Veteran does not demonstrate the symptoms or diagnoses required for additional ratings under other Diagnostic Codes. The evidence shows no ankylosis, no tibial or fibular impairment, and no genu recurvatum. See 38 C.F.R. § 4.71(a), Diagnostic Codes 5256, 5262, 5263. Although the Veteran complained of popping and locking in his knees, a separate rating is not warranted under Diagnostic Code 5258. The Veteran's VA examinations show that he did not have a dislocated semilunar cartilage condition. Additionally, a separate rating under Diagnostic Code 5259 is not warranted as the Veteran did not have his semilunar cartilage removed. The Board has also considered the Veteran's lay statements regarding the Veteran's symptomatology. The Board notes that the Veteran is competent to report observations regarding the severity of his symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, and 1376-77 (Fed. Cir. 2007). The Board finds these lay statements to be credible and consistent with the ratings assigned. To the extent he argues his symptomatology is more severe, the Veteran's statements must be weighed against the other evidence of the record. Here, the specific examination findings of trained health care professionals and documented medical treatment records are of greater probative weight than the more general lay assertions that a higher rating is warranted. The Board has also considered whether extraschedular consideration is warranted under 38 C.F.R. § 3.321(b)(1). Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating criteria adequately contemplate the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Id. If the schedular evaluation does not contemplate the level of disability and symptomatology and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. Id. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Service to determine whether an extraschedular rating is warranted. Id. In this case, the Board finds that the Veteran's service-connected bilateral knee disabilities do not show an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. The Veteran's symptoms of pain and aching were contemplated by the rating criteria. Also, the Veteran's disability did not cause her to have marked interference with employment or frequent hospitalization. Of final note, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, increased ratings are not assignable for the Veteran's service-connected knee disabilities. 3. Entitlement to a TDIU due to service-connected disabilities. In order to establish entitlement to a TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). "Substantially gainful employment" is that employment "which is ordinarily followed by the non-disabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). As further provided by 38 C.F.R. § 4.16(a), "Marginal employment shall not be considered substantially gainful employment." Additionally, marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Marginal employment generally shall be deemed to exist when a Veteran's earned annual income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Id. Marginal employment may also be held to exist on a fact-found basis when earned annual income exceeds the poverty threshold. Id. Such situations may include, but is not limited to, employment in a protected environment, such as a family business or sheltered workshop. Id. The regulatory scheme allows for an award of a TDIU when, due to service-connected disabilities, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, and that if there are two or more disabilities, at least one disability rated at 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. For the purposes of finding one 60 percent disability or one 40 percent disability in combination, disabilities resulting from a common etiology, affecting one or both lower extremities, or affecting a single body system will be considered as one disability. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). It is also the policy of the VA, however, that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Where the veteran fails to meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), an extraschedular rating is for consideration where the veteran is unemployable due to a service-connected disability. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). In May 2019, the United States Court of Appeals for Veterans Claims (Court) held that when addressing whether a Veteran is entitled to an extraschedular TDIU rating, the Board must give attention to 1) the Veteran's history, education, skill, and training; 2) whether the Veteran has the physical ability to perform the types of activities required by the occupation at issue; and 3) whether the Veteran has the mental ability to perform the activities required by the occupation at issue. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The Veteran is service-connected for the following disabilities from May 4, 2010 (date appeal period begins): (1) migraine headaches rated at 50 percent; (2) right knee limitation of flexion rated at 20 percent; and (3) left knee limitation of flexion rated at 20 percent. The Veteran's combined evaluation for compensation is 70 percent from May 4, 2010. The Veteran meets the percentage requirements under 38 C.F.R. § 4.16(a). However, the Board must still determine whether the Veteran's service-connected disabilities prevent him from maintaining a substantially gainful occupation. Based on a thorough review of all evidence of record, the Board finds that the Veteran's service-connected disabilities do not prevent him from maintaining substantially gainful employment. According to a resume the Veteran submitted in December 2014, the Veteran was currently enrolled in college courses; he was studying to work as an occupational safety and health technician. He had been employed with a retail distribution center since August 2005. Some of his duties at this position included loading all merchandise into trailers using conveyer systems, and standup forklifts or manually placing product in trailer by hand. However, in a December 2014 vocational rehabilitation and employment (VRE) counseling record narrative report, it was noted that the Veteran was not currently employed. In March 2014, the Veteran was afforded a VA examination for his headaches. The Veteran stated that his headaches occurred daily and radiated; he described them as occurring constantly. However, the Veteran tolerated the pain and continued to work through pain. The VA examiner noted that the Veteran's headaches impacted his ability to work. The Veteran's severe headaches might require time off from work. His headaches caused by muscle tension that might need accomodation in the workspace, such as ergonomically designed desks and chairs. In November 2016, the Veteran was afforded a VA examination for his headaches. The Veteran reported that he had daily headaches that interfered with his ability to earn a living. In October 2016, the Veteran was afforded a VA examination for his knees. The Veteran reported that he could not stand on his knees for more than an hour before they started to ache. He could not squat comfortably or run very far. Both knees were about the same in symptoms and limitations. He could not sit for long periods of time. The examiner concluded that the Veteran's bilateral knee disability impacted his ability to work. The Veteran had to refrain from activities requiring repeated squatting, jumping, and abrupt turning or twisting. Pain medications at times could affect dexterity and alertness and might pose a safety-sensitive hazard. The VA examiner explained that these restrictions would need to be accommodated. The examiner noted that the Veteran was currently worked at a retail warehouse distribution center. The Veteran used a forklift on his job and did a lot of standing. In February 2019, the Veteran submitted a VA Form 28-1905, Authorization and Certification of Entrance or Reentrance into Rehabilitation and Certification. On this document, the Veteran reported that he was working. It was also noted that the Veteran was still capable of working in his field. In August 2020, VA sent the Veteran a letter requesting him to complete and return a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. However, the Veteran never returned a completed VA Form 21-8940. Based on a thorough review of the evidence of record, including the Veteran's lay statements, and with consideration of the Veteran's work history, education, skill, training, and mental and physical ability, the Board finds that the Veteran is not incapable of sustaining substantially gainful employment due to his service-connected disabilities. Although his bilateral knee disorder caused standing sitting and walking, and he had daily painful headaches, he was still working at a distribution warehouse. During his February 2017 hearing, the Veteran reported that he only worked three days a week. Even if the Veteran's employment was marginal or he was unemployed, it would not be due to his service-connected disabilities. His bilateral knee disorder and migraine headaches did not severely limit his physical functioning and mental ability to the point that he would be prevented from working. The evidence shows that the Veteran, with his level of education, would be able to perform in a job that did not involve rigorous physical activity, but instead able to engage in light physical activity. Overall, the overwhelming evidence demonstrates that the Veteran's service-connected migraine headaches and bilateral knee disorder would not prevent him from doing non-strenuous physical work that is consistent with his work history, skills, education, and training. That is to say, despite the Veteran's disabilities, he retains the economic and non-economic ability to secure or follow a substantially gainful occupation. There is no evidence that service-connected disabilities would impact his mental ability to engage in work activity. Therefore, entitlement to a TDIU is denied. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Crawford, 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.