Citation Nr: 21040214 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-35 015 DATE: July 2, 2021 ORDER Entitlement to an initial rating in excess of 20 percent for left lower extremity radiculopathy prior to February 1, 2016 is denied. Entitlement to a rating in excess of 10 percent for left lower extremity radiculopathy from February 1, 2016 to January 18, 2017 is denied. Entitlement to a rating in excess of 20 percent for left lower extremity radiculopathy from February 1, 2016 to February 28, 2020 is denied. Entitlement to a rating in excess of 30 percent for left lower extremity radiculopathy from February 28, 2020 is granted. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy prior to January 19, 2017 is denied. Entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy from January 19, 2017 is denied. Entitlement to a rating in excess of 20 percent for a low back disability prior to January 19, 2017 is denied. Entitlement to a 40 percent rating, but no higher, for low back disability from January 19, 2017 is granted. Entitlement to a rating in excess of 20 percent for residuals of a right clavicle fracture prior to February 28, 2020 is denied. Entitlement to a rating of 30 percent, but no higher, for residuals of a right clavicle fracture from February 28, 2020 is granted. Entitlement to a rating in excess of 20 percent for a right knee meniscal damage disability is denied. Entitlement to a rating of 30 percent, but not higher, for limitation of right knee extension effective February 28, 2020 is granted. Entitlement to a rating in excess of 10 percent for left knee synovitis is denied. Entitlement to a compensable rating for limitation of extension due to left knee synovitis is denied. Entitlement to a rating in excess of 10 percent for a right ankle disability is denied. Entitlement to special monthly compensation (SMC) by reason of the need for aid and attendance is granted. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to August 19, 2016 is granted. FINDINGS OF FACT 1. Prior to February 1, 2016, left lower extremity radiculopathy ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬manifested as moderate incomplete paralysis of the left sciatic nerve. 2. From February 1, 2016 to January 18, 2017, left lower extremity radiculopathy manifested as mild incomplete paralysis of the left sciatic nerve. 3. From January 18, 2017 to February 28, 2020, left lower extremity radiculopathy ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬manifested as moderate incomplete paralysis of the left sciatic nerve. 4. From February 28, 2020, left lower extremity radiculopathy ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬manifested as moderately severe incomplete paralysis of the left sciatic nerve. 5. Prior to January 19, 2017, right lower extremity radiculopathy manifested as mild incomplete paralysis of the right sciatic nerve. 6. From January 19, 2017, right lower extremity radiculopathy manifested as moderate incomplete paralysis of the left sciatic nerve. 7. Prior to January 19, 2017, the Veteran's low back disability did not manifest as forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. 8. From January 17, 2017, the Veteran's low back disability has manifested as forward flexion of the thoracolumbar spine of 30 degrees. 9. Prior to February 28, 2020, residuals of a right clavicle fracture did not manifest as motion of the major arm limited to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). 10. From February 28, 2020, residuals of a right clavicle fracture manifest as right shoulder flexion to 55 degrees and abduction to 40 degrees. 11. At worst, a right knee disability maximum schedular rating of 20 percent for dislocated cartilage is continued but an additional 30 percent rating for limitation of extension of the right knee is warranted effective February 28, 2020. 12. At worst, left knee synovitis is not shown to have manifested compensable limitations of flexion or extension, recurrent subluxation or lateral instability, dislocated or symptomatic post-removal semilunar cartilage, genu recurvatum, or malunion of tibia or fibula, and is not shown to have been ankylosed. 13. At worst, left knee extension is not shown to be limited to 10 degrees. 14. At worst, the Veteran's right ankle disability results in moderate limited right ankle motion; marked limitation of motion, ankylosis, malunion, or astragalectomy have not been shown. 15. The Veteran needs regular aid and attendance of another person as a result of his service-connected disabilities, effective June 15, 2015, the date of a credible lay statement from the Veteran's spouse regarding the nature and frequency of assistance she provided. 16. Effective April 14, 2014, there is a relative equal balance of evidence for and against a finding that the Veteran was unable to secure or follow substantially gainful employment as a result of service-connected disabilities. CONCLUSIONS OF LAW 1. Prior to February 1, 2016, the criteria for a rating in excess of 20 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520 (2020). 2. From February 1, 2016 to January 18, 2017, the criteria for a rating in excess of 10 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520. 3. From January 18, 2017 to February 28, 2020, the criteria for a rating in excess of 20 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520. 4. From February 28, 2020, the criteria for a 30 percent rating for left lower extremity radiculopathy have been met 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520. 5. Prior to January 19, 2017, the criteria for a rating in excess of 10 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520. 6. From January 19, 2017, the criteria for a rating in excess of 20 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8520. 7. Prior to January 19, 2017, the criteria for a rating in excess of 20 percent for the Veteran's low back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.59. 4.71a, Diagnostic 5237 (2020). 8. From January 19, 2017, the criteria for a 40 percent rating for the Veteran's low back disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.59. 4.71a, Diagnostic 5237. 9. Prior to February 28, 2020, the criteria for a rating in excess of 20 percent for residuals of a right clavicle fracture have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.59. 4.71a, Diagnostic 5201 (2020). 10. From February 28, 2020, the criteria for a 30 percent for residuals of a right clavicle fracture have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.59. 4.71a, Diagnostic 5201. 11. The criteria for a rating in excess of 20 percent for a right knee disability under Diagnostic Code 5258 for cartilage damage have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5258 (2020). 12. The criteria for an additional rating of 30 percent for right knee limitation of extension effective February 28, 2020 are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5261 (2020). 13. The criteria for a rating in excess of 10 percent for left knee synovitis have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5056-63. 14. The criteria for a compensable rating for left knee extension have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2020). 15. The criteria for a rating in excess of 10 percent for a right ankle disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5270-74 (2020). 16. The criteria for SMC based upon the need for regular aid and attendance of another person are met, effective June 15, 2015. 38 U.S.C. § 1114(l) (2012); 38 C.F.R. §§ 3.350, 3.52 (2020). 17. The criteria for a TDIU have been met, effective April 1, 2014. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the United States Air Force from September 1985 to September 1991. These matters come before the Board of Veterans' Appeals from October 2014 and June 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Board remanded these matters for evidentiary development; the Board finds that there has been substantial compliance with its remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Ratings The Veteran asserts that the ratings for the service-connected disabilities on appeal do not contemplate the severity of the respective disabilities. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Left lower extremity radiculopathy Right lower extremity radiculopathy The RO has rated the Veteran's right and left lower extremity radiculopathy under 38 C.F.R. § 4.124a, Diagnostic Code 8520. Diagnostic Codes 8520-8720 address ratings for paralysis of the peripheral nerves affecting the lower extremities, neuritis, and neuralgia. Diagnostic Codes 8520, 8620, and 8720 provide ratings for paralysis, neuritis, and neuralgia of the sciatic nerve. Neuritis and neuralgia are rated as incomplete paralysis. Disability ratings of 10, 20, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. A disability rating of 60 percent is warranted for severe incomplete paralysis with marked muscle atrophy. An 80 percent rating is warranted for complete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. Diagnostic Codes 8526, 8626, and 8726 provide ratings for paralysis, neuritis, and neuralgia of the anterior crural nerve (femoral). A 10 percent disability rating is warranted for mild of the anterior crural nerve, a 20 percent disability rating is warranted for moderate paralysis of the anterior crural nerve, a 30 percent disability rating is warranted for severe paralysis of the anterior crural nerve, and a 40 percent disability rating (the maximum) is warranted for complete paralysis of the anterior crural nerve. 38 C.F.R. § 4.124a. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. 38 C.F.R. §§ 4.123, 4.124a, Diagnostic Code 8620. Similarly, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution to identify the nerve, is to be rated on the same scale, with a maximum rating equal to moderate incomplete paralysis. 38 C.F.R. §§ 4.124, 4.124a, Diagnostic Code 8720. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Evidence and Analysis In March 2014, the Veteran underwent a VA examination. A clinician reviewed the claims file; considered the Veteran's lay accounts; and conducted an appropriate evaluation. The clinician indicated that the Veteran has left and right lower extremity radiculopathy manifesting as mild intermittent pain. The clinician also noted mild left lower extremity paresthesias and/or dysesthesias and mild left lower extremity numbness. The clinician reported the involvement of the bilateral sciatic nerve roots. Lastly, the clinician assessed the overall severity of right lower extremity radiculopathy as mild and left lower extremity radiculopathy as moderate. In April 2015, the Veteran underwent a VA peripheral nerves examination. This clinician reported mild bilateral lower extremity intermittent pain; mild left lower extremity paresthesias and/or dysesthesias; and mild left lower extremity numbness. The Veteran maintained full strength. All reflexes were hypoactive (1+). Sensory examination results were normal with the exception of decreased lower leg ankle (L4/L5/S1) and left foot/toes (L5). The clinician reported that the Veteran's gait was rather antalgic due to low back pain with sciatica. Upon assessment of severity, the clinician provided mild incomplete paralysis of the right sciatic nerve and mild incomplete paralysis of the left sciatic nerve. The clinician opined that bilateral lower extremity radiculopathy (peripheral neuropathy) did not functionally impact the Veteran. Lastly, the clinician indicated that the Veteran's bilateral sciatica was mild-to-moderate in its severity and these disabilities did not impact the Veteran's ability to work. The Veteran underwent another examination in April 2015. Bilaterally, there was mild lower extremity intermittent pain; mild left lower extremity paresthesias and/or dysesthesias; and mild left lower extremity numbness. The clinician reported the involvement of the bilateral sciatic nerve roots. Lastly, the clinician indicated that the severity of right lower extremity radiculopathy was mild and left lower extremity radiculopathy was moderate. In July 2015 lay statements, the Veteran's spouse, daughter, and a co-worker noted that the Veteran falls and experiences shooting pain from his back to his legs. These lay parties also reported that the Veteran experiences trouble sleeping; cannot exercise; and experiences difficulties fulfilling the tasks of his job. In September 2015, the Veteran underwent a VA left lower extremity peripheral nerves examination. The clinician reported mild left lower extremity constant pain; reported mild left extremity intermittent pain; mild left lower extremity paresthesias and/or dysesthesias; and mild left lower extremity numbness. The Veteran maintained full muscle strength. All reflexes were hypoactive (1+). Sensory examination results were normal, with the exception of decreased leg ankle (L4/L5/S1) and foot/toes (L5). The clinician reported that the Veteran's gait was abnormal; he used a walker, had an antalgic gait, and experienced a variety of painful stimuli. The clinician indicated mild incomplete paralysis of the left sciatic nerve. Upon review of the April 2015 examination report (discussed immediately above), this clinician opined that this report, which focused on the Veteran's low back disability, should have indicated that left lower extremity radiculopathy was mild. As a rationale, the clinician opined that all of the elements and findings in the report point to "mild" left lower extremity radiculopathy. Consequently, the clinician found that the notation of "moderate" appeared to be an oversight. Mild left lower extremity radiculopathy was consistent with findings made during the instant examination. In November 2015 VA receive additional copies of the June 2015 lay statements. In an August 2015 VA treatment record, a clinician opined that the Veteran was taking the medication Pregabalin for neuropathic pain. The Veteran underwent a VA examination on January 19, 2017. The Veteran reported mild lower extremity constant pain; moderate intermittent pain; severe paresthesias and/or dysesthesias; and mild numbness. The clinician reported the involvement of the bilateral sciatic nerve roots. This clinician indicated that the severity of the Veteran's bilateral lower extremity radiculopathy was moderate. In a May 2018 lay statement, the Veteran's spouse submitted a statement with the same information as in November 2015. Also, the Veteran submitted a lay statement this month. In pertinent part, he indicated that he had deemed totality disabled and eligible for Social Security Administration (SSA) disability insurance. The Veteran also reported that he had not been employed since April 2014. In January 2020, VA associated the Veteran's SSA adjudication materials and medical records with the claims file. The Veteran received a fully favorable notice of decision in October 2016. The records reveal severe impairments of: 1) degenerative joint disease (DJD) of the knee with multiple surgeries; 2) degenerative disc disease (DDD) of the lumbar spine; 3) obesity; 4) tremor in the right arm; 5) ulnar neuropathy; 6) restless leg syndrome; and 7) anxiety. The Veteran was deemed eligible for SSA disability benefits since April 1, 2014. The medical evidence considered by SSA was substantially the medical evidence associated with the Veteran's VA claims file. Notably, the favorable determination did not include either left lower extremity radiculopathy or right lower extremity radiculopathy explicitly; however, the records reveal similar complaints about the lower extremities, On February 28, 2020, the Veteran underwent a VA lower peripheral nerves examination. The clinician noted mild right lower extremity constant pain; moderate left lower extremity constant pain; mild right lower extremity intermittent pain; moderate left lower extremity intermittent pain; mild right lower extremity paresthesias and/or dysesthesias; moderate left lower extremity paresthesias and/or dysesthesias; mild right lower extremity numbness; and moderate left lower extremity numbness. The Veteran maintained muscle strength of 4/5 (active movement against some resistance). Sensory examination was decreased, except for the left foot/toes (L5) where it was absent. The clinician noted that the Veteran's gait was antalgic due to his right knee disability and bilateral lower extremity radiculopathy. The clinician indicated mild incomplete paralysis of the right sciatic nerve and moderately severe incomplete paralysis of the left sciatic nerve. In another February 2020 examination, the clinician noted mild right lower extremity constant pain; moderate left lower extremity constant pain; mild right lower extremity intermittent pain; moderate left lower extremity intermittent pain; mild right lower extremity paresthesias and/or dysesthesias; moderate left lower extremity paresthesias and/or dysesthesias; mild right lower extremity numbness; and moderate left lower extremity numbness. The clinician indicated involvement of the bilateral sciatic nerve roots. While the severity of right lower extremity radiculopathy was mild, the severity of left lower extremity radiculopathy was moderate. Prior to February 1, 2016, excess of 20 percent for left lower extremity radiculopathy The Veteran (and his spouse, daughter, and wife) contend that his for left lower extremity radiculopathy was more severe that than that contemplated by a 20 percent rating. The Veteran is competent to report discernable symptoms, such as pain and numbness. The Board has considered this lay evidence carefully. 38 C.F.R. § 3.159(a)(2) although the record fails to disclose that the Veteran possesses the medical expertise. 38 C.F.R. § 3.159(a)(1). The Board has discussed the relevant, competent clinical evidence of record, in which the Board assigns significant probative weight. Prior to February 1, 2016, the RO rated the Veteran's left lower extremity radiculopathy at 20 percent. As discussed above, to receive a higher rating, there would need to be a showing of moderately severe incomplete paralysis of the sciatic nerve, such is not shown. While the clinical evidence discloses many left lower extremity peripheral nerve symptoms of diverse severity, this evidence discloses that, at worst, service-connected left lower extremity radiculopathy was productive of moderate incomplete paralysis prior to February 1, 2016. The Board places weight on the assessment of the examining clinicians regarding functional deficits. They noted an antalgic gait and use of support devices but for the combined effects of a lower back, knee, and ankle disabilities. The Veteran was able to ambulate. He reported that he stopped working in 2014 but clinicians did not find the lower extremity neuropathy to preclude work. Consequently, the weight of evidence is against a rating in excess of 20 percent for left lower extremity radiculopathy prior to February 1, 2016. From February 1, 2016 to January 18, 2017, excess of 10 percent for left lower extremity radiculopathy The Board assigns significant probative weight to the September 2015 VA clinician. This clinician indicated that upon review of the April 2015 examination report, which focused on the Veteran's low back disability, it should have indicated that left lower extremity radiculopathy was mild. As a rationale, the September 2015 clinician opined that all of the elements and findings in the April 2015 thoracolumbar spine examination report point to "mild" left lower extremity radiculopathy. Consequently, the clinician found that the notation of "moderate" appeared to be an oversight. Mild left lower extremity radiculopathy was consistent with findings made during that examination. The April 2015 thoracolumbar spine examination is not only an outlier as to "severity" of left lower extremity radiculopathy, the clinician's examination findings are indication of mild incomplete paralysis of the left sciatic nerve. The Board has considered the Veteran's lay contentions; however, greater weight is placed on the specific testing and clinical observations. Consequently, the preponderance of evidence is against a rating in excess of 10 percent for left lower extremity radiculopathy from February 1, 2016 to January 18, 2017. From January 18, 2017, excess of 20 percent for left lower extremity radiculopathy As noted above, to receive a higher rating there would need to be a showing of moderately severe incomplete paralysis of the left sciatic nerve. Upon the February 28, 2020 VA peripheral nerves examination, the clinician indicated that Veteran's left lower extremity manifested as moderately severe incomplete paralysis of the left sciatic nerve. The Board assigns significant probative weight to this clinician's opinion. The Board has considered the Veteran's lay contentions; however, greater weight is placed on the specific testing and clinical observations. As such, the Board finds that the weight of evidence militates in favor of granting a rating of 30 percent for left lower extremity radiculopathy from February 28, 2020, but no earlier. Consequently, the preponderance of evidence warrants granting a rating of 30 percent for left lower extremity radiculopathy from February 28, 2020. Prior to January 19, 2017, excess of 10 percent for right lower extremity radiculopathy. The Board has discussed the relevant, competent clinical evidence of record. The Board assigns significant probative weight to the VA examinations. Prior to January 19, 2017, no clinician indicated that that the Veteran's right lower extremity radiculopathy manifested as more severe than mild incomplete paralysis of the right sciatic nerve. The Board assigns significant probative weight to this body of examinations reports in which clinicians made extensive findings. The Board has considered the Veteran's lay contentions; however, greater weight is placed on the specific testing and clinical observations. Consequently, the preponderance of evidence is against a rating in excess of 10 percent for right lower extremity radiculopathy prior to January 19, 2017. From January 19, 2017, excess of 20 percent for right lower extremity radiculopathy. The Board has discussed the relevant, competent clinical evidence of record. The January 19, 2018 VA clinician indicated that the Veteran's right lower extremity radiculopathy was moderate. And the February 28, 2020 clinician found that the Veteran's service connected right lower extremity radiculopathy was productive of mild incomplete paralysis of the right sciatic nerve. (So as to afford the Veteran the benefit of doubt, the Board will not disturb the 20 percent rating from January 19, 2017.) No clinician from January 19, 2017 indicated that right lower extremity radiculopathy was productive of moderately severe incomplete paralysis of the right sciatic nerve. Therefore, the clinical evidence does not support a rating in excess of 20 percent. The Board has considered the Veteran's lay contentions; however, greater weight is placed on the specific testing and clinical observations. Consequently, the preponderance of evidence is against a rating in excess of 20 percent for right lower extremity radiculopathy from January 19, 2017. Low back disability The RO has rated the Veteran's back disability under 38 C.F.R. § 4.71a, Diagnostic Code 5295. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. In evaluating 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). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate 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. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202, 206-8 (1995). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable Diagnostic Code. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain and numbness in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. See Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). Musculoskeletal VA examinations, to be adequate, must address particular issues when are where that are practicable and medically possible to include active and passive motion; weight bearing and non-weight bearing; range of motion of an opposing joint; and findings as to loss of motion during flare-ups. See Correia v. McDonald, 28 Vet. App. (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). Diagnostic Code 5295, effective prior to September 26, 2003, contemplated lumbosacral strain and Diagnostic Code 5294 represented a sacroiliac injury and weakness. The rating criteria for both Diagnostic Codes provided that a noncompensable rating was warranted for slight subjective symptoms only. A 10 percent rating was appropriate for characteristic pain on motion. A 20 percent rating contemplated muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position. A 40 percent rating was awarded for severe lumbosacral strain or sacroiliac injury and weakness with listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in the standing position, loss of lateral motion with osteoarthritis changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a. The words "slight," "moderate," and "severe," as used in various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the ends that its decision is "equitable and just." 38 C.F.R. § 4.6 Effective September 26, 2003, Diagnostic Codes 5237 and 5242 provide that lumbosacral or cervical strain should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula, a 10 percent rating is assigned 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. 38 C.F.R. § 4.71a, Diagnostic Code 5237. A 20 percent rating is assigned 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. Id. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Id. An alternative method of evaluating spine disabilities is pursuant to Diagnostic Code 5243, which compensates based on incapacitating episodes due to intervertebral disc syndrome (IVDS). These ratings are not to be combined, and only the rating which results in a higher evaluation is to be granted. 38 C.F.R. § 4.71a, Diagnostic Code 5243. When considering disability of the musculoskeletal system, arthritis is considered. An evaluation of traumatic arthritis, Diagnostic Code 5010, is rated under the criteria for Diagnostic Code 5003, which in turn evaluates disabilities based on the degree of limitation of motion under the appropriate Diagnostic Codes. 38 C.F.R. § 4.71a. If the disability is noncompensable under the appropriate Diagnostic Code for the joint involved, a 10 percent rating will be for application for such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a. The rating criteria pertaining to Diagnostic Code 5010 was revised effective February 7, 2021. Posttraumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under an affected joint. If there are two or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Evidence and Analysis In July 2001, VA received treatment records from Dr. E., a private physician. This physician noted the Veteran's reports that he started experiencing low back pain 4 years earlier. The Veteran indicated that he experienced 3-to-4 episodes of low back pain a year. Pain manifested in the lower lumbar region and traveled down the left buttock into the posterior left extremity. Dr. E. reported that x-ray imaging showed a large central disc herniation to the left side L5-S1. In an October 2001 VA consultation report, a clinician noted that the Veteran sought neurological evaluation for back pain. The clinician indicated tenderness at the sacroiliac joints and a loss of flexion in range of motion. The Veteran maintained full muscle strength. This clinician opined that magnetic resonance imaging (MRI) showed a large disc fragment over the S1 root area. 2014 and 2015 VA progress notes show that the Veteran sought outpatient care at a VA rheumatology clinic for low back pain. The Veteran was provided a roster of physical therapy (PT) exercises, which clinicians encouraged. Additionally, he was encouraged to use a TENS unit and icing as tolerated. Also, a clinician suggested that the Veteran do yoga. The Veteran reported that Valium and Vicodin helped with pain and sleep maintenance. A clinician noted that a 2-injection round of steroids did not ameliorate low back pain. In March 2014, the Veteran underwent a VA thoracolumbar spine examination. This clinician diagnosed lumbosacral strain; degenerative arthritis of the spine; and IVDS. The Veteran reported flare-ups when everything "completely stops." The Veteran had forward flexion to 65 degrees, with pain at 55 degrees; extension to 5 degrees, with pain at zero degrees; right lateral flexion to 20 degrees, with pain at 15 degrees ; left lateral flexion to 15 degrees, with pain at 10 degrees; right lateral rotation to 20 degrees, with endpoint pain; and left lateral rotation to 20 degrees, with endpoint pain. The Veteran was not capable of repetitive use (of at least three repetitions) without additional loss in ranges of motion. The clinician indicated that pain prevented repetitive use test, despite the Veteran's good-faith effort. As such, the clinician could not indicate any additional loss in range of motion upon repetitive use. However, the clinician reported that less movement than normal; pain on movement; and interference with sitting, standing, and/or weight bearing were contributing factors to functional loss. Muscle spasm did not result in abnormal gait or spinal contour. There was tenderness to palpation over L5-S1spinous spinous processes. The Veteran maintained full strength (5/5) and there was no evidence of muscle atrophy. Reflexes were all hypoactive; however, sensory examination was normal at all points, except the left foot/toes (L5) which was decreased. There was no evidence of ankylosis or other neurological abnormalities. The clinician indicated that the Veteran had IVDS, with incapacitating episode of a total duration of at least two weeks but less than 4 weeks during the past 12 months. The Veteran reported that he used a cane occasionally. X-ray imaging showed a large L1-L2 left paracentral disc extrusion and degenerative changes. The Veteran's spine disabilities functionally impacted his ability to work. The Veteran reported that he found it difficult to perform the duties of his job even though it was sedentary in nature. In remarks, the clinician opined that he expected that the Veteran would have 10 degrees of loss in motion upon flexion and 5 degrees of loss in extension, bilateral lateral flexion. And bilateral rotation upon flare-ups and repetitive use (with moderate weakness, moderate fatigability, and moderate loss of coordination). In April 2014 VA received private medical reports which disclose an active problem of localized secondary arthritis. These private records also disclose that physicians prescribed narcotics for back pain. In August 2014, Dr. H., a VA physician, submitted a letter. In pertinent part, this physician wrote that the Veteran suffered from chronic low back pain. This pain surfaced when the Veteran stays in one position for extended periods or when he stands for prolonged periods (20 to 30 minutes). In an October 2014 VA addendum, a clinician indicated that the Veteran's diagnoses of lumbar strain, DJD of the lumbar spine, IVDS and bilateral sciatic nerve involvement were a progression of service-connected chronic muscular strain of the lower back with "degenerative" with superimposes developmental instability. As a rationale, the clinician indicated that chronic muscular strains of the lower back with degenerative disease and superimposed developmental instability are known to progress to IVDS and bilateral sciatic nerve involvement. In April 2015, the Veteran underwent a VA thoracolumbar spine examination. The Veteran endorsed flare-ups, described as decreased range of motion due to increased pain. Also, the Veteran reported functional loss or functional impairment, namely deceased motion, and increased pain. The Veteran had forward flexion to 45 degrees; extension to zero degrees; right lateral flexion to 15 degrees; left lateral flexion to 15 degrees; right lateral rotation to 10 degrees; and left lateral rotation to 10 degrees. The clinician reported that less movement than normal contributed to function loss. There was neither evidence of pain with weight bearing or pain on palpation of the joints of associated soft tissue. The clinician could not perform repetitive use testing because the Veteran reported that such was too painful and there appeared to be instability and increased risk of falling. However, the Veteran indicated that upon repetitive use over time pain, weakness, and fatigue caused reduction in range of motion. Examination did not take place during a flare-up. The Veteran indicated that during flare-ups, weakness, and fatigue caused reduction in range of motion. Chronic muscle strain, localized tenderness, and guarding resulted in abnormal gait or abnormal spinal contour. The clinician attributed this symptomatology to degenerative changes. The Veteran maintained full strength (5/5) and there was no evidence of muscle atrophy. Reflexes were normal (2+). Sensory results were normal, with the exceptions of left lower leg (L4/L5/S1) and left foot/toes (L5) which were decreased. The clinician reported that there was no evidence of ankylosis or other neurological abnormalities (other than radiculopathy which, as noted above, has been evaluated separately). IVDS was present, with episodes of bed rest having a total duration of at least two weeks but less than 4 weeks during the last 12 months. The Veteran reported that he used a walker on a regular basis. The Veteran's spine disabilities functionally impacted his ability to work. The Veteran reported that he found it difficult to perform the duties of his job even though it was sedentary in nature. The clinician opined that the Veteran was capable of employment, which did not require extensive movement, in a loosely supervised situation involving negligible interaction with the public. In July 2015 lay statements, the Veteran's spouse, daughter, and co-worker reported that the Veteran experienced falls and shooting pain from his back to his legs. These lay parties also reported that the Veteran experienced trouble sleeping; cannot exercise; and experienced difficulties fulfilling the tasks of his job. In a July 2015 lay statement, the Veteran indicated that his low back pain had worsened. Physical therapy (PT) caused injury. The Veteran also reported that he attended yoga classes and included yoga movements into his daily stretching routine. He expressed dismay at the findings of the April 2015 VA clinician's findings. Upon a September 2015 VA neurology consultation, a clinician noted that the Veteran took Vicodin for chronic low back pain. The Veteran had tried Methadone, but this proved unsuccessful as the drug induced nightmares. In a July 2016 substantive appeal (VA Form 9), the Veteran asserted that he had been afforded inadequate examinations to assess the severity of this disability. In a February 2018 affidavit, the Veteran swore that his pain medications for service-connected disabilities induced drowsiness and compromised his ability to pay attention because of a "mental fog." The Veteran also swore that back episodes caused him to collapse and knee episode causes "lock ups" and falls. Consequently, due to his service-connected disabilities' pain and medications, the Veteran swore that he had exhausted every opportunity to maintain his current employment and it has become impossible to continue working in any capacity. The Veteran's representative submitted correspondence in August 2016 with an attached physician's "medical source statement." This physician did not indicate whether she reviewed the Veteran's claims file and provided the report to an attorney representing the Veteran before the Social Security Administration. The sole indication that the physician "treated" the Veteran are filled in lines which state treatment from "FIRST 2/27/2015" and "LAST 7/5/2016". The report contains limited, generalized findings which include neither clinical testing nor goniometric measurements." Despite these deficits, this physician noted that the Veteran experienced back pain daily and "it's just there." The Board acknowledges this "medical source statement," but assigns less probative weight to the consultant's conclusory findings for the above-noted reasons. See Sklar v. Brown, 5 Vet. App, 140 (2003) (noting that the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion). On January 19, 2017, the Veteran underwent a VA thoracolumbar spine examination. The Veteran endorsed flare-ups following all movement, standing, and walking eliciting pain only rectified by lying down. Also, the Veteran endorsed functional loss or functional impairment, namely limited motion and movements due to pain. The Veteran had forward flexion to 30 degrees; extension to zero degrees; right lateral flexion to 10 degrees; left lateral flexion to 10 degrees; right lateral rotation to 15 degrees; and left lateral rotation to 15 degrees. The clinician reported that decreased movement due to pain contributed to function loss. There as pain with weight bearing. The clinician reported that pain is moderate-to-severe on palpation of the lumbar spine. The Veteran was capable of repetitive use (of at least three repetitions) without additional loss in ranges of motion. Examination did not take place immediately after repeated use in time. Examination did take place during a flare-up, where pain, weakness, fatigability, lack of endurance, and incoordination significantly limited functional ability. The clinician characterized this in loss of degrees in range of motion as forward flexion to 25 degrees; extension to zero degrees; right lateral flexion to 5 degrees; left lateral flexion to 5 degrees; right lateral rotation to 10 degrees; and left lateral rotation to 10 degrees. There was no evidence of muscle spasm; however, there was evidence of guarding that did not result in abnormal gait or abnormal spinal contour. Notably, the clinician indicated that the Veteran guarded due to pain on all terminal motion in all planes. The Veteran maintained full strength (5/5) and there was no evidence of muscle atrophy. Reflexes were hypoactive (1+). Sensory examination was decreased at all planes. There was no evidence of ankylosis (as noted, radiculopathy has been evaluated separately). There was no evidence of any additional neurological abnormalities. While the Veteran had IVDS, IVDS did not require any periods of physician-directed bedrest over the past 12 months. The Veteran indicated that he used a walked constantly. The clinician indicated functional impact on the Veteran's ability to work. The Veteran could perform no lifting, standing, or sitting. As such, the clinician opined that no work was feasible at the time of the instant examination. In a January 2017 VA progress note, a physician noted that the Veteran reported that he needed help getting dressed and eating. Additionally, the Veteran reported that he had not worked in three years because of back pain. As already noted, VA associated the Veteran's SSA adjudication materials and medical records with the claims file in January 2020. The Veteran received a fully favorable notice of decision in October 2016. The records reveal severe impairments of: 1) degenerative joint disease (DJD) of the knee with multiple surgeries; 2) degenerative disc disease (DDD) of the lumbar spine; 3) obesity; 4) tremor in the right arm; 5) ulnar neuropathy; 6) restless leg syndrome; and 7) anxiety. The Veteran was deemed eligible for SSA disability benefits since April 1, 2014. The medical evidence considered by SSA was substantially the medical evidence associated with the Veteran's VA claims file. On February 28, 2020, the Veteran underwent a VA thoracolumbar spine conditions examination. The Veteran endorsed flare-ups of stabbing and radiating pain. The Veteran endorsed functional loss and impairment, notably difficulty dressing; termination of his sex life; urinary leakage; and reliance on a wheeled walker. The Veteran had forward flexion to 45 degrees; extension to zero degrees; right lateral flexion to 51 degrees; left lateral flexion to 15 degrees; right lateral rotation to 5 degrees; and left lateral rotation to 10 degrees. The clinician indicated that range of motion contributed to functional loss (bending and standing up straight). Pain was elicited at all planes. There was pain with weight bearing. The clinician reported tenderness at the L4-S2 spinous processes. The Veteran could not perform repetitive use testing at his request due to pain. However, the clinician did opine that pain, weakness, fatigability, lack of endurance, and incoordination significantly limited functional ability upon repeated use. The clinician estimated such loss as: forward flexion to 40 degrees; extension to zero degrees; right lateral flexion to 10 degrees; left lateral flexion to 10 degrees; right lateral rotation to zero degrees; and left lateral rotation to 5 degrees. Examination did not take place during a flare-up and the clinician replicated the findings for limited functional ability upon flare-ups. There was no muscle spasm; however, there was guarding resulting in abnormal gait or abnormal spinal contour, as discerned through the Veteran's forward leaning posture. Additionally, the clinician reported instability of station; disturbance of locomotion; interference with sitting; and interference with standing. The Veteran's strength was 4/5 (active movement against some resistance), with the exception of great toe extension which was 3/5 (active movement against gravity). Reflexes were hypoactive at the bilateral knees and absent at the bilateral ankles. Sensory examination was decreased at every index, except left foot/toes (L5) where is was absent. There was no evidence of ankylosis or other neurological abnormalities (as noted, radiculopathy is separately rated). While the Veteran had IVDS, IVDS did not require any periods of physician-directed bedrest over the past 12 months. The Veteran reported that he regularly used a cane, walker, and wheeled walker. He occasionally used a brace. The Veteran was positive for the bilateral pelvic rock test with L>R and positive for opposite leg cross over test at R to L. X-ray imaging disclosed arthritis; however, there was no evidence of a thoracic vertebral fracture with loss of 50 percent of height. MRI comparative findings rendered an impression of stable to improved multilevel degenerative changes ans improved appearance of the Veteran's L1-2-disc protrusion. Non-weight bearing and passive range testing were not medically appropriate. The clinician opined that the Veteran's low back disability was moderate-to-severe. There was functional impact on the Veteran's ability to work, namely difficulties sitting, standing, walking, and bladder leakage. The Veteran (and the other lay parties noted above) contend that his low back disability is more severe than that contemplated by a 20 percent rating. As discussed, the Veteran is competent to report discernable symptoms, such as pain and stiffness. The current 20 percent rating under Diagnostic Code 5237 is assigned for this disability. To receive a higher disability rating, there would need to be a showing of forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. The Board has discussed the pertinent evidence above. Upon examination on January 19, 2017, the clinician indicated that the Veteran had forward flexion exactly to 30 degrees, such a clinical finding would warrant a 40 percent rating under Diagnostic Code 5237 as of January 19, 2017. The Board has considered whether rating in excess of 40 percent might be warranted. For a higher rating, there would need to be a showing of unfavorable ankylosis of the entire thoracolumbar spine. No examination during the evaluation period found indicated a presence of ankylosis. The most recent (February 28, 2020) clinician indicated that pain, weakness, fatigability, lack of endurance, and incoordination significantly limited functional ability upon repeated use and during flare-ups. Pain may cause a functional loss, but of itself does not constitute functional loss. See Saunders, 886 F. 3d 1356. Rather, as is the case here, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Indeed, the Board does not question whether the Veteran has sustained functional loss; however, such loss was contemplated by the 20 percent rating assigned prior to January 19, 2017. The Board has considered the updated Diagnostic Codes that went into effect on February 7, 2021, and whether an increased rating for the Veteran's low back disability was warranted however the Board finds that such is not applicable. Consequently, the Board finds that the weight of the evidence is against the claim for a rating in excess of 20 percent prior to January 19, 2017 but warrants granting a 40 percent rating, but no higher, from January 19, 2017. Residuals of a right clavicle fracture The RO has rated the Veteran's residuals of right clavicle fracture under 38 C.F.R. § 4.71a, Diagnostic Code 5201 The rating criteria pertaining to Diagnostic Code 5201 was revised effective February 7, 2021, a 20 percent rating is warranted for motion of both major and minor arms limited to shoulder level (flexion and/or abduction limited to 90 degrees). A 20 percent rating is warranted for motion of the minor arm limited to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). A 30 percent rating is warranted for motion of the major arm limited to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). A 30 percent rating is warranted for limitation of the minor arm to flexion and/or abduction limited to 25 degrees from the side. And, a 40 percent rating is warranted for limitation of the major arm to flexion and/or abduction limited to 25 degrees from the side. 38 C.F.R. § 4.71a Evidence and Analysis In a March 2002 lay statement, the Veteran reported that his right shoulder symptoms had worsened. In an April 2014 medical record, a clinician at R., a private facility, indicated that the Veteran complained of bilateral forearm pain that radiated into his shoulder. In a September 2014 a clinician at R. remarked that the Veteran had full range of motion in his bilateral shoulders. In April 2015, the Veteran underwent a VA right shoulder examination. The Veteran reported that he was not receiving treatment for his right shoulder. The clinician noted that the Veteran was right-handed. The Veteran endorsed flare-ups of decreased range of motion due to increased bouts of pain. Likewise, the Veteran endorsed functional loss again as decreased range of motion due to increased bouts of pain. The Veteran had flexion to 155 degrees; abduction to 160 degrees; external rotation to 65 degrees; and internal rotation to 75 degrees. The clinician opined that less motion than normal contributed to functional loss. Pain was present at all planes. There was no pain with weight bearing; no evidence of localized pain on palpation of the right shoulder or associated soft tissue; and no evidence of crepitus. The Veteran was able to perform repetitive use testing (of at least three repetitions), without additional loss of range of motion. The clinician indicated that pain, fatigability, and weakness significantly limited functional ability upon repeated use. The Veteran reported that his range of motion was reduced. Examination did not lake place immediately after repeated use in time or during a flare-up. The clinician indicated that pain, fatigability, and weakness significantly limited functional ability during flare-ups. The Veteran maintained full strength (5/5). There was neither evidence of muscle atrophy nor ankylosis. The clinician reported that he did not suspect a right rotator cuff condition and there was no evidence of instability, dislocation, or labral pathology. There was no evidence of right shoulder arthritis. There was no loss of flail shoulder, nonunion, or fibrous union of the humerus. In remarks, the clinician opined that the Veteran right shoulder disability had resolved and there were no longer residuals related to the Veteran's in-service right clavicle fracture. As such the residuals of a right clavicle fracture did not functionally impact the Veteran's ability to perform any occupational task. In a May 2015 VA rheumatology outpatient note, a clinician reported that the Veteran complained of pain between his shoulder blades when he fell asleep on the couch. In July 2015 lay statements, the Veteran's spouse, daughter, and co-worker reported that the Veteran falls and experiences shooting pain from his back to his legs. These lay parties also reported that the Veteran experienced trouble sleeping; cannot exercise; and had difficulties fulfilling the tasks of his job. In his July 2015 NOD, the Veteran asserted that he had not been afforded an adequate right shoulder examination. In his July 2016 VA Form 9, the Veteran wrote that the residuals of a right clavicle fracture had not resolved; he had learned to live with this disability. The Veteran also reiterated his assertion that the April 2015 right shoulder examination was inadequate. A review of 2018 and 2019 VA treatment records show that the Veteran sought treatment for a right shoulder sprain. The Veteran indicated that he had sustained a right shoulder injury during this period. VA clinicians provided consultations. The Veteran indicated that this new right shoulder injury caused a "dramatic" flare-up of his residuals of his service-connected residuals of a right clavicle fracture. February 2019 VA multiplanar imaging of the right shoulder disclosed a low-grade articular surface partial tear of the infraspinatus tendon which extended interstitially; mild supraspinatus tendinopathy; mild tenosynovitis of the proximal biceps long head tendon; small glenohumeral joint effusion; and mild widening of the ACL joint suggesting grade I sprain injury. In February 28, 2020, the Veteran underwent another VA right shoulder examination. The Veteran endorsed flare-ups when his right shoulder "hurts like hell." The Veteran also endorsed functional loss attributable to right shoulder pain. The Veteran had right shoulder flexion to 55 degrees; abduction to 40 degrees; external rotation to 20 degrees; and internal rotation to 50 degrees. The clinician opined that range of motion itself contributed to functional lossspecifically reaching and lifting. Pain was present at all planes. There was pain on weight bearing and tenderness at the anterior subdeltoid space among others. There was also evidence of crepitus. The Veteran was not able to perform repetitive use testing (of at least three repetitions), at his own request due to pain. The clinician indicated that that pain, fatigability, lack of endurance, incoordination and weakness significantly limited functional ability upon repeated use. The clinician rendered this into right shoulder flexion to 45 degrees; abduction to 35 degrees; external rotation to 20 degrees; and internal rotation to 50 degrees. Examination did not lake place immediately after repeated use in time bur did take place during a flare-up. The clinician indicated that that pain, fatigability, lack of endurance, incoordination and weakness significantly limited functional ability during flare-ups. The clinician rendered this into right shoulder flexion to 45 degrees; abduction to 35 degrees; external rotation to 20 degrees; and internal rotation to 50 degrees. Other factors contributing to this disability included (presumably limited) lifting and reaching. The Veteran's strength tabulated to active movement against some resistance (4/5). This reduction was due to the Veteran's rotator cuff and biceps tendinopathy. The was no evidence of ankylosis, instability, dislocation, or labral pathology. There was no loss of flail shoulder, nonunion, or fibrous union of the humerus. The clinician noted a right upper extremity tremor. The Veteran reported that he occasionally used a sling. This clinician replicated the findings from the February 2019 multiplanar imaging of the right shoulder. There was evidence of pain on passive range of motion and pain in non-weight bearing. As the contralateral joint range of motion, the clinician indicated that such testing would yield no useful data as the left shoulder is service-connected. Lastly, the clinician underscored that the Veteran's residuals of a right clavicle fracture are mild in severity. Upon examination, right shoulder pain and functional limitations are due to a recent superimposed right shoulder incurred in November 2018. The Veteran and the other lay parties contend that his residuals of a left clavicle fracture is more severe than that contemplated by a 20 percent rating. As discussed, the Veteran is competent to report discernable symptoms, such as pain and limitations of function. The current 20 percent rating under Diagnostic Code 5201 is assigned for this disability. The February 28, 2020 clinician reported right shoulder flexion to 55 degrees; abduction to 40 degrees. Consequently, again granting the benefit of doubt to the Veteran despite the superimposed right shoulder injury of November 2018, the Board finds that the Veteran's residuals of a right clavicle fracture warrant a 30 percent rating from February 28, 2020, but no earlier. The Board has considered whether rating in excess of 30 percent might be warranted. For a higher rating, there would need to be a showing of for limitation of the major arm to flexion and/or abduction limited to 25 degrees from the side. The clinical evidence fails to disclose such a degree of limitation. The most recent (February 28, 2020) clinician indicated that pain, weakness, fatigability, lack of endurance, and incoordination significantly limited functional ability upon repeated use and during flare-ups. Pain may cause a functional loss, but of itself does not constitute functional loss. See Saunders, 886 F. 3d 1356. Rather, as is the case here, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Indeed, the Board does not question whether the Veteran has sustained functional loss; however, such loss was contemplated by the 20 percent rating assigned prior to February 28, 2020. As the Veteran is being granted more than the minimum compensable rating as of February 28, 2020 under 38 C.F.R. § 4.71a, Diagnostic 5201, these provisions are not for application. Consequently, the Board finds that the preponderance of the evidence is against the claim for a rating in excess of 20 percent prior to February 28, 2020 but the preponderance of evidence warrants granting a 30 percent rating, but no higher, from February 28, 2020. Right knee Left Knee Disabilities of the knee and leg are generally rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 through 5263. Under Diagnostic Code 5260 for limitation of flexion, a noncompensable rating is assigned for flexion limited to 60 degrees; a 10 percent rating is assigned for flexion limited to 45 degrees; a 20 percent rating is assigned for flexion limited to 30 degrees; and a 30 percent rating is assigned for flexion is limited to 15 degrees. Diagnostic Code 5003 evaluates disabilities based on the degree of limitation of motion under the appropriate Diagnostic Codes. 38 C.F.R. § 4.71a. If the disability is noncompensable under the appropriate Diagnostic Code for the joint involved, a 10 percent rating will be for application for such major joint or group of minor joints affected by limitation of motion. Id. The rating criteria pertaining to Diagnostic Code 5010 was revised effective February 7, 2021. Posttraumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under an affected joint. If there are two or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Prior to February 7, 2021, under Diagnostic Code 5257 for recurrent subluxation or lateral instability, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability of the knee; a 20 percent rating is warranted for medical evidence showing that the recurrent subluxation or lateral instability can be characterized as moderate; and a 30 percent rating is warranted for recurrent subluxation or lateral instability which medical evidence discloses can be characterized as severe. Under Diagnostic Code 5261 for limitation of extension, a noncompensable rating is assigned for extension limited to 5 degrees; a 10 percent rating is assigned for extension limited to 10 degrees; a 20 percent rating is assigned for extension limited to 15 degrees; a 30 percent rating is assigned for extension is limited to 20 degrees; a 40 percent rating is assigned for extension is limited to 30 degrees; and a 50 percent rating is assigned for extension is limited to 45 degrees. Diagnostic Code 5256 pertains to ratings for ankylosis of a knee. Diagnostic Code 5262 applies to ratings for impairment of the tibia and fibula. Diagnostic Code 5258 applies to a dislocated semilunar cartilage. Diagnostic Code 5259 applies to removal of the semilunar cartilage. Diagnostic Code 5263 applies to rating genu recurvatum. The rating criteria pertaining to Diagnostic Code 5262 were revised effective February 7, 2021. Diagnostic Code 5258 provides a maximum schedular rating of 20 percent for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court held that under 38 C.F.R. § 4.71, a separate evaluation may be assigned for meniscal problems under Diagnostic Codes 5258 or 5259, even when ratings are in effect under Diagnostic Codes 5257 and 5261. The Board must also consider functional impairment with respect to the baseline ROM noted during clinical evaluation. English v. Wilkie, 30 Vet. App. 347 (2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups). The RO has rated the Veteran's right knee under 38 C.F.R. § 4.71a, Diagnostic Code 5258. Whereas, the RO has rating left synovitis under Diagnostic Code 5020-5260 and left knee limitation of extension under Diagnostic Code 5261. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.29. As noted above Diagnostic Code 5260 pertains to limitations in flexion. Evidence and Analysis In March 2003, the Veteran indicted that his knees had worsened. In March 2013, the Veteran underwent a VA knees examination. The Veteran reported painful popping, aching, swelling, and difficulties maneuvering. The Veteran endorsed flare-ups, noting that he had become sedentary and was forced to employ someone to do his lawn. The Veteran had bilateral knee flexion to 110 degrees with endpoint pain and extension to zero with no pain. Repetitive use testing resulted in no additional limitation in range of motion bilaterally. Bilaterally, less movement than normal. Interference with sitting, standing and weight bearing as well as pain on movement contributed to functional loss upon repetitive us. Right knee swelling also contributed to additional functional loss. There was tenderness present bilaterallyat the anterior medical joints. Muscle strength was normal bilaterally, without atrophy. Bilaterally, there was no evidence of patellar subluxation/dislocation. Bilaterally, there was no evidence of shin splints, stress fracture, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The clinician reported right meniscal tear; frequent episodes of joint pain; and frequent episodes of joint effusion. The Veteran had undergone a right knee meniscectomy and a left knee diagnostic arthroscopy without residuals. The Veteran reported that he occasionally braces and a cane. X-ray imaging showed right knee arthritis and no evidence of bilateral patellar subluxation. The clinician indicated that the Veteran's bilateral knee disabilities did not functionally impact his ability to work. Lastly the clinician indicated that there would be a been 10 degrees loss of flexion and 5 degrees loss of extension and mild-to-moderate weakness, fatigability, and incoordination upon repetitive use and during flare-ups bilaterally. The problems list from R. include osteoarthritis of the right knee. In November 2013, a VA clinician noted that she had recommended Capsaicin ointment three times daily for knee discomfort. In April 2015, the Veteran underwent a VA knees examination. The Veteran reported that there had been no changes in his bilateral knees since his March 2014 examination. The Veteran reported flare-ups manifesting as decreased range of motion due to pain. On examination, the Veteran demonstrated bilateral knee flexion to 110 degrees with pain and extension to zero without pain. There was bilateral pain with weight bearing and crepitus. However, there was no objective evidence bilaterally of localized tenderness or pain on palpation of the joints or associated soft tissue. Repetitive use testing resulted in no additional limitation in range of motion bilaterally. Pain significantly limited functional ability with repeated use over time and during flare-ups. Muscle strength was normal bilaterally, without atrophy. There was no evidence of ankylosis bilaterally. Bilaterally joint testing was normal. There was no joint instability for either the right or left knee. Bilaterally, there was no evidence of shin splints, stress fracture, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The clinician reported right meniscal tear; frequent episodes of joint pain; and frequent episodes of joint effusion. The Veteran had undergone a right knee meniscectomy and a left knee diagnostic arthroscopy without residuals. The Veteran indicated that he used braces regularly. X-ray imaging showed bilateral arthritis. The clinician indicated that the Veteran's bilateral knee disabilities did not functionally impact his ability to work. The clinician remarked that the Veteran's bilateral knee disabilities were moderate and stable. Lastly, the clinician opined that the Veteran's bilateral knee disabilities would not render the Veteran to secure and maintain substantially gainful employment in a loosely supervised setting without much ambulation and little public interaction. 2015 VA rheumatology clinic notes disclose that the Veteran complained of knee pain from walking and squatting. In July 2015 lay statements, the Veteran's spouse, daughter, and co-worker reported that the Veteran falls and experiences shooting pain from his back to his legs. These lay parties also reported that the Veteran experiences trouble sleeping; cannot exercise; and experiences difficulties fulfilling the tasks of his job. At this time, the Veteran submitted a lay statement in which he noted the severity of his bilateral knees. In a February 2018 affidavit, the Veteran swore that his pain medications for service-connected disabilities induced drowsiness and compromised his ability to pay attention because of a "mental fog." The Veteran also swore that back episodes caused him to collapse and knee episode causes "lock ups" and falls. Consequently, due to his service-connected disabilities' pain and medications, the Veteran swore that he had exhausted every opportunity to maintain his current employment and it has become impossible to continue working in any capacity. In January 2020, VA associated the Veteran's SSA adjudication materials and medical records with the claims file. The Veteran received a fully favorable notice of decision in October 2016. The records reveal severe impairments of: 1) degenerative joint disease (DJD) of the knee with multiple surgeries; 2) degenerative disc disease (DDD) of the lumbar spine; 3) obesity; 4) tremor in the right arm; 5) ulnar neuropathy; 6) restless leg syndrome; and 7) anxiety. The Veteran was deemed eligible for SSA disability benefits since April 1, 2014. To a great extent, the medical evidence replicates the medical evidence associated with the Veteran's VA claims file. On February 28, 2020, the Veteran underwent a VA knees examination. The clinician followed VA exam protocols. The Veteran endorsed flare-ups and functional loss with repeated use, reported as dull aching and sharp pain aggravated by standing, walking, or traversing stairs. On examination, the Veteran demonstrated right knee flexion to 105 degrees with pain and extension to 15 degrees with pain. Left knee flexion was to 100 degrees with pain and extension was to zero without pain. There was bilateral pain with weight bearing. Tenderness was present at the right medial and lateral joint line, medial and lateral patellofemoral joint and popliteal fossa, with objective evidence of crepitus. Tenderness was present at the left medial and lateral joint line, medial and lateral patellofemoral joint, with objective evidence of crepitus. Repetitive use testing was not performedat the Veteran's request due to pain. Pain, fatigue, weakness, lack of endurance, and incoordination significantly impacted right knee functional use with repeated use over time. The clinician translated this into flexion to 100 degrees and extension to 20 degrees. Pain and fatigue significantly impacted left knee functional use with repeated use over time. The clinician translated this into flexion to 105 degrees and extension to zero degrees. Pain significantly impacted left knee functional use during flare-ups. The clinician reported that he was unable to translate this into degreesin light of the Veteran's medical history and objective findings upon examination. Right knee strength was active movement against some resistance (4/5). Here, the clinician attributed 50 percent of this reduction in strength to right lumber radiculopathy. Right knee strength was active movement against some resistance (4/5). Here, the clinician attributed 100 percent of this reduction in strength to left lumber radiculopathy. The Veteran had muscle atrophy at the right lower extremity. Bilaterally, there was no objective evidence of ankylosis. There was no bilateral history of recurrent subluxation. Joint stability testing was normal bilaterally. Bilaterally, there was no evidence of shin splints, stress fracture, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The clinician reported right meniscal tear with residuals, The Veteran reported that he occasionally used braces, regularly used a cane, regularly used a walker, and regularly used a wheeled walker, X-ray imaging revealed right mild-to-moderate tricompartmental degenerative arthrosis mildly progressed when compared with the VA knees examination and left mild degenerative changes of the medial compartment unchanged when compared to the prior VA knees examination. There was functional impact on the Veteran's ability to perform any type of occupational task, namely considerable difficulty with tasks that required standing, walking, or traversing stairs. There was evidence of pain on non-weight bearing and passive range of motion bilaterally. The clinician did not perform contralateral joint testing as both knees were abnormal. Overall, the clinician opined that the Veteran's right knee is moderate in severity and his left knee is mild in severity. The Veteran (and the other lay parties noted above) contended that his right knee disability, left knee synovitis and left knee limitation of extension are more severe than that contemplated by the assigned percent ratings. As discussed, the Veteran is competent to report discernable symptoms, such as pain; however, this lay evidence does not constitute competent medical/clinical evidence. 38 C.F.R. § 3.159(a)(1). The current 20 percent rating for right knee disability is under Diagnostic Code 5258; the current 10 percent for left knee synovitis is under Diagnostic Code 5020-5260; and noncompensable for left knee extension is under Diagnostic Code 5261. The pertinent evidence is summarized above. Diagnostic Code 5258 provides a maximum schedular rating of 20 percent for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. As such, a higher rating is not available. Diagnostic 5260 provides a 20 percent rating when flexion is limited to 30 degrees. Diagnostic 5261 provides a 10 percent rating when extension is limited to 10 degrees; a 20 percent rating when limited to 15 degrees, and a 30 percent rating when limited to 20 degrees. The examinations consistently show no lateral or patellofemoral instability so that the regulations including those revised effective February 7, 2021 do not result in additional ratings. Consequently, a higher rating is not possible for the Veteran's right knee disability under Diagnostic Code 5258. However, starting February 28, 2020, an additional 30 percent rating is warranted for the right knee under Diagnostic Code 5261 for limitation of extension to 20 degrees during flare-ups. At worst, left knee synovitis manifests as flexion limited to 100 degrees. At worst, left knee extension is limited to zero degrees. As such, higher ratings are not possible for Diagnostic Codes 5258, 5260, or 5261. Likewise, no examination found subluxation, ankylosis, genu recurvatum, tibia or fibula impairment. Consequently, separate compensable ratings under Diagnostic Codes 5257, 5256, 5259, 5260, 5262, or 5263 are not warranted. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, supra. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, the minimal compensable rating for the both knees is already assigned, and the analysis must turn to whether functional loss warranting a higher than 10 percent disability rating is reasonably shown. The most recent, February 28, 2020 clinician indicated that pain, fatigue, weakness, lack of endurance, and incoordination significantly impacted right knee functional use with repeated use over time; and pain, fatigue, and weakness significantly impacted right knee functional use during flare-ups. As to the left knee, the clinician indicated that pain and fatigue significantly impacted left knee functional use with repeated use over time; and pain significantly impacted left knee functional use during flare-ups. In degrees, right knee was to 100 degrees in flexion and extension to 20 degrees upon repeated use in time; and 100 degrees in flexion and extension to 20 degrees. In degrees, left knee was to 105 degrees in flexion and extension to zero degrees upon repeated use in time; and untranslatable into degrees in light of the Veteran's medical history and objective findings upon examination during flare-ups. Under Diagnostic Code 5261 limited to 20 degrees is analogous to the 20 percent rating that is already assigned to the right knee disability. Whereas, the other findings are noncompensable as to flexion (Diagnostic Code 5260) or Diagnostic Code 5261. Consequently, increased disability ratings based on functional limitations due these factors are not warranted. While the Veteran has been shown to experience bilateral knee pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but of itself does not constitute functional loss. See Saunders, 886 F. 3d 1356. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss warranting an increased rating. See 38 C.F.R. § 4.40. The Board acknowledges the Veteran's report that his right and left knee disabilities result in the functional limitations that he has endorsed, as discussed above. These limitations are contemplated by the criteria for the respective 20 and staged 30 percent, 10 percent, and noncompensable ratings that are assigned. The Board also finds that the right and left knee disabilities shown do not include any that are not adequately addressed by the schedular rating criteria. Right ankle disability The RO has rated this disability under 38 C.F.R. § 4.71a, Diagnostic Code 5271. Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected ankle disorders, including Diagnostic Code 5270 (ankylosis of the ankle); Diagnostic Code 5272 (ankylosis of subastragalar or tarsal joint); Diagnostic Code 5273 (malunion of os calcis or astragalus); and Diagnostic Code 5274 (astragalectomy). However, the Veteran's right ankle disorder is not shown to have not been manifested by ankylosis, malunion of os calcis or astragalus, or astragalectomy. Therefore, these Diagnostic Codes are not for application here. Diagnostic Code 5271 (limited motion of ankle) provides a 10 percent rating for moderate limited ankle motion and a 20 percent rating for marked limited ankle motion. The rating criteria pertaining to Diagnostic Code 5271 was revised effective February 7, 2021. A moderate ankle limitation of motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) is assigned a 10 percent rating and a marked ankle limitation of motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) is assigned a 20 percent rating. Normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. Evidence and Analysis In April 2015, the Veteran underwent a VA right ankle examination. The Veteran reported flare-ups, noting increased pain which causes loss in range in motion. The Veteran endorsed functional loss as less motion than normal. The Veteran had dorsiflexion to 10 degrees and plantar flexion to 25 degrees. Less motion than normal contributed to functional loss and pain caused functional loss. There was pain with weight bearing. There was no evidence of localized tenderness or crepitus. The clinician indicated that repetitive use testing was possible with no additional loss in range of motion. Pain and fatigue contributed to functional loss with repeated use in time. Pain contributed to functional loss during flare-ups. The Veteran maintained normal right ankle strength (5/5). The clinician indicated that there was no objective evidence of muscle atrophy, ankylosis, instability, shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of os calcis or astragalus, or astragalectomy. The Veteran reported that he did not use assistive devices. There was no evidence of arthritis. The clinician reported that the Veteran's right ankle disability did not functionally impact the Veteran's ability to perform any occupational task. The clinician indicated that the right ankle disability was mild and stable. In his July 2015 lay statement, the Veteran reported that his right ankle has worsened to the degree that the pain caused episodes of tripping and falling. In July 2015 lay statements, the Veteran's spouse, daughter, and co-worker reported that the Veteran falls and experiences shooting pain from his back to his legs. These lay parties also reported that the Veteran experiences trouble sleeping; cannot exercise; and experiences difficulties fulfilling the tasks of his job. In his February 2018 affidavit, the Veteran swore that he had exhausted every opportunity to maintain his current employment and it has become impossible to continue working in any capacity. On February 28, 2020, the Veteran underwent another VA right ankle examination. The Veteran endorsed flare-ups of pain that was sharp and froze his ankle up. The Veteran endorsed functional loss of lock-ups for 4-to-5 hours. The Veteran had dorsiflexion to 15 degrees and plantar flexion to 45 degrees with endpoint pain. Range of motion did not contribute to functional loss; however, pain contributed to functional loss. The clinician reported that there was no pain with weight bearing and no objective evidence of crepitus. There was localized mild tenderness at the anterior level and lateral joint line. The clinician indicated that repetitive use testing was possible with no additional loss in range of motion. Pain and incoordination contributed to functional loss with repeated use in time. The clinician translated this into dorsiflexion to 10 degrees and plantar flexion to 45 degrees. Pain and incoordination contributed to functional loss during flare-ups. The clinician translated this into dorsiflexion to 10 degrees and plantar flexion to 45 degrees. Interference with standing contributed to the degree of disability. The Veteran maintained strength of active movement against some resistance (4/5). The clinician indicated that 50 percent of this diminution of muscle strength was attributable to lower extremity lumbar radiculopathy. There was evidence of muscle atrophy. The clinician indicated that there was no objective evidence of ankylosis, instability, shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of os calcis or astragalus, or astragalectomy. The clinician suspected joint instability. The Veteran reported that he did not use an assistive device. X-ray imaging revealed irregularity of the distal anterior margin of the tibia, suggestive of an old minimally displaced fracture. The clinician reported that the Veteran's right ankle disability did functionally impact the Veteran's ability to perform any occupational task. Namely lock-ups and impaired locomotion. The clinician reported pain on passive range of motion and pain in non-weight bearing. The contralateral joint was undamaged. Lastly, the clinician opined that the Veteran's right ankle disability was mild in severity. The Veteran (and the other lay parties) contend that right ankle disorder is more severe than that contemplated by a 10 percent disability rating. Indeed, the Veteran is competent to report that which is discernable, such as right ankle pain. However, the Veteran lacks the medical knowledge and orthopedic expertise to assess the clinical severity of a right ankle disorder. See 38 C.F.R. § 3.159(a)(1). As noted above, the highest schedular rating under both versions of Diagnostic Code 5271 is 20 percent, which is assigned when there is marked limited ankle motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion). At worst, right ankle dorsiflexion was to 10 degrees and plantar flexion was to 25 degrees As noted above, normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. The Board finds that the limitation of motion, pain requiring limitation in walking endurance; and locking is best assessed as moderate limitation, indicative of a 10 percent disability rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Th ae Board considered the Veteran's reporting that his ankle "freezes" on occasion. However, clinical observations show that the ankle is not ankylosed and a rating in excess of 10 percent would not represent the overall level of severity and loss of function. Considering the foregoing, the Board finds that the preponderance of the evidence is against granting a rating in excess of 10 percent rating for the Veteran's right ankle disability. SMC for Aid and Assistance The Veteran contends that he is entitled to SMC based upon the need of regular aid and assistance of another person because of his combined service-connected disabilities. Under 38 U.S.C. § 1114(1), SMC is payable if, as the result of service-connected disability, the Veteran has an anatomical loss or loss of use of both feet, or of one hand and one foot; has blindness in both eyes with visual acuity of 5/200 or less; is permanently bedridden; or is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114(1); 38 C.F.R. § 3.350(b). Need for aid and attendance means being so helpless as to require the regular aid attendance of another person. 38 C.F.R. § 3.350(b). Under 38 C.F.R. § 3.352(a), the following factors will be accorded consideration in determining whether the Veteran is in need of regular aid and attendance of another person: inability of the claimant to dress and undress himself or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliance; inability of the claimant to feed himself through loss of coordination of the upper extremities or through extreme weakness; inability to tend to the wants of nature; or incapacity, physical or mental, which requires care and assistance on a regular basis to protect the claimant from the hazards or dangers incident to his daily environment. It is not required that all the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352(a); see also Turco v. Brown, 9 Vet. App. 222, 224 (1996) (holding that at least one factor listed in § 3.352(a) must be present for a grant of SMC based on need for aid and attendance). For the purposes of 38 C.F.R. § 3.352(a), "bedridden" will be a proper basis for the determination of whether the Veteran is in need of regular aid and attendance of another person. "Bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that the claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). Evidence and Analysis As of the rendering of this decision, the Veteran is in receipt of service connection: 1) depression at 30 percent; 2) degenerative changes to left AC joint at 20 percent; 3) residuals of a right clavicle fracture now at 30 percent; 4) right knee disability at 20 percent and 30 percent from February 28, 2020; 5) low back disability at 40 percent; 6) left lower extremity radiculopathy at 30 percent; 7) right lower extremity radiculopathy at 20 percent; 8) left knee synovitis at 10 percent; 9) right wrist ganglion cyst at 10 percent; 10) right ankle disability at 10 percent; and 11) left knee limitation of extension at a noncompensable rating. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). In a June 2015 rating decision, the RO denied the form of SMC because the criteria of 38 C.F.R. § 3.350 had not been met. In his July 2015 lay statement, the Veteran reported that even with orthotic and support devices he needed assistance getting to restrooms. The Veteran also reported that he needed assistance dressing, grooming, toileting, and bathing. In her lay statement of the same month, the Veteran's spouse wrote that on most occasions the Veteran needs help dressing, opening doors, and bathing. Even though, the spouse described a dangerous fall that the Veteran sustained hobbling and crawling to his car, she did not indicate that the Veteran was unable to drive. Neither of these lay accounts provide guidance as to the Veteran's being "bedridden," as articulated above. The evidence is summarized above, the clinical record, pertinent to the instant appeal, fails to disclose that the Veteran is so helpless as to require the regular aid attendance of another person. Upon a January 2016 VA mental health examination, a psychologist indicated that the Veteran was competent and capable of handling his own financial affairs. The psychologist opined that the Veteran's mental health disability was productive of occupational and social impairment with occasional decrease in work efficiency and intermediate periods of inability to perform occupational tasks, although generally functioning satisfactorilywith normal routine, self-care, and conversation. While the psychologist noted that the Veteran endorsed that he felt hopeless and helpless related to minimal functioning and reliance on the assistance of his spouse, the psychologist did not make this a psychometric finding. In his February 2018 affidavit, the Veteran swore, while employed, there were numerous days that he could not get out of bed because of pain (back, sciatica, and knees). However, the Veteran did not swear that he was permanently bedridden, had an anatomical loss or loss of use of both feet, or of one hand and one foot; or had blindness in both eyes with visual acuity of 5/200 or less. This affidavit further fails to disclose that the Veteran swore the he is so helpless caused by depression; right knee disability; low back disability; left lower extremity radiculopathy; left lower extremity radiculopathy; left knee synovitis; right wrist ganglion cyst; degenerative changes to left AC joint; residuals of a right clavicle fracture; right ankle disability; and/or left knee limitation of extensionas to be in need of regular aid and attendance of another person. While the Veteran swore that he frequently had to lie down and take naps, he did not swear that a clinical professional had prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure. While SSA records reveal severe impairments of: 1) degenerative joint disease (DJD) of the knee with multiple surgeries; 2) degenerative disc disease (DDD) of the lumbar spine; 3) obesity; 4) tremor in the right arm; 5) ulnar neuropathy; 6) restless leg syndrome; and 7) anxiety, they do not provide guidance, or even suggest, that the Veteran's is so helpless that he must rely upon the assistance of another person. The Veteran's representative has excerpted portions of VA and private medical records, to include the August 2016 consultant's "medical source statement." The representative also underscores the lay statements of the Veteran, his spouse, and his daughter. The Board recognizes that several clinicians and the Veteran's closest family members have indicated that the Veteran has severe limitations. While the Board acknowledges that the Veteran experiences difficulties dressing, bathing, toileting, exercising, and grooming, the Veteran's service-connected disabilities do not prevent him from feeding himself, driving, as well as taking care of his personal affairs and medication schedules. As to protection from the hazards or dangers incident to his daily environment, other than the lay statements of family members and a consultant's "medical source statement" of diminished probative weight (Cf., Sklar, 5 Vet. App. 140), the evidence of record does not support that the Veteran meets the standards delineated in 38 C.F.R. § 3.350. Stated more definitively, there is insufficient evidence that reveals that the Veteran has a history of actual injury or intervention from harm to him or others. The Veteran's representative bases her argument on selected excerpts of clinical reports and the lay statements of family members; however, neither she nor the Veteran have submitted any comprehensive reports which assess the Veteran's living situation, daily routine, or descriptions of any hazards inherent in the Veteran's environment. The Board assigns probative weight to the many examination reports of record. In each instance, a clinical professional reviewed the claims file; considered lay accounts; and conducted an extensive evaluation of the limitations imposed upon the Veteran by each of his service-connected disabilities. After carefully weighing the entire record of evidence, the Board finds that the evidence is in relative equal balance both for and against a finding that the Veteran's service-connected disabilities cause him to be so helpless as to require regular aid and attendance of another person. There are certain factors present that fall with the scope of 38 C.F.R. § 3.352(a) and they are based almost entirely on the reports of the Veteran and his family to VA, SSA, and his clinicians and examiners. However, the severity of his mental and physical dysfunction is not fully consistent with the observations of VA clinicians when assessing the individual disabilities. For example, a physician reported that the Veteran was so weak as to not be able to use a telephone or computer and his spouse reports the need to assist in dressing and toileting, yet he is still able to drive a car. probative clinical evidence of record, discussed exhaustively above, fails to support that the Veteran so helpless as to require the regular aid attendance of another person. See 38 C.F.R. § 3.350(b Consequently, the Board concludes that SMC based upon the need for regular aid and attendance of another person is warranted because of a relative equal balance of credible supportive lay evidence including that reported to treating clinicians and less supportive medical evidence based on clinical observations See 38 U.S.C. § 5107(b). Entitlement to a TDIU Prior to August 19, 2016 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. See 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, 529 (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 her age or to the impairment caused by nonservice-connected disabilities. See 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 nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore (Robert) v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. §§ 4.16(a), The regulatory scheme for a TDIU provides both objective and subjective criteria. Hatlestad, 5 Vet. App. 524; VAOPGCPREC 75-91 (Dec. 27, 1991) 57 Fed. Reg. 2317 (1992). The objective criteria, set forth at 38 C.F.R. § § 3.340(a)(2), provide for a total rating when there is a single disability or a combination of disabilities that results in a 100 percent schedular evaluation. Subjective criteria, set forth at 38 C.F.R. §§ 4.16(a), provide for a TDIU when, due to service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). As threshold matter, the Veteran's representative suggests that the Veteran's April 1, 2014 SSA fully favorable disability decision is determinative of a grant of entitlement to a TDIU, the Board notes that disability for SSA purposes and VA purposes are not analogouseither legally or factually. Prior to August 19, 2016, the Veteran had the following service-connected disabilities: 1) depression at 30 percent, effective from September 23, 2015; 2) residuals of a left clavicle fracture at 20 percent, effective from March 13, 2002; 3) residuals of a right clavicle fracture at 20 percent from March 13, 2002; (4) right knee disability at 20 percent; 5) low back disability at 20 percent and 10 percent; 6) left lower extremity radiculopathy at 10 percent; 7) left lower extremity radiculopathy at 10 percent; 8) left knee synovitis at 10 percent; 9) right ankle strain at 10 percent; (10) right wrist cyst rated as 10 percent; and 11) left knee limitation of extension at a noncompensable rating. Thus, the combined rating was 80 and later 90 percent, and the combined ratings of the bilateral lower extremities including radiculopathy, knee and ankle disabilities are of one orthopedic system and meet the criteria for a single disability with a combined rating of 70 percent. The Veteran did meet the schedular requirements for entitlement to a TDIU prior to August 19, 2016. See 38 C.F.R. §§ 4.16(a). Upon a March 2014 VA knees examination, the clinician opined that he expected that the Veteran would have 10 degrees of additional loss in motion upon flexion and 5 degrees of additional loss in extension, bilateral lateral flexion, and bilateral rotation during flare-ups and repetitive use (with moderate weakness, moderate fatigability, and moderate loss of coordination. Upon a March 2014, VA thoracolumbar spine examination, the Veteran reported that he found it difficult to perform the duties of his job even though it was sedentary in nature. In remarks, the clinician opined that he expected that the Veteran would have 10 degrees of additional loss in motion upon flexion and 5 degrees of additional loss in extension, bilateral lateral flexion, and bilateral rotation upon flare-ups and repetitive use (with moderate weakness, moderate fatigability, and moderate loss of coordination). In August 2014, Dr. H., a VA physician, submitted a letter. In pertinent part, this physician wrote that the Veteran suffered from chronic low back pain. This pain surfaced when the Veteran stays in one position for extended periods or when he stands for prolonged periods (20 to 30 minutes). Although the physician referred to both arms and hands, he reported limited strength as to preclude the use of a computer or telephone. He also noted that medications for his pain interfered with concentration. Upon an April 2015 VA right shoulder examination, the clinician opined that the Veteran right shoulder disability had resolved and there were no longer residuals related to the Veteran's in-service right clavicle fracture. As such the residuals of a right clavicle fracture did not functionally impact the Veteran's ability to perform any occupational task. Upon an April 2015 VA peripheral nerves examination, the clinician indicated that the Veteran's bilateral sciatica was mild-to-moderate in its severity and these disabilities did not impact the Veteran's ability to work. Upon an April 2015 right ankle examination, the clinician reported that the Veteran's right ankle disability did not functionally impact the Veteran's ability to perform any occupational task. The clinician indicated that the right ankle disability was mild and stable. In July 2015 lay statements, the Veteran's spouse, daughter, and co-worker reported that the Veteran falls and experiences shooting pain from his back to his legs. These lay parties also reported that the Veteran experiences trouble sleeping; cannot exercise; and experiences difficulties fulfilling the tasks of his job. At this time, the Veteran submitted a lay statement in which he noted the severity of his bilateral knees. Upon a January 2016 VA mental health examination, a psychologist indicated that the Veteran was competent and capable of handling his own financial affairs. The psychologist opined that the Veteran's mental health disability was productive of occupational and social impairment with occasional decrease in work efficiency and intermediate periods of inability to perform occupational tasks, although generally functioning satisfactorilywith normal routine, self-care, and conversation. A review of the Veteran's SSA records discloses that he has a 4-year college education and has been employed in the retail industry and loss prevention sector. The Veteran's work history includes several managerial postings in these industries. And, the evidence of record also discloses that the Veteran is able to drive an automobile by himself. While the Veteran asserts that his service-connected disabilities rendered him unable to obtain or retain employment consistent with his education and experience prior to August 19, 2016, the evidence of record shows that the Veteran has a college education and extensive managerial expertise in the retail industry and loss prevention sector. Collectively, the Board finds that this combination of education and work experiences, prior to August 19, 2016, were sufficient for the Veteran to obtain and maintain substantial employment considering his specific education and specific managerial experience in the retail and loss prevention fields. See Withers v. Wilkie, 30 Vet. App. 139 (2018). The Board recognizes that prior to August 19, 2016, the Veteran experienced intermediate periods of inability to perform occupational tasks due to his mental health disability and locomotion problems posed by his other service-connected disabilities. The evidence of record does not reveal that any one of his service-connected disabilities; however, there is a relative equal balance of evidence both for and against a finding that the entirety of his service-connected disabilities, precluded him from obtaining and maintaining gainful employment from April 1, 2014. The Board points to the clinical evidence summarized above including the consistent lay evidence, reports to clinicians, and work history and education. Prior to August 19, 2016, the Veteran's job skills would have lent themselves to employment in any industry that required managerial and administrative expertise including office or telework where the duties could be accomplished using electronic devices and did not require extended standing or walking, or any lifting or carrying. As of August 19, 2016, accommodations pursuant to the Americans with Disabilities Act (ADA) would allow for downtime due to disabilities. In the Veteran's case, it would have been feasible for an employer to provide breaks in quiet settings where the Veteran could collect himself during periods of intermittent distraction and bouts of symptoms associated with his service-connected disabilities. The Veteran reported that it was difficult to drive and he preferred not to do so, but he did report that he could still drive when necessary. He was limited in standing, sitting and walking but not so severely that it would preclude working at an administrative job. The report that he was so weak as to be unable to use a telephone or computer is not consistent with being able to drive. On the other hand, his and his families' reports of severe pain and the effects of medication were made consistently, accepted by his treating clinicians, and were consistent since April 2014 prior to the currently assigned effective date of August 19, 2016. Recognizing that the Board assigned an effective date in June 2015 for SMC based largely on lay statements from the Veteran and his spouse, and that he reported leaving his job in April 2014, the Board finds sufficient balance of evidence to grant a TDIU effective April 1, 2014. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.