Citation Nr: 21041112 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 16-59 516 DATE: July 8, 2021 ORDER Entitlement to service connection for a back disability is denied. Entitlement to an initial rating in excess of 20 percent for a left knee disability is denied. Entitlement to an initial rating in excess of 10 percent for residuals of a gunshot wound, right leg, muscle group XI is denied. Entitlement to an initial rating in excess of 10 percent for a left hip disability, to include arthritis and limitation of extension, is denied. Entitlement to an initial rating in excess of 10 percent for a right hip disability, to include arthritis and limitation of extension, is denied. Entitlement to an initial compensable rating for flexion of the left thigh is denied. Entitlement to an initial compensable rating for flexion of the right thigh is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. Entitlement to special monthly compensation (SMC) based on loss of use is denied. FINDINGS OF FACT 1. The Veteran's back disability was not incurred in or due to his time in service nor is it proximately due to any of his service-connected disabilities. 2. The Veteran's left knee disability is not manifested by severe recurrent subluxation or lateral instability and the Veteran's record does not indicate his knee disability is manifested by unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. 3. The Veteran's residuals of a gunshot wound to right muscle group XI is not manifested by a moderately severe muscle injury. 4. The Veteran's left hip, to include arthritis and limitation of extension is not manifested by occasional incapacitating exacerbations, affected by limitation of motion. The Veteran's left hip disability is rated at the maximum allowable under for impairment of extension. 5. The Veteran's right hip, to include arthritis and limitation of extension is not manifested by occasional incapacitating exacerbations, affected by limitation of motion. The Veteran's left hip disability is rated at the maximum allowable under for impairment of extension. 6. The Veteran's left hip flexion is not limited to 45 degrees or less. 7. The Veteran's right hip flexion is not limited to 45 degrees or less. 8. The Veteran does not meet the requirements for a schedular TDIU and referral to the Director of Compensation and Pension is not warranted. 9. As a result of service-connected disabilities, the Veteran did not have loss of use of one foot, both feet or both legs. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for an initial rating in excess of 20 percent for a left knee disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.385, 4.1, 4.3, 4.7, 4.85, 4.71a, Diagnostic Codes (DCs) 5010-5257. 3. The criteria for a rating in excess of 10 percent for residuals of a gunshot wound affecting the right muscle group XI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.130, DC 5311. 4. The criteria for an initial rating in excess of 10 percent for a left hip disability, to include arthritis and limitation of extension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.385, 4.1, 4.3, 4.7, 4.85, 4.71a, DCs 5003-5251. 5. The criteria for an initial rating in excess of 10 percent for a right hip disability, to include arthritis and limitation of extension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.385, 4.1, 4.3, 4.7, 4.85, 4.71a, DCs 5003-5251. 6. The criteria for an initial compensable rating for a left hip flexion disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.385, 4.1, 4.3, 4.7, 4.85, 4.71a, DCs 5003-5252. 7. The criteria for an initial compensable rating for a right hip flexion disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.385, 4.1, 4.3, 4.7, 4.85, 4.71a, DCs 5003-5252. 8. The criteria for TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 9. The criteria for entitlement to SMC pursuant to 38 U.S.C. § 1114 (k) have not been met. 38 U.S.C. § 1114 (k); 38 C.F.R. § 3.350(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1973 to December 1974. These matters are on appeal from October 2013 and June 2014 rating decisions by a Department of Veterans Affairs Regional Office. These matters were previously before the Board and were remanded for further development in December 2018. The development has been completed and the matters are again before the Board. Service Connection Claim Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Veteran contends that he has a back disability that was incurred in or due to his time in service or that is proximately due to his service-connected disabilities, in particular his knee disability. The Veteran has been diagnosed with a back disability, to include degenerative arthritis. The Veteran's service treatment records (STRs) are negative for mention of an ongoing back problem and his separation examination does not mention any back complaints or treatments. An October 2013 letter reported the Veteran had mild degenerative arthritis in his lower spine that "may or may not be responsible for [his] hip symptoms." The Veteran had an examination for his back in June 2016 in which the examiner saw the Veteran in person, reviewed his file, and noted the Veteran's contentions that the onset was 35 years ago when he hurt himself in the 1970s. The Veteran reported he started walking funny because of intermittent lower back pain. The examiner noted the Veteran's STRs were silent for an ongoing back problem. This examiner provided a clarification opinion from the October 2013 examiner who gave a positive opinion but a negative rationale. This examiner opined the Veteran's back disability was not proximately due to or the result of altered gait from his service-connected hip and knee disabilities. The examiner based this opinion on a review of the Veteran's record, medical literature, and clinical experience. The examiner reported the Veteran had severe obesity documented in 2005 and that there was no objective evidence of gait limping or instability and that the Veteran's weight continued to increase. Medical literature supports that degenerative changes in joints are usually age-related, accentuated by weight gain. Extra weight can put more pressure and wear on joints which leads to increased pain and accelerated disc deterioration. To insure the above finding was correct, the Veteran had an examination for his back in January 2020 in which the examiner saw the Veteran in person, reviewed his file, and noted his back diagnosis of degenerative arthritis. The examiner opined it was less likely than not the Veteran's back condition was secondary to, the result of, or aggravated by his left knee. The examiner noted that a review of the Veteran's record intermittently noted a limp, but also a smooth gait at other times. On this examination, the Veteran stated he started dragging his right leg following his stroke in 2004, but the examiner noted the medical treatment records noted it was his left foot. However, per medical literature, it was unlikely that injuries such as meniscal tear that caused a mild or moderate degree of limping would have a major detrimental effect on the back or opposite lower extremity. The examiner noted there was no evidence of limping prior to 2005. In August 2020, an addendum opinion was obtained. The August 2020 examiner reviewed the Veteran's file and took note of the conflicting evidence. The examiner opined it was less likely than not the Veteran's back condition was due to his time in service as the Veteran's STRs were silent for any back injury and his degenerative joint disease was not found via imaging until 40 years after service. The examiner also opined it was less likely than not that the Veteran's back disability was due to his service-connected knee or any other service-connected disabilities. The examiner noted the Veteran stated that he believed his back arthritis was due to his altered gait due to his knee but the Veteran's record didn't support that finding. In 2004 and 2005, treatment records show that the Veteran's stroke left hemiparesis with circumduction of the gait and the Veteran's record was negative for mention of limping prior to 2005. The examiner lastly opined that the Veteran's back was not aggravated by his service-connected conditions, saying that the actual cause couldn't be selected from potential causes without resort to mere speculation. The examiner noted that per medical literature, many factors can contribute to osteoarthritis, that it is one of the most common causes of chronic disability due to pain and altered joint function due to pathological changes of articular cartilage, bone, synovium, and soft tissues. Other factors that can play a role were age, injury, obesity, and genetics. An October 2013 note said that the pain in his hips (x-rays Sep 2013 showed mild degenerative changes) could actually be his back which radiates pain into hips. The Board notes that the Veteran's STRs are negative for mention of ongoing back problems in service and his currently diagnosed disability did not manifest itself until decades after his separation from service. Therefore, the claim will be denied on a direct basis. While in October 2013 objective evidence notes and examinations say that his service-connected disabilities "may" be responsible for his back disability, these notes and opinions do not rise to the level of certainty of at least as likely as not. Additionally, these speculative opinions do not appear to have considered the Veteran's entire record and are not accompanied by a supporting explanation. Therefore, the Board places little probative on these statements. The Board finds the August 2020 addendum to be of more probative value. This examiner considered the conflicting evidence of record and opined the Veteran's condition was not proximately due to or aggravated by his service-connected disabilities, relying on a review of the Veteran's record, medical literature, giving an explanation supporting the opinion. Based on this opinion and the other negative opinions of record, the Board will deny the claim. Increased Rating Claims Effective February 7, 2021, new musculoskeletal ratings went into effect. Thus, the Board will consider both the old regulations and the new regulations and apply whichever one grants the most benefit to the Veteran. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § § 4.27. In June 2013, the Veteran's spouse submitted a statement, saying that the Veteran did not drive much due to his knees, legs, and hips. The Veteran had to go down the stairs sideways, relies on others for directions, and has had to hire someone to help with work around the house, including lawn mowing, maintenance, painting, fixing computers, and vehicle maintenance. Left Knee Disability The Veteran's knee disability is rated under DC 5010. Under DC 5010, arthritis, due to trauma substantiated by x-ray findings warrants a 10 percent rating with evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent rating is warranted with x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The Veteran's left knee is also rated under DC 5257. Under 38 C.F.R. § 4.71a, DC 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling. And severe recurrent subluxation or lateral instability warrants a 30 percent rating. The terms "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under the new regulations that went into effect on February 7, 2021, DC 5010 applies to post-traumatic arthritis: Rate as arthritis, limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Under DC 5257, recurrent subluxation or lateral instability with sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation warrants a 10 percent evaluation. Recurrent subluxation or lateral instability with one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation warrants a 20 percent evaluation. Recurrent subluxation or lateral instability with unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation warrants a 30 percent rating. Patellar instability with a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. Patellar instability with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker warrants a 20 percent rating. Patellar instability with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent evaluation. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). The Veteran's left knee is currently rated as 20 percent disabling. In October 2012, the Veteran submitted a private left knee evaluation. The Veteran reported increased pain and decreased function with clicking and popping. The Veteran also reported his left knee gave out unpredictably and caused multiple near falls. The Veteran's left knee flexion was limited to 60 degrees with extension being sub-optimal with pain. The examiner stated that the Veteran's knee was beyond rehabilitation and a knee replacement surgery may be necessary. In October 2012, the Veteran's left knee extension was normal with flexion limited to 90 degrees. The Veteran had an examination for his left knee in October 2013 in which the examiner saw the Veteran in person and reviewed his file. The Veteran did not report flare ups and the examiner found the Veteran's left knee flexion was to 85 degrees with pain beginning at 45 degrees with extension ending at 10 degrees with painful motion beginning at 20 degrees. After repetitive use testing, there was no additional loss of range of motion. The Veteran had functional loss in the form of less movement than normal, pain, swelling, and disturbances of locomotion. But did not have any joint instability or history of patellar subluxation. The Veteran had an examination for his knees in January 2020 in which the examiner saw the Veteran in person, reviewed his file, and noted his left knee traumatic arthritis. The Veteran did not report flare ups of his knee disability but did report functional loss in that he had received injections for his knee and that it clicks. The Veteran also reported that after his stroke, he has trouble getting up on a curb and since he lost almost 60 pounds, he can almost go up onto a curb without turning sideways. The Veteran's extension was 100 to 0 degrees and his flexion was to 100 degrees with pain on examination that did not result in functional loss. The Veteran was able to perform repetitive use testing with no additional loss in range of motion. The Veteran's left knee strength was normal but the Veteran was found to have slight lateral instability with frequent episodes of pain due to his meniscus condition. The Veteran also had left knee surgery in 1973. The Veteran did not require the use of assistive devices, but did report using grab bars, a cane, and a walker at home but prefers to not use them outside the home. The Veteran's treatment records show he continued to seek treatment for his knee. In April 2009, his knee extension more than normal with his right knee flexion to 122 degrees and his left knee flexion to 105 degrees. For example, in October 2012, it was noted the Veteran's knee arthritis led to increasing interference with activities of daily life, a clicking sensation, trouble with prolonged activity, pain with walking, and discomfort at night. In October 2013, it was noted the Veteran had advanced arthritis and it was recommended to proceed with a total knee arthroplasty. The Board notes the Veteran is at the maximum allowable rating under DC 5010. Therefore, a higher rating is not available under this diagnostic code. The Veteran's record indicates that an examiner noted his recurrent subluxation or lateral instability was mild in nature, which would not result in a higher evaluation. The Board has also considered the Veteran's disability under the new criteria for DC 5257. However, in several examinations, the Veteran reported sometimes using assistive devices at home but not outside his home. Additionally, the Veteran's record does not indicate his knee disability is manifested by unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. It was noted that the Veteran's knee gave out, leading to near falls in an October 2012 private examination. However, there is not continued documentation of such and in subsequent examinations, the Veteran did not report such problems. Thus, even if the Veteran went through a period of his knee giving way, in light of the entire body of evidence in which these types of episodes were not reported, the Board does not find that this report in October 2012 rises to the level of severe subluxation or instability. The Board has also considered the Veteran's knee condition under diagnostic codes pertaining to knee flexion and extension. However, in order to qualify for a higher rating, the Veteran's flexion would have to be limited to 15 degrees or his extension would have had to be limited to 20 degrees. The objective evidence of record does not indicate the Veteran's left knee flexion or extension was so limited, even when considering when his pain on motion began. Therefore, the Board will deny the claims. Residuals of Gun Shot Wound, Muscle Group XI The Veteran's gunshot wound disability is rated as 10 percent disabling under DC 5311. Injuries to muscle group XI are rated under 38 C.F.R. § 4.73, DC 5311. These muscles include the posterior and lateral crural muscles and muscles of the calf, including the triceps surae (gastrocnemius and soleus), tibialis posterior, peroneus longus, peroneus brevis, flexor hallucis longus, flexor digitorum longus, popliteus, and plantaris. The functions of these muscles are propulsion, plantar flexion of the foot, stabilization of the arch, flexion of the toes, and flexion of the knee. 38 C.F.R. § 4.73, DC 5311. Under DC 5311, which outlines the rating criteria for impairments of the calf muscle, a slight muscle disability warrants a noncompensable rating, a moderate muscle disability warrants a 10 percent rating, a moderately severe muscle disability warrants a 20 percent rating, and a severe muscle disability warrants a 30 percent rating. As such, the Board will review the claims file for evidence of severe muscle disability. Under the new regulations that went into effect on February 7, 2021, there were no changes to DC 5311. In June 2016, the Veteran had an examination for his muscle injury. The examiner saw the Veteran in person and reviewed his file. The Veteran reported his injury was "good" until 15 to 20 years ago when he developed calf muscle pain and that he would still get some leg cramps. The examiner noted Group XI was affected on the right side and that the Veteran had a scar associated with the muscle injury but no other cardinal signs or symptoms due to his muscle injury. The Veteran had normal muscle strength and there was no functional impairment that would require amputation. X-ray evidence showed retained metallic fragments. The Veteran had an examination for his muscle injuries in January 2020 in which the examiner saw the Veteran in person, reviewed his file, and noted the residuals of the gunshot wound in his right leg. The Veteran did not have any cardinal signs or symptoms of muscle disability and had normal muscle strength with no muscle atrophy. The Veteran did not require the use of an assistive device. The Board notes the Veteran's treatment records do not contain multiple ongoing complaints of muscle pain or discomfort due to his residual gunshot wound. Additionally, multiple examinations haven't found any cardinal signs or symptoms due to this injury. While the Veteran has been noted to have a scar (for which he is service-connected), the Veteran's medical records and examinations do not indicate that he suffers from ongoing muscle discomfort, pain, the need for amputation, the use of continuous assistive devices to walk or stand. The Veteran has reported some leg cramping, but his records do not show this is severe enough that he seeks continuous treatment for such or needs any sort of assistive devices or has more serious symptoms. Therefore, the Board finds the Veteran is appropriately rated for his muscle disability. Bilateral Hip and Thigh Disabilities The Veteran's hip disability with arthritis and limitation of extension is rated as 10 percent disabling under DC 5003 and DC 5251. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent is assigned for each such major joint or group of minor joints, with occasional incapacitating exacerbations, affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Under DC 5251, a 10 percent rating is warranted for limitation of extension to 5 degrees. Under the new regulations that went into effect on February 7, 2021, the only change to DC 5003 is that it now only relates to degenerative arthritis, other than post-traumatic arthritis. There was no change to DC 5251 or DC 5252. The Veteran's thigh flexion disability is rated as noncompensable under DC 5003 and DC 5252. Under DC 5252, hip flexion limited to 45 degrees is rated as 10 percent disabling, flexion limited to 30 degrees is rated as 20 percent disabling, flexion limited to 20 degrees is rated as 30 percent disabling, flexion limited to 10 degrees is rated as 40 percent disabling. In October 2012, the Veteran reported pain in bilateral hip that intensified with walking. The Veteran had an examination for his hips in October 2013. The examiner saw the Veteran in person and reviewed his file. The examiner found flexion in both hips ended at 80 degrees with painful motion beginning at 40 degrees and extension in both hips was greater than 5 with painful motion beginning at zero degrees or greater than five. The Veteran's abduction was not lost beyond 10 degrees, was not limited such that the Veteran could not cross his legs, and rotation was not limited such that the Veteran couldn't toe-out more than 15 degrees. After repetitive use testing, there was no additional loss of range of motion. There was no ankylosis and normal muscle strength. The Veteran had an examination for his hips and thighs in January 2020 in which the examiner saw the Veteran in person, reviewed his file, and noted relevant medical history. The examiner noted the Veteran was diagnosed with arthritis in both hips which was diagnosed per imaging in 2013. The Veteran did not report flare ups but did have functional loss, noting that he can't put his leg over his knee to tie his shoe and had pain dancing. The examiner noted the Veteran's hip flexion on both sides was to 90 degrees and his extension was to 30 degrees and that the Veteran's adduction was not limited such that he could not cross his legs. The examiner reported the Veteran had pain on examination but that it did not result in functional loss. After repetitive use testing, there was no additional loss of range of motion. The Veteran had normal strength in both hips with no problems with malunion of his femur, flail hip joint, or leg length discrepancy. The Veteran also did not require the use of an assistive device, but that the Veteran did report using grab bars, cane, and a walker following his stroke in 2004 but prefers not to use them when walking. The Veteran's treatment records show he was seen for his hips, with a January 2005 examiner noting his normal gait with no joint misalignments. In April 2009, the Veteran's hip extension was both to 10 degrees with hip flexion both to 110 degrees. The Board notes that the Veteran's hip arthritis is not noted to include occasional incapacitating exacerbations, affected by limitation of motion. The Veteran has consistently denied flare ups of his hip condition and his medical treatment records do not show he suffered from incapacitating exacerbations of his hip arthritis. Therefore, a higher rating based on arthritis is not warranted. The Board notes the highest available evaluation for limitation of thigh extension under DC 5251 is 10 percent. The Board notes this is the highest available rating under this diagnostic code and therefore, a higher rating is unavailable. A higher rating is also not warranted under DC 5252 as it is not shown the Veteran's flexion is limited to 45 degrees. In January 2020, the Veteran's flexion was noted to be to 90 degrees. The examiner stated the Veteran had some pain on testing but that it did not lead to functional impairment. While the October 2013 examiner found the Veteran had pain beginning at 40 degrees, the examiner found the Veteran's overall range of motion was to 80 degrees. Additionally, the Veteran's treatment records also show the Veteran's hip flexion to be to 110 degrees (see e.g. April 2009 treatment record) and there are no other indications the Veteran's hip flexion was limited to less than 45 degrees. Therefore, the claim will be denied. Regarding all increased rating claims discussed above, neither the Veteran nor his representative has identified any other rating criteria that would provide a higher rating or an additional rating. However, the potential applications of various provisions of Title 38 of the Code of Federal Regulations (2016) have been considered as required by the holding of the Court in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). TDIU Claim The law provides that a total disability rating may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). 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). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran had a combined rating of 50 percent and does not currently meet the criteria for a schedular TDIU. Provided a veteran does not meet these minimum percentage rating requirements of § 4.16(a) for consideration of a TDIU, he may still be entitled to this benefit on an extra-schedular basis under § 4.16(b) if it is established he is indeed unemployable on account of his service-connected disabilities. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. If the record supports the claim, the Board must first forward the case to the Director of the Compensation Service for extraschedular consideration. The Board upon receipt of that determination is not bound to accept it, and may resolve the question of extraschedular entitlement of its own accord. See Wages v. McDonald, 27 Vet. App. 233, 236 (2015) (the findings of the Director of Compensation Service on extraschedular consideration are not evidence, but rather a decision of the AOJ reviewed de novo by the Board). Upon review of all the evidence of record, both lay and medical, the Board finds that referral for an extraschedular consideration of a TDIU is not warranted. The Board acknowledges and has considered the Veteran's statements addressing his employability. The Board notes the Veteran is competent and credible to report the subjective symptoms and functional limitations he experiences regarding his service connected disabilities. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board notes that, for a Veteran to prevail on a claim for TDIU on an extraschedular basis, it is necessary the record reflect some factor which places the case in a different category than other Veterans with an equal rating of disability. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The pertinent question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Id. This is so because a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Simply stated, a 50% disability rating will cause the Veteran problems. The Board notes that entitlement to a TDIU is a legal question, not a medical question. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA not a medical examiner."). After a review of the record, the Board does not find the record demonstrates the Veteran is precluded from securing or following substantially gainful employment solely by reason of his service-connected disability or that he is incapable of performing the mental and physical acts required by employment, even assessed in the context of subjective factors such as his occupational background and level of education. The Veteran had previous experience as a distribution specialist and an inventory specialist. An October 2012 evaluator stated the Veteran was unemployable due to his knee and bilateral hip disabilities. However, this examiner did not appear to have reviewed the Veteran's entire file or his complete medical treatment records and this opinion does not appear to be supported by the Veteran's record. Therefore, the Board places little probative weight on this opinion. Other evidence shows the Veteran does have trouble with his ability to work, but do not prevent him from working at all. His service connected disabilities lead to problems sitting, lifting, and standing for long periods of time. However, multiple records indicate the Veteran is unable to work due to other factors, such as his stroke in 2004 and non-service-connected disabilities. October 2013 examinations reported the Veteran retired after his stroke as it left him unable to work. Social Security Administration (SSA) benefits were granted but were based on non-service-connected disabilities such as vascular, hypertension, hyperlipidemia, psych. Such a report provides evidence against the claim as it clearly indicated nonservice-related problems cause the Veteran many issues. The January 2020 examinations showed that while the Veteran's hips and knee impacted his ability to work, his pain had not precluded activities such as walking and golfing and that while strenuous activities were not recommended, joint-friendly low-impact physical activity could be useful. The Board acknowledges that the Veteran's symptoms may impact his ability to work (and, in fact, he may not be able to work as the result of his service and nonservice connected problems), but finds that they are not prohibitive, and they do not preclude him from securing or following substantially gainful employment given his educational background, and his occupational background. There is no evidence in the Veteran's file that he is mentally or physically unable to perform a job when considering only his service-connected disabilities. Therefore, the Board finds referral to the Director for extraschedular consideration not to be warranted. SMC Claim Entitlement to an additional payment of compensation is established when service-connected impairment imposes a special level of disability. Entitlement to special monthly compensation is not warranted in this case because the criteria regarding loss of use have not been met. 38 C.F.R. § 3.350 Special monthly compensation under 38 U.S.C. § 1114(k) is payable for each anatomical loss or loss of use of one hand, one foot, both buttocks, one or more creative organs, blindness of one eye having only light perception, deafness of both ears, having absence of air and bone conduction, complete organic aphonia with constant inability to communicate by speech or, in the case of a woman veteran, the anatomical loss of 25 percent or more of tissue from a single breast or both breasts in combination (including loss by mastectomy or partial mastectomy) or has received radiation treatment of breast tissue. As discussed extensively above, it is clear that the Veteran's knee and hip problems lead to problems with pain, walking, standing, and sitting for long periods of time. The fact that these service-connected disabilities cause problems is not in dispute. As such, it was demonstrated that the Veteran had actual remaining function of the feet and legs, to include as to balance and propulsion. In sum, therefore, the Board finds that, as a result of service-connected disabilities, the Veteran did not have loss of use of one foot, both feet or both legs. As such, the Board concludes that the criteria for entitlement to SMC pursuant to 38 U.S.C. §§ 1114 (k), 1114(l) or 1114(m) have not been met and, to this extent, the Veteran's claims are therefore denied. 38 U.S.C. §§ 1114 (k), 1114(l), 1114(m); 38 C.F.R. §§ 3.350 (a), 3.350(b), 3.350(c). Regarding all the above, the Board acknowledges the Veteran's statements and his family's statements that he believes his back is due to his time in service or otherwise related to his service-connected disabilities and that he believes his knee, muscle disability, and hip problems are worse than indicated by his current ratings. However, while the Veteran and his family are competent to report symptoms of the Veteran's disabilities, they are not competent to opine on matters requiring medical knowledge, such as determining the nature, etiology, and severity of his medical conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board places more probative weight on the objective medical evidence of record and has weighed it as discussed above. The Board notes it finds the examinations of record to be adequate as the examiners saw the Veteran in person, reviewed his file, considered the Veteran's statements regarding his symptoms, and performed all necessary testing and the opinions as to etiology discussed offer opinions backed by explanations. While his multiple conditions clearly bother him a great deal, it is important for the Veteran to understand that this is the basis for the current findings. If his conditions did not bother him at all, there would be no basis for the compensable ratings. The fact that the Veteran has these disabilities is not in doubt; the only question is the degree. Regarding all the above, the Board has considered the applicability of the benefit of the doubt doctrine. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57(1990). John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Snoparsky 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.