Citation Nr: 22010366 Decision Date: 02/23/22 Archive Date: 02/23/22 DOCKET NO. 17-16 971A DATE: February 23, 2022 ORDER Entitlement to a rating of 30 percent, but not higher, for a service-connected right knee disability manifested by instability is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a separate compensable rating of 10 percent for a right knee disability manifested by a limitation of flexion from December 1, 2014, until May 1, 2015, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating of 60 percent but not higher for a right total knee replacement from July 1, 2016, to January 31, 2017, is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 60 percent for a right total knee replacement effective from February 1, 2017, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) effective from July 1, 2016, but not earlier, is granted. FINDINGS OF FACT 1. The Veteran's right knee exhibited a severe level of instability. 2. The Veteran's knee exhibited pain and lost range of motion prior to his total knee replacement surgery. 3. The Veteran had a total knee replacement on May 1, 2015 4. Following the Veteran's total knee replacement, the Veteran exhibits severe painful motion or weakness. 5. The Veteran's knee prevented him from maintaining gainful employment CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating of 30 percent, but not higher, for a right knee disability manifested by instability have been met. 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263. 2. The criteria for entitlement to a separate compensable rating of 10 percent for a right knee disability manifested by a limitation of flexion from December 1, 2014 until May 1, 2015 have been met. 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263. 3. The criteria for entitlement to a rating of 60 percent, but not higher, for a right total knee replacement from July 1, 2016, to January 31, 2017 have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.45, 4.71a, Diagnostic Code 5055. 4. The criteria for entitlement to a rating in excess of 60 percent for a right total knee replacement effective from February 1, 2017 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.45, 4.71a, Diagnostic Code 5055. 5. The criteria for entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) effective from July 1, 2016 have been met. 38U.S.C. §§1155, 5110(a), (b)(2);38C.F.R. §§3.102, 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1997 to June 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision by the Department of Veterans Affairs (VA). In March 2017, the RO issued a rating decision that increased the Veteran's right knee replacement disability to 60 percent disabling effective from February 1, 2017. The RO also granted TDIU effective from February 1, 2017. In March 2021, the Veteran testified at a Board hearing. The transcript of that hearing has been associated with the Veteran's claims file. In May 2021, the case came before the Board. The Board remanded the Veteran's claims for entitlement to increased ratings for a right knee disability. The Board also remanded the Veteran's claim for entitlement to PTSD for an additional VA examination. Lastly, the Board remanded the Veteran's claim for TDIU because it was inextricably intertwined with the claims on appeal. In November 2021, the RO issued a rating decision that awarded entitlement to service connection for PTSD. Thus, this issue is no longer before the Board. The Board acknowledges that the RO mistakenly included entitlement to an earlier effective date for the award of service connection on the latest Supplemental Statement of the Case even though the Veteran has not challenged the effective date for the award of service connection for PTSD. Thus, the Board finds that the issue is not properly before the Board. The periods of the appeal in which the Veteran received the maximum schedular rating of 100 percent for post-surgical convalescence is also not before the Board. Increased Rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in such cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, in Mitchell, the Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, and less or more movement than is considered normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board observes that the words "slight," "moderate," 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. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in the process of arriving at a decision regarding an increased rating. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. In considering the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a rating in excess of 10 percent for a right knee disability prior to May 1, 2015 2. Entitlement to a separate compensable rating of 10 percent for a right knee disability manifested by a limitation of flexion from December 1, 2014, until May 1, 2015. VA received the Veteran's claim for an increased rating on October 30, 2014. The Veteran's disability was rated as 10 percent disabling according to Diagnostic Code 5257. The Veteran's right knee was awarded a temporary 100 percent rating for surgery necessitating convalescence, from October 30, 2014, until December 31, 2014. For purposes of this decision, the Board notes that the average normal range of motion of the knee is flexion from 0 to 140 degrees and extension from 140 to 0 degrees. 38 C.F.R. § 4.71. Disabilities of the knee are rated under Diagnostic Code 5256 through Diagnostic Code 5263 of 38 C.F.R. § 4.71a. A knee disorder can receive separate ratings, based on symptoms related to arthritis, stability, flexion, and extension. Where a Veteran has degenerative joint disease, which is evaluated under Diagnostic Code 5003, a separate, compensable evaluation may be assigned under Diagnostic Code 5257 or 5258 if there are concomitant symptoms, such as knee instability or subluxation. See VAOPGCPREC 23-97. When a Veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. See VAOPGCPREC 9-98. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees is rated 30 percent disabling; in flexion between 10 degrees and 20 degrees is rated 40 percent disabling; in flexion between 20 degrees and 45 degrees is rated 50 percent disabling; and extremely unfavorable, in flexion at an angle of 45 degrees or more is rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent disability rating for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for symptomatic residuals of removal of a semilunar cartilage. Ratings under DC 5259 require consideration of 38 C.F.R. §§ 4.40 and 4.45 because removal of a semilunar cartilage may result in complications producing loss of motion. VAOGCPREC 9-98. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated at 0 percent disabling, flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated 0 percent disabling, extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5262 provides ratings for impairment of the tibia and fibula. A 10 percent rating is warranted for malunion with slight knee or ankle disability. A 20 percent rating is warranted for malunion with moderate knee or ankle disability. A 30 percent rating is warranted for malunion with marked knee or ankle disability. A 40 percent rating is warranted for nonunion with loose motion and requiring a brace. 38 C.F.R. § 4.71a. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. Diagnostic Code 5257 is one of the diagnostic codes that was amended. VA thus must consider the claim for a higher disability rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. As of February 7, 2021, under the amended version of Diagnostic Code 5257, criteria for recurrent subluxation or lateral instability has been changed as the following: 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 is rated as 30 percent. If one of the following is met, 20 percent is assigned: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or (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. 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 is rated as 10 percent. In addition, the amended version of Diagnostic Code 5257 now includes new criteria for "patellar instability." 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 is rated as 30 percent disabling. 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 is rated as 20 percent. 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 is rated as 10 percent. Note (1) of this newly added "patellar instability" section provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) provides that 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). As to a current diagnosis, the Board notes that the Veteran's right knee disability was diagnosed as right anterior cruciate ligament and meniscus tears with degenerative joint disease. As to the Veteran's lay statements, the Board notes that the Veteran testified that prior to the knee replacement, he was having issues with the ligaments and arthritis. The Veteran stated that his knee would be swollen and painful. The Veteran stated that he couldn't walk very far. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination in February 2017. The February 2017 VA examination report indicated that the examiner was unable to perform any joint stability testing. In September 2021, the Veteran attended a VA examination. The Veteran stated that he is in constant pain. The Veteran stated that his pain is an 8 on a scale of 10. The Veteran stated that his pain with flares is 10 on a scale of 10. The Veteran stated that his knee is constantly swollen, and he uses a cane. The Veteran stated that he is prone to falling because his knee locks. The examiner indicated that the Veteran has persistent instability. The examiner indicated that the Veteran was prescribed a cane. Lastly, the examiner opined that the Veteran has a history of severe recurrent subluxation of the right knee. The Board has also reviewed the Veteran's private treatment records and VA treatment records. The Board notes that the Veteran's records show that the Veteran exhibits chronic pain and lost range of motion in his knee. In sum, the Board finds that the Veteran's right knee disability manifested by instability has remained consistent and an increased rating is warranted. After a review of the record, the Board finds that the Veteran's disability is best represented by a 30 percent rating. The Board has reached this conclusion based on the Veteran's reports regarding instability and the findings of the September 2021 VA examiner. Thus, for the above stated reasons, the Board finds that a 30 percent rating, but not higher, for the Veteran's right knee instability is warranted. The Board acknowledges that the Secretary has repeatedly conceded before the Court of Appeals for Veterans Claims that the law provides for separate ratings under Diagnostic Codes 5055 and 5257. Since the assigned 60 percent rating under Diagnostic Code 5055 does not contemplate instability, the Board finds a separate 30 percent rating is warranted for the severe instability of the right knee under Diagnostic Code 5257. The Board also finds that a separate compensable rating of 10 percent, but not higher, is warranted for the Veteran's lost range of motion prior to his total knee replacement. The Board has reached this conclusion because the evidence of record established that the Veteran's knee exhibited pain that resulted in a loss of range of motion that is separate from the Veteran's service-connected instability. The Board has considered a rating in excess of 10 percent; however, the evidence of record does not establish that the Veteran exhibited lost range of motion that met the criteria for a rating in excess of 10 percent. Thus, after weighing all of the evidence, both positive and negative, the Board concludes that entitlement to a separate compensable rating is at least in equipoise. Under such circumstances and granting the Veteran the benefit of any doubt in this matter, the Board finds that the criteria for 10 percent rating, but not higher, for limitation of flexion, effective from December 1, 2014 until May 1, 2015. 3. Entitlement to a rating in excess of 30 percent for a right total knee replacement from July 1,2016, to January 31, 2017 4. Entitlement to a rating in excess of 60 percent for a right total knee replacement effective from February 1, 2017. On May 1, 2015 the Veteran underwent a total right knee replacement. During this stage of the appeal, the Veteran's disability was rated according to Diagnostic Code 5055. The Veteran's disability was awarded a 30 percent rating from July 1, 2016 until January 31, 2017. Subsequently, the Veteran's disability was increased to 60 percent disabling effective from February 1, 2017. Under Diagnostic Code 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. (The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30). Thereafter, the minimum rating of 30 percent is warranted for a knee replacement with intermittent degrees of residual weakness, pain, or limitation of motion, to be rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The next and highest rating of 60 percent is assignable for a knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. As to the Veteran's lay statements, the Board notes that the Veteran testified that following his knee replacement he still experiences pain, pressure, and swelling. The Veteran also testified that he has difficulty walking correctly. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination in February 1, 2017. The Veteran stated that he was unable to walk greater than 150 yards. The Veteran stated that he cannot kneel, and he has to sit with his right knee extended. The Veteran stated that he cannot run or jump. The Veteran stated that he has increased pain with climbing stairs. The Veteran reported flare-ups that occur twice per week, lasting for 1 to 2 days. The Veteran stated that pain is worse than usual, has increased swelling with flare-ups and he has to elevate his knee. Upon examination, the examiner indicated that the Veteran exhibited flexion 10 to 115 degrees and extension 115 to 10 degrees. The examiner also indicated that the Veteran was able to perform repetitive testing with no additional lost range of motion. Lastly, the examiner opined that the Veteran exhibited chronic residuals consisting of severe painful motion or weakness. In September 2021, the Veteran attended an additional VA examination. The Veteran stated that he has chronic constant pain that is an 8 on a scale of 10, and with flares the pain is a 10 on a scale to 10. The Veteran stated that during a flareup he cannot walk less than 50 feet without a flareup and that he can't stand for form than 2 minutes. The Veteran stated that he has difficulty sitting for more than 10 minutes. Upon examination, the examiner indicated that the Veteran exhibited flexion to 115 degrees and extension to 20 degrees. The examiner also indicated that the Veteran was able to perform repetitive testing with no additional range of motion loss. Furthermore, the examiner indicated that the Veteran's disability would not be equally well-served by an amputation with prosthesis. Lastly, the examiner opined that the Veteran exhibited chronic residuals consisting of severe painful motion or weakness. The Board has also reviewed the Veteran's private treatment records and VA treatment records. The Board notes that the Veteran's records show that the Veteran exhibits chronic pain in his knee. In sum, the Board finds that the Veteran's right knee disability has remained consistent and an increased rating is warranted. After a review of the record, the evidence indicates that the Veteran experiences frequent pain that limits his range of motion. The Board also notes that the Veteran experiences frequent flareups that result in increased levels of pain and further levels of lost range of motion. Based on the foregoing and resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's left knee disability is best represented by a rating of 60 percent effective from July 1, 2016, which is the maximum schedular rating available according to this diagnostic code. In sum, the Board finds that the Veteran's right knee disability has remained consistent since July 1, 2016 and that an increased rating under Diagnostic Code 5055 is not warranted. Moreover, Diagnostic Code 5055 does not provide for a schedular rating in excess of 60 percent, other than a 100 percent rating for the one-year period following implantation of a prosthesis. Therefore, there is no basis in the law for awarding a schedular rating in excess of 60 percent for the disability. Furthermore, a disability rating greater than 60 percent is arguably not available for the Veteran's right knee, because such a rating would exceed the maximum 60 percent allowable under the "amputation rule." 38 C.F.R. § 4.25, 4.68, 4.71a, Diagnostic Codes 5162 to 5164. Under the "amputation rule" the combined rating for disabilities of an extremity may not exceed the rating for the amputation at the elective level, were the amputation to be performed. 38 C.F.R. § 4.68. Under Diagnostic Code 5161, an 80 percent rating is assigned for an amputation extending one-third of the distance from the perineum to the knee joint; however, the medical evidence of record does not show that the Veteran would be a candidate for an amputation. 5. TDIU prior to February 2017 The Veteran contends that his disabilities prevent him from being able to maintain gainful employment. 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. 38 C.F.R. § 4.16. A finding of total disability is considered to be appropriate, "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. §§ 3.340 (a)(1), 4.15. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet those percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is nonetheless unable to obtain or retain substantially gainful employment due to service-connected disability. 38 C.F.R. § 4.16(b). The phrase "substantially gainful employment" is defined as that type of 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 v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). In the process of determining whether unemployability exists, consideration may be given to a Veteran's level of education, any special training, and any previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The term substantially gainful occupation is not defined in the rating schedule. Rather, the Court in Ray v. Wilkie, found the phrase has two components: an economic one and a noneconomic one. 31 Vet. App. 58 (2019). In assessing the veteran's ability to secure and follow a substantially gainful occupation, the Board is to consider the veteran's history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Id. Such specific physical ability factors include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. Id. Specific mental ability factors include memory, concentration, ability to adapt to change, handle workplace stress, getting along with coworkers, and demonstrating reliability and productivity. Id. In March 2015, VA received a VA Form 21-8940 which details the Veteran's work experiences, education, and training. The Veteran reported that he was unable to work due to his PTSD and his right knee disability. The Veteran reported that had a high school education and he attended one year of college. The Veteran also reported that he had experience working as in manual labor and as an equipment operator. Initially, the Board notes that the Veteran has met the schedular criteria for a TDIU from July 1, 2016. The Veteran's service connected disabilities are as follows: 60 percent for right total knee replacement, 30 percent for right knee instability, 10 percent for tinnitus, a noncompensable rating for status post rupture of the tendon of the 5th finger, and a noncompensable rating for tuberculosis. As to the Veteran's lay statements, the Board notes that the Veteran testified that he was unable to work because of his PTSD and right knee disability. Turning to the medical evidence at hand, the Board notes that the February 2017 and September 2021 VA examiner's opined that the Veteran's right knee disability impacted his ability to work. After a thorough review of the record and resolving all doubt in favor of the Veteran, the Board finds that the evidence of record supports the assignment of TDIU from July 1, 2016. The record shows that the Veteran's right knee symptoms impaired his ability to function in an occupational setting. Specifically, the Board notes that the Veteran's condition impairs his ability to walk. Upon consideration of the record in its entirety, the Board finds that the Veteran's service-connected right knee disability rendered him unable to secure and follow a substantially gainful occupation in accordance with his occupational background. Based on the foregoing, the Board finds that entitlement to a TDIU is warranted effective from July 1, 2016. The Board has considered referring this claim prior to July 1, 2016, to the Director of the Compensation Service or Under Secretary for Benefits for extra-schedular consideration. However, the evidence of record prior to this date does not show that the Veteran's disabilities exhibited an exceptional disability picture that warranted extra schedular consideration. The record also does not show frequent hospitalizations or excessive absences from work. Most notably, the Board acknowledges that the Veteran's right knee did show an impairment with walking long distances, sitting for long periods of time, running, and jumping; however, the evidence of record did not demonstrate that the Veteran was unable to obtain gainful employment because of his right knee. The Board notes that the Veteran's March 2015 VA-Form 21-8940 indicated that he was seeking employment as a heavy equipment operator in October 2014. The Veteran's application for unemployability indicated that he had seven years of experience in this career field. The medical evidence of record did not demonstrate that the Veteran was unable to perform duties associated with heavy equipment operation. Moreover, despite some pain and mobility issues, the record shows that the Veteran was subsequently seeking employment as an equipment operator and a floor hand. This is evidence against a finding that the Veteran is precluded from all forms of substantially gainful employment due to his service-connected disabilities during the relevant period. While the Veteran's service-connected disabilities cause some occupational impairment, the record does not show that they, singularly or in combination, prevented him from obtaining and maintaining employment in the career fields in which he had experience in. Accordingly, the record does not show that the Veteran's service-connected disabilities rendered him unemployable prior to July 1, 2016 and as such, referral for TDIU consideration on an extraschedular basis is not warranted. The most persuasive evidence weighs against the claim in this regard; thus, the benefit of the doubt doctrine is not applicable. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Rescan, 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.