Citation Nr: 22012229 Decision Date: 03/03/22 Archive Date: 03/02/22 DOCKET NO. 09-40 940 DATE: March 3, 2022 ORDER Entitlement to a rating in excess of 10 percent for left knee osteoarthritis for painful limitation of flexion is denied. Entitlement to a rating in excess of 10 percent for right knee osteoarthritis for painful limitation of flexion is denied. Entitlement to a separate 10 percent rating, but no higher, for left knee osteoarthritis for painful limitation of extension is granted from January 17, 2008. Entitlement to a separate 10 percent rating, but no higher, for right knee osteoarthritis for painful limitation of extension is granted from January 17, 2008. Entitlement to a 20 percent rating for left knee instability is granted is from January 17, 2008. Entitlement to a 20 percent rating percent for right knee instability is granted from January 17, 2008. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted from March 25, 2010. FINDINGS OF FACT 1. Since January 17, 2008, the left knee osteoarthritis has been manifested by painful limitation of flexion to no more than 110 degrees. 2. Since January 17, 2008, the right knee osteoarthritis has been manifested by painful limitation of flexion to no more than 110 degrees. 3. Since January 17, 2008, the Veteran's left knee osteoarthritis has been manifested by painful limitation of extension to 10 degrees. 4. Since January 17, 2008, the Veteran's right knee osteoarthritis has been manifested by painful limitation of extension to 10 degrees. 5. Since January 17, 2008, the Veteran's left knee disability has been manifested by no more than moderate instability. 6. Since January 17, 2008, the Veteran's right knee disability has been manifested by no more than moderate instability. 7. The Veteran's service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation since March 25, 2010. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for left knee osteoarthritis manifested by painful limitation of flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Codes (DCs) 5003, 5260. 2. The criteria for entitlement to a rating in excess of 10 percent for right knee osteoarthritis manifested by painful limitation of flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DCs 5003, 5260. 3. Since January 17, 2008, the criteria for a separate 10 percent rating, but no higher, for left knee osteoarthritis manifested by painful limitation of extension are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DCs 5003, 5261. 4. Since January 17, 2008, the criteria for a separate 10 percent rating, but no higher, for right knee osteoarthritis manifested by painful limitation of extension are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DCs 5003, 5261. 5. Since January 17, 2008, the criteria for entitlement to a 20 percent rating for moderate left knee instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DC 5257. 6. Since January 17, 2008, the criteria for entitlement to a 20 percent rating for moderate right knee instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DC 5257. 7. The criteria for a TDIU are met since March 25, 2010. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1972 to August 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which, in relevant part, continued 10 percent ratings for left and right knee osteoarthritis and granted separate 10 percent ratings for right and left knee subluxation, effective January 17, 2008. In January 2015, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. The appeal was remanded for further development in March 2015, June 2019, and March 2021. Increased Ratings 1. Entitlement to a rating in excess of 10 percent for left knee osteoarthritis for painful limitation of flexion is denied. 2. Entitlement to a rating in excess of 10 percent for right knee osteoarthritis for painful limitation of flexion is denied. 3. Entitlement to a separate 10 percent rating, but no higher, for left knee osteoarthritis for painful limitation of extension is granted from January 17, 2008. 4. Entitlement to a separate 10 percent rating, but no higher, for right knee osteoarthritis for painful limitation of extension is granted from January 17, 2008. 5. Entitlement to a 20 percent rating for left knee instability is granted is from January 17, 2008. 6. Entitlement to a 20 percent rating percent for right knee instability is granted from January 17, 2008. I. General Rating Principles Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation of parts of the system, to perform the normal working movements of the body with normal excursion, strength, coordination, and endurance. 38 C.F.R. § 4.40. The functional loss may be due to the loss of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervations, 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. Id. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. Other important factors include excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating. See DeLuca v. Brown, 8 Vet. App. 202(1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged ratings" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Additionally, the primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. 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 required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. II. Rating Criteria The Veteran is currently rated under DC 5014 for osteomalacia, which states that the disease will be rated on limitation of motion of affected parts, as degenerative arthritis. Under DC 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). 38 C.F.R. § 4.71a, DC 5003. Under DC 5260, a 10 percent disability rating is assigned for flexion limited to 45 degrees, a 20 percent disability rating is assigned for flexion limited to 30 degrees, and a 30 percent disability rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. A noncompensable rating is warranted for limitation of extension to 5 degrees, a 10 percent rating is warranted for limitation of extension to 10 degrees, a 20 percent rating is warranted for limitation of extension to 15 degrees, a 30 percent rating is warranted for limitation of extension to 20 degrees, a 40 percent rating is warranted for limitation of extension to 30 degrees, and a 50 percent rating is warranted for limitation of extension to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. Pettiti v. McDonald, 27 Vet. App. 415, 425 (2015) (holding that § 4.59 serves as a bridge linking painful motion and limitation of motion, such that a claimant with painful motion is deemed to have limited motion under DC 5003 even though actual motion is not limited). Moreover, the provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis, so must be considered when raised by the claimant or reasonably by the record, even in non-arthritis contexts. See Burton v. Shinseki, 25 Vet. App. 1 (2011). To this end, 38 C.F.R. § 4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. 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. VA thus must consider the claim for a higher 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). Thus, 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. Prior to the February 7, 2021 amendments, DC 5257 provided ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee that is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a. Effective February 7, 2021, DC 5257 provides separate criteria for ratings based on recurrent subluxation or lateral instability and patellar instability. For recurrent subluxation or lateral instability, a 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for either (a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribed either a brace and/or assistive device; 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. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. For patellar instability, a 10 percent rating is warranted for 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. A 20 percent rating is warranted for 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. A 30 percent rating is warranted for 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. The words "slight", "moderate", and "severe" used in DC 5257 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 Board does note, for reference and illustrative purposes only, that the definitions for "mild" includes not very severe. WEBSTER'S II NEW COLLEGE DICTIONARY at 694 (1995). A synonym for "mild" is "slight," which is defined as small in size, degree, or amount. Id. at 1038. The definitions for "moderate" include of average or medium quantity, quality, or extent. Id. at 704. Finally, definitions for "severe" include extremely intense. Id. at 1012. III. Analysis The Veteran is in receipt of a 10 percent rating from September 1, 1992, for his service-connected bilateral knee disability; beginning January 17, 2008, he is in receipt of separate 10 percent ratings for each knee. He is also in receipt of 10 percent ratings from January 17, 2008, for service-connected left knee and right knee subluxation. The appeal period is from January 17, 2008, the date of his increased rating claim, plus the one-year "look back" period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). As a preliminary matter, the Board notes that although the Veteran presented for VA examinations in February 2008, November 2010, April 2013, September 2015, August 2020, and July 2021, only the most recent July 2021 examination is compliant with the requirements set forth by Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). However, the September 2015 examination reveals results more favorable regarding painful limitation of extension. Accordingly, the September 2015 and the July 2021 VA examination reports will be utilized for evaluation of the Veteran's bilateral knee disability with regard to range of motion for reasons outlined above. In this regard, the Board emphasizes that the February 2008, November 2010, April 2013, and August 2020 non-compliant examination reports shows range of motion findings less favorable than the September 2015 (extension) and July 2021 (flexion) VA examination reports. Additionally, the Board will consider the Veteran's lay statements and other favorable medical findings other than range of motion testing contained in the non-compliant reports. Thus, there is no prejudice to the Veteran in not considering the non-compliant reports to rate his disability based on limitation of motion and DeLuca factors. Throughout the appeal period, the Veteran has complained of chronic pain, instability, limited range of motion, locking, stiffness, swelling, and radiating pain in his bilateral knees. He also reported occasional or constant use of a cane and regular use of a walker. See June 2008 through November 2021 VA treatment records; see also February 2008, November 2010, April 2013, September 2015, August 2020, and July 2021 VA examination reports and January 2015 Board Hearing Transcript at 6-8. During the September 2015 VA examination, the Veteran reported daily knee pain with occasional instability. He also reported using a walker or cane every day because of his knees. He denied flare-ups and functional loss. Examination revealed range of motion to 130 degrees of flexion and 10 degrees of extension in the right knee and 110 degrees of flexion and 10 degrees of extension in the left knee with no pain noted on the examination. No additional loss with repetitive use was and the examiner stated that Deluca factors did not significantly limit his functional ability with repetitive use over time. No additional contributing factors were indicated. Muscle strength testing was normal in flexion bilaterally and slightly reduced (4/5) in extension bilaterally. Joint instability testing was normal. No history of recurrent subluxation or recurrent effusion was endorsed. No muscle atrophy or ankylosis was indicated. No meniscal condition or scars were indicated. The examiner noted constant use of a cane and regular use of a walker and indicated the Veteran's ability to work was impacted due to his limited mobility. Most recently the Veteran was afforded a VA examination in July 2021. The Veteran reported constant pain and instability with walking down stairs, staggering a lot, swelling in both knees after prolonged weightbearing, and pain that is located over the anterior side of both knees that sometimes radiates up to the middle of his anterior thigh. He denied flare-ups but reported functional loss described as avoiding prolonged walking or standing and going up or down more than 12 stairs. The Veteran also reported a history of recurrent subluxation/instability, stating he staggers a lot, and his knees feel like they will give out and that he uses a cane occasionally for stability. He reported a history of recurrent effusion. Examination revealed range of motion of flexion to 120 degrees and extension to zero degrees in both knees with objective evidence of painful motion on flexion that causes functional loss. The examiner stated that Deluca factors would significantly limit his functional ability during with repeated use over time and an estimated 10 degrees of additional loss of flexion to 110 degrees, bilaterally. No additional contributing factors were noted. No muscle atrophy or ankylosis was indicated. The examiner endorsed recurrent subluxation or persistent instability but found no ligament tear (sprain), no prescription by a medical provider for ambulation, no recurrent patellar instability, no prescription by medical provider for ambulation for patellar instability, no meniscus conditions, no surgeries, and no scars. Occasional use of a cane was noted. The examiner noted the Veteran's ability to work was impacted due to avoiding prolonged walking or standing and going up or down more than about 12 stairs. In a contemporaneous July 2021 addendum opinion, the examiner noted the Veteran's report of intermittent pain that radiates from his knees to the middle of his anterior thighs is a symptom of osteoarthritis, not a separate diagnosis of a neurological condition that is supported my medical literature. He noted a study done with 109 patients that demonstrated that "some of the knee OA patients had a neuropathic pain component as the underlying cause of knee pain." To this end, the examiner stated that on physical examination, the Veteran did not display any neuropathic symptoms because symptoms are intermittent and were not elicited at that time. He noted the Veteran's physical limitations were described in the Disability Benefit Questionnaire (DBQ) and that he was limited in weight bearing abilities to include standing and walking; an inability to tolerate going up or down more than about 12 steps at a time; medial and lateral laxity; and that he experienced increased instability with walking, standing, and stairs. The examiner noted the Veteran has slightly reduced (4/5) muscle strength and both knees were tender to palpation. He noted the Veteran denied flare-ups but does say that he experiences increased swelling, pain, fatigue, and decreased range of motion with repetitive activities. Thus, the examiner stated that with minimal speculation, he could conclude that the Veteran experiences further decrease in range of motion of about 10 degrees after prolonged activity and that due to the support of medical evidence and the physical examination, it is as likely as not that the Veteran has bilateral neuropathic pain symptoms due to his bilateral knee osteoarthritis. As such, given the totality of the evidence, when considering the Veteran's lay statements and the medical evidence of record including DeLuca factors and functional loss with repeated use over time and during flare-ups, the Board finds that a rating in excess of 10 percent for limitation of flexion is not warranted at any time during the appeal period as limitation of flexion was to no less than 110 degrees for both knees, consistent with a 10 percent rating, or the minimum rating for painful motion under 38 C.F.R. § 4.59. However, separate 10 percent ratings are warranted from January 17, 2008, for limitation of bilateral knee extension to 10 degrees, warranting a 10 percent rating under DC 5261; in this regard, only the September 2015 VA examination conducted during the appeal period indicates findings of limitation of motion with extension to 10 degrees and the July 2021 VA examiner noted further decrease in range of motion by 10 degrees. Moreover, the Veteran has consistently reported painful limited range of motion in his bilateral knees and all other VA examination reports are not compliant with Sharp and Correia thus resolving all reasonable doubt in his favor, the Board finds he experienced painful limitation of extension throughout the appeal period, which regardless would warrant a minimum 10 percent rating under 39 C.F.R. § 4.59 or to 10 degrees of extension, which would warrant a 10 percent rating under DC 5261 as noted above. Moreover, when considering the Veteran's competent and credible statements and the other medical evidence of record, the Board finds that 20 percent ratings for recurrent subluxation/lateral instability under the old criteria for DC 5257 are warranted for the entire appeal period for both knees, as the evidence of record demonstrates moderate instability including the Veteran's complaints of instability, giving out, staggering, occasional or constant use of a cane and regular use of a walker, the February 2008 VA examiner's notation of bilateral knee instability with 0.5 cm medial and lateral laxity in the left knee, the August 2008 VA treatment record noting the same 0.5 cm medial and lateral laxity in the right knee, and the April 2015 and July 2021 VA examiner's findings of slightly reduced muscle strength (4/5) and the July 2021 examiner's endorsement of recurrent subluxation or persistent instability, corresponding with 20 percent ratings. Ratings in excess of 20 percent are not warranted, as severe (intense) instability is not shown at any time during the appeal period. Specifically, all joint stability testing was normal except the February 2008 and August 2008 VA examiners' report of 0.5 cm medial and lateral laxity and muscle strength testing was normal except slightly reduced with extension in the April 2015 VA examination and with flexion and extension in July 2021, which is contemplated in the 20 percent ratings and none of the above-cited evidence points towards symptomatology that is closer to intense (severe) instability, particularly given no objective findings of recurrent subluxation/dislocation/instability until the July 2021 VA examiner's endorsement. The Veteran's condition has been consistently manifested by moderate instability based on findings by the VA examiners and the objective evidence and lay statements of record support the examiners' findings in this regard. Additionally, the Board finds that although there is evidence dated after February 7, 2021, the July 2021 VA examination report, that requires the Board to review the evidence under both the old and new criteria, the old criteria allows for a higher rating under DC 5227. To this end, although the July 2021 VA examiner endorsed recurrent subluxation or persistent instability, the examiner did not endorse a ligament tear (sprain), prescription by a medical provider for ambulation, recurrent patellar instability, or prescription by a medical provider for ambulation for patellar instability such that a higher rating would be warranted under the new DC 5257 criteria. Thus, it is more favorable for the Veteran to rate under the old criteria for reasons discussed above. Additionally, the Veteran is not entitled to separate compensable rating under DCs 5256, 5258, 5259, 5262, or 5263. The record does not reflect the Veteran ever had ankylosis, removal of symptomatic cartilage, dislocation of semilunar cartilage, nonunion of the tibia and fibula or genu recurvatum during the appeal period. Moreover, the evidence of record does not demonstrate the presence of any right knee scars. Thus, a separate compensable rating for any related scar is not warranted. See 38 C.F.R. § 4.118, DCs 7801, 7802, 7804, 7805. Additionally, regarding any neurologic conditions secondary to the Veteran's bilateral knee condition, the July 2021 VA examiner noted no separate diagnosis of any neurologic condition. Specifically, as noted above, the examiner noted the Veterans long-standing complaints of radiating pain throughout his knees but found that this is a symptom of his bilateral knee osteoarthritis, neuropathic pain, and not a separate diagnosis for another disability. An August 2021 VA examiner also found no current diagnosis of any peripheral nerve condition related to a bilateral knee condition and that the Veteran's symptoms of diabetic peripheral neuropathy (with no current peripheral nerve diagnosis) are a separate entity entirely from the subluxation of the right/left knees and is unrelated to it. There is no indication of any other bilateral knee neurologic condition at any time during the appeal period. Thus, given the above-noted probative evidence, separate compensable ratings for any associated neurologic condition are not warranted at any time during the appeal period. Finally, to the extent that the Veteran's representative generally asserts that he preserves for appeal "all legal errors, errors in fact-finding, failure to follow Manual M21-1, failure to discharge the duty to assist, or any other due process errors," such vague assertions do not amount to a specific procedural argument in this case and thus need not be addressed. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (the Board's obligation to read filings in a liberal manner does not require the Board or the Veterans Court to search the record and address procedural arguments when the claimant fails to raise them before the Board). TDIU 7. Entitlement to a TDIU due to service-connected disabilities is granted from March 25, 2010. Total disability ratings for compensation 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, and that, if there are two or more such 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. 38 C.F.R. § 4.16(a). The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran's ability to secure or follow substantially gainful employment, including factors such as the veteran's history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See id. Here, the Veteran submitted a formal claim for a TDIU on February 15, 2019. However, as the Veteran has asserted IU in relation to his knee disabilities, the period for consideration is from January 17, 2008, the dating of his increased rating claims for his knees. See Harper v. Wilkie, 30 Vet. App. 356 (2018). The Veteran is service-connected for posttraumatic stress disorder (PTSD) rated as 30 percent disabling from September 20, 2013, and a 100 percent disabling from November 2, 2018; sleep apnea rated as 50 percent disabling from February 12, 2008; bilateral retropatellar pain syndrome rated as 10 percent disabling from September 1, 1992 to January 17, 2008; right knee retropatellar pain syndrome with osteoarthritis rated as 10 percent disabling from January 17, 2008; left knee retropatellar pain syndrome with osteoarthritis rated as 10 percent disabling from January 17, 2008; left knee osteoarthritis manifested by painful limitation of extension now rated as 10 percent disabling from January 17, 2008; right knee osteoarthritis manifested by painful limitation of extension now rated as 10 percent disabling from January 17, 2008; left knee subluxation associated with retropatellar pain syndrome now rated as 20 percent disabling from January 17, 2008; right knee subluxation associated with retropatellar pain syndrome now rated as 20 percent disabling from January 17, 2008; bilateral tinnitus rated as 10 percent disabling from January 17, 2008; perennial rhinitis rated as noncompensable disabling from September 1, 1992 and 10 percent disabling from July 5, 2012; residuals of left middle finger chip fracture rated as noncompensable from September 1, 1992; right hand foreign body excision rated as noncompensable from September 1, 1992; miliaria rubra rated as noncompensable from September 1, 1992; left foot degenerative joint disease rated as noncompensable from July 5, 2012; right foot degenerate joint disease rated as noncompensable from July 5, 2012; status post septoplasty and turbinectomies rated as 10 percent from May 13, 2008 and noncompensable from May 1, 2013; and right hand foreign body incision removal scar rated as noncompensable from November 2, 2018. Thus, he meets the schedular criteria for a TDIU from January 17, 2008, when he combined rating is 70 percent. See 38 C.F.R. § 4.16(a). The Veteran has a high school diploma with two years of completed college courses. His last known employment was on March 24, 2010 as a security guard. See April 2019 VA Form 21-8940. Thus, the Veteran meets the economic component for a TDIU from March 25, 2010, or the day following his last day of full time employment. The evidence of record indicates that the Veteran is unemployable due his service-connected disabilities. Specifically, in an April 2019 letter, Dr. H. S. outlined a complete history of the Veteran's service-connected disabilities and resulting complaints and restrictions due to said disabilities and recalled the Veteran's statement that in his previous work as a security guard he worked day and nights and had to walk every hour on the property to check on things and that his increased foot pain made it difficult for him to complete his job. To this end, Dr. H. S. that based on his review of the records and in-person interview with the Veteran he would be required to have at least one more break other than the standard 30-minute lunch and two 15-minutes morning and afternoon breaks provided by most employers three or more days per month. Additionally, he stated that the Veteran would need to miss three or more days of work or leave early three or more days per month due to his service-connected PTSD, bilateral knee retropatellar pain syndrome with osteoarthritis, subluxation of the bilateral knees, tinnitus, perennial rhinitis, status post septoplasty and turbinectomies, residuals of chip fracture left middle finger, miliaria rubra, foreign body incision right hand, and bilateral degenerative joint disease of the feet, and side effects caused by the medications used to treat his service-connected disabilities impact his ability to stay focused at work and that three or more days he would not be able to stay focused for a normal seven to eight hour workday as the Veteran has stated his medications make him tired and drowsy, specifically he cannot concentrate after taking his hydrocodone that treats his pain. Thus, he opined that it is more likely than not the Veteran would not be able to maintain substantially gainful employment due to the combined effects of his service-connected disabilities and side effects caused by medications to treat his service-connected disabilities. The Board acknowledges that the Dr. H.S. considered the Veteran's PTSD in his April 2019 opinion, which at the time was 100 percent disabling. However, the opinion notes significant impairment from his disabilities other than PTSD, and other evidence as detailed below shows that these other disabilities warrant a TDIU after November 2018, when the 100 percent rating for his PTSD is in effect. Thus, for TDIU purposes, the Board will only consider the effects of his PTSD on his employability until November 2, 2018, the date of his receipt of a 100 percent rating. The August 2014 VA examiner noted symptomatology of his psychiatric condition that would interfere with his ability to work including, anxiety, suspiciousness, irritable behavior and angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, and difficulty in establishing and maintaining effective work and social relationships. The September 2015 VA examiner indicated the Veteran's ability to work was impacted by his bilateral knee disability due to his limited mobility. In a November 2018 opinion, a VA examiner stated that the Veteran's bilateral knee condition would allow him to perform any light duty or sedentary tasks, but he would need to avoid standing for long periods or walking great distances, which is inconsistent with his job history as a security guard. The January 2019 VA examiner indicated his ability to work was impacted by his bilateral foot condition due to his limited ability to walk two hours out of an eight-hour day. The April 2019 private examiner indicated his sleep apnea impacts his ability to work due to his sleep disturbances at night, which leads him to be groggy during the day. The August 2020 VA examiner indicated the Veteran's ability to work was impacted by his bilateral knee disability due to him having to avoid repetitive squatting, kneeling, crawling and he can walk a maximum distance of 1/4 mile then requires rest/break. The July 2021 VA examiner indicated the Veteran's ability to work was impacted by his bilateral knee disability due to him having to avoid prolonged walking or standing and going up or down more than about 12 stairs. In an August 2021 VA unemployability opinion, the examiner indicated the Veteran could perform sedentary work (which the Board interprets to mean white collar office-type work), exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull. She further explained that sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time and that jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met. Additionally, Social Security Administration records received in July 2015 reveal the Veteran is in receipt of disability benefits, in part, due to his bilateral knee disabilities and sleep apnea since March 2010. Moreover, the Veteran has competently and credibly reported that he was no longer able to work due to his bilateral knee and feet conditions and that during his previous employment as a security guard it became increasingly more difficult to fulfill the duties of his job, mainly walking every hour around the property due to his orthopedic disabilities. See January 2015 Board Hearing Transcript at 8 and April 2019 private letter at 5. Moreover, VA treatment records throughout the appeal period note continuing issues with his bilateral knees including instability, use of assistive devices for ambulation, pain, staggering, giving out, swelling, and radiating pain that would affect his mobility in an employment environment. The Board notes some VA examiners stated the Veteran's ability to work was not impacted by his various service-connected disabilities, and others indicate that he could perform sedentary work. However, given (1) the Veteran's receipt of SSA disability benefits due, in part, to service-connected disabilities since March 2010; (2) his credible and competent reports of consistent severe symptomatology affecting his ability to ambulate or prolonged walking due to his knees and feet; (3) his work history as security guard, which involves prolonged standing and walking, and does not meet the criteria for sedentary work; (4) the medical opinion of Dr. H. S. noting his ongoing symptoms of his service-connected disabilities and the side effects from medications to treat said disabilities and stating he is unable to maintain gainful employment as a result and VA examination reports and VA treatment records noting continuing symptomatology in his bilateral knees and feet, including limited mobility and an inability to engage in prolonged standing or walking, all of which are inconsistent with his work as a security guard; and (5) affording the Veteran the benefit of the doubt, the Board finds he is precluded from a substantial gainful occupation due to his service-connected disabilities. Accordingly, a TDIU is granted from March 25, 2010, the day following his last day of full-time employment. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Asante, Ruby 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.