Citation Nr: 22018648 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 16-47 300 DATE: March 30, 2022 ORDER Entitlement to an evaluation in excess of 20 percent for right knee ligament laxity from June 28, 2016, is denied. Entitlement to an evaluation in excess of 20 percent for left knee ligament laxity from June 28, 2016, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. FINDINGS OF FACT 1. On and after June 28, 2016, the Veteran had a moderate left knee ligament laxity condition and the evidence does not show he had an unrepaired or failed repair of complete ligament tear, nor patellar instability. 2. On and after June 28, 2016, the Veteran had a moderate right knee ligament laxity condition and the evidence does not show he had an unrepaired or failed repair of complete ligament tear, nor patellar instability. 3. The Veteran's service-connected disabilities do not preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 20 percent for left knee ligament laxity from 28, 2016 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257. 2. The criteria for entitlement to a rating in excess of 20 percent for right knee ligament laxity from June 28, 2016 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257. 3. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the U.S. Army from June 2004 to January 2009. This matter comes to the Board of Veterans' Appeals (Board) on appeal from January 2016 and August 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019 and July 2021, the Board remanded the Veteran's claim for further development. The Board finds the required development has been completed and the matter is properly before the Board at this time. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). It is also valuable to note that the Veteran has already been found to be 100 percent disabled by VA, effective July 23, 2020. In this case, the Board is only dealing with the limited outstanding issues that it must address under the law. Post-Remand and Correia and Sharp Concerns Initially, in adjudicating below whether the Veteran meets the criteria for a higher evaluation for his bilateral knee disorder the Board has not overlooked the Court's holdings in Sharp v. Shulkin, 29 Vet. App. 26 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016). Tellingly, the Board finds that the record is adequate to address the concerns raised by the Court in both these cases as well as the Board Remands, in January 2019 and July 2021. Specifically, the Board finds that the December 2015, June 2016, July 2020, an addendum medical opinion in December 2020 to specifically address estimated lost ranges of motion, and January 2022 VA examinations provide VA with medical opinion evidence adequate to rate the Veteran's disabilities when considering his complaints of pain with and without weight bearing and resistance in passive and active range of motion (see Correia, supra) as well as during flare-ups (see Sharp, supra) because, when taken together, the examiners specifically addressed each of these concerns. Therefore, the Board finds that further delay by remanding these issues to provide the Veteran with a new VA examination is not required. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided); see also Correia v. McDonald, 28 Vet. App. 158 (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). Increased Rating The Veteran contends that his bilateral knee disorder is more severely disabling than represented by the rating assigned at all times during the appeal. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. An increase in the evaluation assigned for a disability is warranted when the average impairment in earning capacity resulting from such diseases and injuries in civil occupations has increased and the disability picture meets the criteria required for a higher rating. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. 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). Separate higher or lower compensable 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 Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. The Board further notes, in Esteban v. Brown, 6 Vet. App. 259, 261 (1994), the United States Court of Appeals for Veterans Claims (Court) held that in cases where the record reflects that the Veteran has multiple problems due to service-connected disability, it is possible for a Veteran to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. Importantly, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. Id. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in 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 38 C.F.R. §§ 4.40, 4.45, 4.59 (2016); DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (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); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell 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, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. 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. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Moreover, in Jones v. Shinseki, 26 Vet. App. 56, 61-63 (2012) the Court held that the Board may not deny entitlement to an increased rating on the basis of relief provided by medication when those effects are specifically contemplated by the rating criteria. The Court in Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016) held that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. Lastly, in Chavis v. McDonough, 34 Vet. App. 1 (2021), the Court held that ankylosis of the spine may be shown based on symptoms of fixation of the joint equivalent to ankylosis. The Board notes that except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). In evaluating the evidence, 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). 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). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). 1. Entitlement to an evaluation in excess of 20 percent for right knee ligament laxity from June 28, 2016 2. Entitlement to an evaluation in excess of 20 percent for left knee ligament laxity from June 28, 2016 The Veteran's service-connected knee disorder is rated as 10 percent disabling, bilaterally, from May 4, 2015, and 20 percent disabling, bilaterally, from June 28, 2016, under Diagnostic Code 5020-5257 for medial collateral ligament laxity. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. Additionally, the Veteran's service-connected knee disorder is separately rated as 10 percent disabling, bilaterally, from January 13, 2009, under Diagnostic Code 5024-5261 for limitation of extension. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board notes that during the course of this appeal, the schedular rating for evaluating other impairments of the knee has been amended. Specifically, the criteria pertaining to recurrent subluxation or instability of the knee and impairment of the tibia and fibula under 38 C.F.R. § 4.71a were amended, effective February 7, 2021, as discussed below. See 85 Fed. Reg. 76, 453 (November 30, 2020). The Board finds that the Veteran will not be prejudiced by adjudicating his claim without first providing notice of the amendment because the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied at all times after February 7, 2021. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Under 38 C.F.R. § 4.71a, Diagnostic Code 5256, ankylosis at a favorable angle in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent rating; ankylosis with flexion between 10 degrees and 20 degrees warrants a 40 rating; ankylosis with flexion between 20 degrees and 45 degrees warrants a 50 rating; and extremely unfavorable ankylosis (flexion at an angle of 45 degrees or more) warrants a 60 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257, prior to the regulatory change, the rating schedule provided for a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Effective February 7, 2021, under the amended criteria for Diagnostic Code 5257, for recurrent subluxation or lateral instability, a 10 percent rating is warranted for 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 (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. 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 (e.g., cane(s), crutch(es), walker) and bracing for ambulation. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Also, as of February 7, 2021, under the amended criteria for Diagnostic Code 5257, for recurrent 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. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, removal of the semilunar cartilage when symptomatic warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. If extension of the knee is limited to 30 degrees a 40 percent rating is in order. If extension of the knee is limited to 45 degrees a 50 percent rating is in order. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Under 38 C.F.R. § 4.71a, Diagnostic Code 5262, and prior to the regulatory change, the rating schedule provided for a 10 percent rating for malunion of the tibia and fibula with slight knee or ankle disability, a 20 percent rating for moderate knee or ankle disability, a 30 percent rating for malunion with marked knee or ankle disability, and a 40 percent rating for nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. As of February 7, 2021, under the amended criteria for Diagnostic Code 5262, malunion of the tibia and fibula is evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation, and a noncompensable rating is assigned for medial tibial stress syndrome (MTSS), or shin splints with Treatment less than 12 consecutive months, one or both lower extremities, a 10 percent rating is for Requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities, a 20 percent rating for Requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity, a 30 percent rating for Requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities, and a 40 percent rating is unchanged still requiring nonunion of the tibia and fibula with loose motion requiring a brace. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. Importantly, In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), that Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In this regard, VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disorder includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disorder includes both arthritis and instability, provided of course, that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-97 (July 1, 1997). In this regard, as noted above, the Veteran's bilateral knee disability is currently rated separately under two diagnostic codes, for limitation of extension due to pain under Diagnostic Code 5261, and for medial collateral ligament laxity (i.e., lateral instability) under Diagnostic Code 5257. See Estaban, supra; VAOPGCPREC 23-97 (July 1, 1997). As to higher ratings, from June 28, 2016, under Diagnostic Code 5257, the December 2015, June 2016, July 2020, and January 2022 VA examinations are uniform in finding that the Veteran's bilateral knee condition is productive of mild to moderate instability and without patellar instability. In fact, the December 2015 examiner reported the Veteran had no indications of joint instability, no recurrent subluxation, no history of lateral instability, and no history of recurrent effusion. The June 2016 examiner reported the Veteran was found to have slight (1+) medial instability, bilaterally and no history of recurrent effusion or recurrent subluxation. The July 2020 examiner reported the Veteran was found to have moderate (2+) medial instability, bilaterally and no history of recurrent effusion and slight recurrent subluxation. In the remarks section of the recent January 2022 VA examination, the examiner reported there is moderate recurrent subluxation of the knee, bilaterally, with a history of moderate lateral instability and joint instability. Bilateral knee anterior instability test, knee posterior instability test and medial instability test, were all found normal. The knee lateral instability test, bilaterally, resulted in a slight 1+ (0-5mm) finding. Tellingly, there is no indication at any VA examination of severe recurrent subluxation or lateral instability, which is required for a rating in excess of 20 percent under Diagnostic Code 5257. Therefore, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, Chavis, and DeLuca, and when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), his functional losses do not equate to the criteria required for higher, 30 percent rating, because the evidence does not support a severe recurrent subluxation or lateral instability at all of his VA examinations. Moreover, while treatment records document the Veteran's complaints and treatment for bilateral knee instability problems, nothing in these records contradicts the above VA examiners findings. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). The Board finds that the Veteran is not competent to diagnosis severe recurrent subluxation or lateral instability because this is a medical finding. See Davidson, supra. Consequently, the Board finds that a higher rating is not warranted for the Veteran's bilateral knee disorder under Diagnostic Code 5257 at any time during the appeal. See 38 C.F.R. § 4.71a; Hart, supra; Fenderson, supra. Importantly, under the amended Diagnostic criteria from February 7, 2021, nothing in the record indicates the Veteran ever had a diagnosed condition of patellofemoral complex. See VA Examinations for Knee Conditions, December 2015, June 2016, July 2020, and January 2022. The record does, however, show the Veteran diagnosed with an incomplete 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, which satisfies the requirements for a 20 percent disability rating, for recurrent subluxation or lateral instability under the February 2021 amended criteria. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). Importantly, as required for a 30 percent rating under the February 2021 amended criteria, there is no evidence of unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribed both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Id. Accordingly, the Veteran is not entitled to a rating in excess of 20 percent under the amended criteria from February 7, 2021. As to higher or separate higher rating for limitation of flexion of the Veteran's left and right knee, from June 28, 2016, under Diagnostic Code 5260 and VAOPGCPREC 9-2004, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, Chavis and DeLuca, and when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), his functional losses do not equate to the criteria required for at least a 0 percent noncompensable rating because flexion of the left and right knee is not limited to 60 degrees at any of his VA examinations. Specifically, it was as follows: Right knee flexion was 130 degrees at the December 2015 examination, 135 degrees at the June 2016 VA examination, 140 degrees at the July 2020 VA examination, later amended to 120 degrees in a December 2020 addendum opinion to consider estimated loss of range of motion during flare ups and after repetitive use, and 105 degrees at the January 2022 VA examination. Left knee flexion was 130 degrees at the December 2015 examination, 135 degrees at the June 2016 VA examination, 140 degrees at the July 2020 VA examination, later amended to 120 degrees in a December 2020 addendum opinion to consider estimated loss of range of motion during flare ups and after repetitive use, and 100 degrees at the January 2022 VA examination. Moreover, while the Veteran's treatment records document his complaints and treatment for left and right knee problems, the Board finds that above VA examiners ranges of motion are not contradicted by any other medical evidence of record because treatment records never document less flexion in either knee. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra, Colvin, supra. The Board finds that the Veteran is not competent to diagnosis further limitations on his ranges of motion because this is a medical finding requiring diagnostic testing. See Davidson, supra. Consequently, the Board finds that a higher and/or separate rating is not warranted for the Veteran's bilateral knee disorder under Diagnostic Code 5260 at any time during the appeal. See 38 C.F.R. § 4.71a; Hart, supra; Fenderson, supra. The Board highlights, as noted above, the Veteran's service-connected knee disorder is already separately rated as 10 percent disabling, bilaterally, from January 13, 2009, under Diagnostic Code 5261 for limitation of extension. Nonetheless, as to a higher rating and/or a higher separate rating for the Veteran's left and right knee limitation of extension from June 28, 2016, under Diagnostic Code 5261, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of his observable adverse symptomatology (see Davidson, supra), his functional losses do not equate to the criteria required for even a 20 percent rating, because extension of the left and right knee is not limited to 15 degrees, much less 20 degrees required for a 30 percent rating, because it was 10 degrees or less at all of his VA examinations. Specifically, it was as follows: Right knee extension was 0 degrees at the December 2015 examination, 0 degrees at the June 2016 VA examination, 0 degrees at the July 2020 VA examination, and 5 degrees at the January 2022 VA examination. Left knee extension was 0 degrees at the December 2015 examination, 0 degrees at the June 2016 VA examination, 10 degrees at the July 2020 VA examination, and 5 degrees at the January 2022 VA examination. Moreover, while the Veteran's treatment records document his complaints and treatment for left and right knee problems, the Board finds that above VA examiners ranges of motion are not contradicted by any other medical evidence of record because treatment records never document greater extension in either knee. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra, Colvin, supra. The Board finds that the Veteran is not competent to diagnosis ranges of motion because this is a medical finding. See Davidson, supra. Consequently, the Board finds that a higher and/or separate rating is not warranted for the Veteran's bilateral knee disorder under Diagnostic Code 5261 at any time during the appeal. See 38 C.F.R. § 4.71a; Hart, supra; Fenderson, supra. As to higher and/or separate ratings under Diagnostic Code 5256 for ankylosis at any time during the appeal, while the range of motion of both knees are restricted at the VA examinations, the record on appeal never shows the knees being ankylosed. In fact, the December 2015, June 2016, July 2020, and January 2022 VA examiners specifically opined they are not ankylosed, and these medical opinions are not contradicted by any other medical opinion of record. See Colvin, supra. Moreover, the Board finds that the Veteran is not competent to diagnosis ankylosis because this is a medical finding. See Davidson, supra. Consequently, the Board finds that a higher rating is not warranted for the Veteran's bilateral knee disorder under Diagnostic Code 5256 at any time during the appeal. See 38 C.F.R. § 4.71a; Hart, supra; Fenderson, supra. Lastly, as to separate or higher ratings under Diagnostic Codes 5258 and 5259 the Board finds there is no evidence showing dislocated semilunar cartilage or removal of the semilunar cartilage when symptomatic. Additionally, the Board finds there is no evidence showing tibia and/or fibula impairment to warrant a separate and/or higher rating under Diagnostic Code 5262. Moreover, there is no evidence of genu recurvatum, under Diagnostic Code 5263. Therefore, increased and/or separate ratings under Diagnostic Codes 5258, 5259, 5262 and 5263 is denied. See 38 C.F.R. § 4.71a; Hart, supra; Fenderson, supra. Accordingly, for the reasons outlined above, the Board finds that the criteria for a rating in excess of 20 percent for the Veteran's bilateral knee disability is not met at any time during the appeal, to include from June 28, 2016. See Fenderson, supra; Hart, supra; Davidson, supra; Colvin, supra. Nothing above suggests that the Veteran is not having problems with this disability. The only question is the degree of the problem based on the evidence and the law. It is important for the Veteran to understand that the medical findings provide highly probative evidence against the claim that the Board cannot, unfortunately, ignore. In addition, the Board has not overlooked the claims from the Veteran regarding his adverse symptomatology. See Davidson, supra. However, the Board finds the VA examiner's opinions as to the Veteran's adverse symptomatology more probative than the lay claims from the appellant to the contrary even though his symptomatology is observable by a lay person because the examiner has medical training. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data); Caluza v. Brown, 7 Vet. App. 498 (1995) (giving factors to consider when assessing the credibility of evidence, to include facial plausibility, internal consistency, consistency with other evidence, self-interest or bias, and lay statements made during treatment). In reaching the above conclusions the Board has considered the applicability of the benefit of the doubt doctrine. However, as there is not an approximate balance of positive and negative evidence regarding the claim that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). TDIU Claim 3. Entitlement to a TDIU Entitlement to a TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The fact that a Veteran is unemployed or has difficulty obtaining employment is not enough to warrant a TDIU. See Van Hoose v. Brown, 4 Vet. App. 361 (1993). 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). Turning to the evidence, the Veteran is currently service connected for the following: Posttraumatic stress disorder (PTSD) rated as 50 percent disabling from May 4, 2015; Obstructive sleep apnea rated as 30 percent disabling from May 4, 2015; Cervical strain rated as 10 percent disabling from May 4, 2015 and 30 percent disabling from July 23, 2020; Bilateral medial collateral ligament laxity (knee) rated as 10 percent disabling from May 4, 2015 and 20 percent disabling from June 28, 2016; Right shoulder strain and impingement syndrome rated as 0 percent disabling from May 4, 2015 and 20 percent disabling from July 23, 2020; Bilateral upper extremity radiculopathy associated with cervical strain rated as 20 percent disabling from July 23, 2020; Bilateral tendonitis (knee) rated as 10 percent disabling from January 13, 2009; Degenerative disk/joint disease, lumbosacral spine, with muscle strain, right trapezius rated as 20 percent disabling from January 13, 2009 and as 10 percent disabling from July 20, 2015; Tinnitus rated as 10 percent disabling from May 4, 2015; Scar, hernia repair surgery rated as 10 percent disabling from January 13, 2009; and Right inguinal hernia, bilateral lateral collateral ligament sprain, sensorineural bilateral hearing loss, each rated as noncompensable. The Veteran's total combined disability rating is 40 percent from January 13, 2009, 90 percent from May 4, 2015 and 100 percent effective July 23, 2020. Accordingly, the Board finds that the schedular requirements for a TDIU are met from May 4, 2015. See 38 C.F.R. § 4.16(a). Accordingly, at issue is whether the Veteran is unable to secure and follow a substantially gainful occupation as due to service-connected disabilities. Notably, the January 2019 Board decision indicated the record raised a claim for a TDIU and remanded the matter for further development. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The RO mailed a development letter to the Veteran in January 2021 requesting that he complete a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability) with no response received to date. In February 2021 and January 2022 Supplemental Statement of the Cases (SSOC), the RO denied entitlement to a TDIU. VA treatment records show the Veteran currently maintains employment as both an emergency medical technician (EMT) and also as a volunteer firefighter. See VA Treatment Records, August 2021. The Board highlights the fact that it does not appear the Veteran is claiming, or is seeking to claim, a TDIU in this case. Despite the lack of response from the Veteran in this case, on the issue of a TDIU, as well as evidence that shows the Veteran has been substantially and gainfully employed throughout the appeal, the Board will nonetheless proceed to adjudicate the issue without a completed VA Form 21-8940 on file. See Rice, supra. The Court has held that the phrase "unable to secure and follow a substantially gainful occupation" has an economic component and a noneconomic component. Ray v. Wilkie, 31 Vet. App. 58, 67-76 (2019). The economic component considers the Veteran's ability to secure and follow an occupation earning more than marginal income. See 38 C.F.R. § 4.16a (marginal employment shall not be considered substantially gainful employment). The noneconomic component considers such factors as the Veteran's employment history, education, skill, training, physical ability, and mental ability. The Court has also held that the Veteran's ability or inability to engage in substantial gainful activity has to be looked at in a practical manner, and the test is whether a particular job is realistically within the physical and mental capabilities of the Veteran. Moore v. Derwinski, 1 Vet. App. 356, 359 (1991). The ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one, but a factual determination for the adjudicator. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Regarding the economic component, the Board notes that during his December 2015 mental health examination, the Veteran reported working as a truck driver after leaving service, from February 2009 until November 2015. See December 2015 VA Mental Health Examination. The Veteran also reported working for 14 separate companies in the 6 years immediately after his discharge. Id. He was fired from one of the jobs, laid off from two jobs, and quit the others all due to anger issues. Id. Despite the above, however, the Veteran then reported he has been able to maintain consistent employment over the prior two years and he denied any then-current occupational impairment. Id. At his June 2016 VA examination the Veteran reported work was going well after he started his own vehicle escort business. See June 2016 VA Mental Health Examination. At the May 2020 VA examination, it was reported that he did this job from about November 2016 to September 2018 working 2-4 weeks, then home for 1-2 weeks steadily. See May 2020 VA Mental Health Examination. Importantly, the Board finds his period of self-employment is not considered marginal or "protected" employment for purposes of entitlement to a TDIU due to his service-connected disabilities. The Board has reached this conclusion because the evidence of record shows that he maintained work "steadily" throughout the period of self-employment and also because the record shows that he started his own business for reasons related to the custody of his child, rather than for reasons related to his service-connected physical or mental disabilities. See May 2020 VA Mental Health Examination. Thereafter, the Veteran obtained a position working as an EMT from October 2018 to present. Id; see VA Treatment Records, August 2021. While he reported having some "triggers" due to his service-connected disabilities and processing difficulties with co-workers, at his current job, especially with "large volumes of blood involved", he also reported that he likes his job due to autonomy and excitement. Id. Importantly, it was recently reported in VA treatment records that the Veteran is still working as an EMT and also volunteers as a firefighter. See VA Treatment Records, August 2021. Therefore, the Board finds the Veteran does not meet the economic component for consideration of entitlement to a TDIU because the factual evidence of record does not show the Veteran is now, or has been since service, incapable of substantial gainful employment. In fact, a long work history, of substantially gainful employment, up to present, is shown by the record in this case. See e.g., VA Examination for Cervical Neck, July 2020 ("Veteran does not miss work ever."); VA Examination for Shoulder and Arm, July 2020 (shoulders cause pain with lifting and pulling, but he has missed less than 1 week of work in the past year); VA Examination for Knee and Leg (missed 1 week of work in the past year when he twisted his right knee unloading a patient and had to wear a knee brace for a week); VA Treatment Records, August 2021 (Veteran working for an ambulance company and also is a volunteer at the local fire department). Regarding the noneconomic component, the Board has considered the evidence of record pertaining to the Veteran's employment history, education, skill, training, physical ability, and mental ability, and finds the evidence is, overall, against the claim for a TDIU. As to his employment history, as discussed in detail above, the evidence of record shows a long and productive work history, as a truck driver, small business owner and presently as an EMT and firefighter. As to his education, skill and training, the evidence of record shows the Veteran graduated from high school degree with a 3.96 grade point average and has post-secondary education to include community college coursework from August 2002 to April 2004 studying diesel technology. See VA Form 28-1902w (Rehabilitation Needs Inventory), February 2010. The Veteran is also an EMT and has education related to his EMT training and certification. See May 2020 VA Examination for Mental Health. As to his physical and mental abilities, the Board finds the best evidence in this case, which are the many VA examinations, across many years, in addition to the Veteran's own lay testimony, show that the Veteran's PTSD, sleep apnea, shoulder and upper extremity neuropathy conditions, knee and ankle conditions, as well as his back and neck conditions, and tinnitus each have some functional impact on his ability to work, but do not create a total disability, or an inability to engage in substantial gainful activity. The Board has reached this conclusion because the medical evidence regarding his physical and mental abilities is uniform in opining that the Veteran has, at most, a mild to moderate (i.e., not total) limitation on his ability to engage in substantial gainful activity due to his service-connected disabilities. For example, at the December 2015 VA examinations for his bilateral ankle condition, shoulder and arm condition, knee and lower leg, the same examiner, as well as the examiner that performed the December 2015 VA examination for sleep apnea, opined that the Veteran's disabilities, in each case, did not impact his ability to work, in any way. Moreover, at the December 2015 VA examination for mental health conditions, the Veteran gave his own testimony relating to doing well at work and not having any conflict with coworkers and denied any occupational impairment, by his own account. At the June 2016 knee and lower leg conditions and cervical neck conditions examination, the same examiner opined there was no functional impact on this Veteran's ability to work due to his service-connected knee instability and cervical spine conditions, in each case. At the May 2020 VA examination for mental health conditions, the examiner opined the Veteran is able to maintain employment in environments with autonomy and little supervision (i.e., as an EMT and volunteer firefighter). The Veteran reported some conflict with co-workers but has been able to continue working as an EMT and volunteer firefighter using mechanisms to de-escalate tension at the workplace. At his July 2020 VA examinations for neck, shoulder, arms, knees and lower legs, the Veteran provided lay testimony that he did not miss work "ever" (1 week or less) in the previous 12 month period. The same examiner in each case reported the Veteran had some pain with work-related tasks such as lifting, pulling, walking, sitting or standing for prolonged periods; however, nothing in any of the noted VA examinations show an inability to engage in substantial gainful activity due to service-connected disabilities. The Board acknowledges the Veteran's testimony concerning the frequency of his pain at the January 2022 VA examination for his knee condition, where he reported that his knee pain is unbearable at times and that he must take frequent breaks due to pain and fatigue. See also October 2020 VA Tinnitus Examination (Veteran reporting impact of tinnitus on his life requiring frequent breaks). However, importantly, when questioned about the history of his bilateral knee condition, to include the severity and frequency of flare ups, the Veteran testified that since he left truck driving work (in 2015) his flare ups only occur sporadically at the present time (in 2022). See January 2022 VA Knee and Lower Leg Examination. As such, the Board finds the Veteran is not an accurate historian of his medical history, based on conflicting statements with regard to the functional impact of his service-connected disabilities, which reduces the credibility of his testimony on appeal. Therefore, for the reasons outlined above, the Board also finds the Veteran does not meet the noneconomic component for entitlement to a TDIU, where the best evidence of record pertaining to the Veteran's employment history, education, skill, training, physical ability, and mental ability fails to show that he is incapable of substantial gainful employment due to his service-connected disabilities. Put simply, while the Board finds the Veteran's service-connected disabilities impact his ability to work on some level, the economic and noneconomic factors, as outlined above, do not show that the Veteran is totally incapable of employment at this time. See Geib, supra; Ray, supra. While the Veteran clearly has problems with his service-connected disabilities (if he did not, there would be no basis for the current compensation levels) the Board finds the medical evidence of record (to include the competent, credible and probative opinions of medical examiners on examination) to be highly probative as to the current nature, extent, severity, and, importantly, functional impact of the Veteran's disabilities on his ability to work. The medical reports were based on physical examinations and a review of the Veteran's prior medical history, as well as lay statements regarding the history of each disability and current symptoms, and provide sufficient information to allow the Board to find the evidence is, overall, against the claim in this case. Thus, although the Veteran's competent and credible reports of symptoms have been considered and are probative, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). As such, the objective medical findings and opinions provided by the VA examiners, across many years on appeal, have been accorded greater probative weight and outweigh the Veteran's contentions to the contrary where applicable. It is important for the Veteran to understand that nothing in this decision prevents him from filing a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability), if he so chooses, to pursue a claim for a TDIU in the future. Nonetheless, since the Veteran is already rated at a 100 percent combined disability evaluation, the issue of a TDIU (100%) is effectively moot in this case. (Continued on the next page) Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching the above conclusions the Board has considered the applicability of the benefit of the doubt doctrine. However, as there is not an approximate balance of positive and negative evidence regarding the claim that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Davidson 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.