Citation Nr: 22019844 Decision Date: 04/03/22 Archive Date: 04/03/22 DOCKET NO. 15-30 933A DATE: April 3, 2022 ORDER Entitlement to an initial rating in excess of 20 percent for arthritis of the left hip with limitation of abduction is denied. Entitlement to an initial rating in excess of 10 percent for arthritis of the left hip with limitation of extension is denied. Entitlement to an initial compensable rating for arthritis of the left hip with limitation of flexion is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted from October 29, 2010. REMANDED Entitlement to TDIU, to include on an extraschedular basis, before October 29, 2010, is remanded. FINDINGS OF FACT 1. Arthritis of the left hip with of the left hip with limitation of abduction manifests in painful motion with abduction limited so that motion is lost beyond 10 degrees, limited rotation of the left hip/thigh preventing the Veteran from crossing his legs, and external rotation limited to 10 degrees. 2. Arthritis of the left hip with limitation of extension of the left thigh manifests in painful motion with extension of the left thigh limited to 5 degrees. 3. Arthritis of the left hip with limitation of flexion of the left thigh is manifest in painful motion and flexion greater than 45 degrees. 4. Effective October 29, 2010 (for payment purposes), the Veteran's service-connected disabilities precluded him from securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for arthritis of the left hip with limitation of abduction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253. 2. The criteria for an initial rating in excess of 10 percent for arthritis of the left hip with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 3. The criteria for a compensable initial rating for arthritis of the left hip with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 4. From October 29, 2010, the criteria for TDIU on a schedular basis have 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 on active duty from June 1974 to June 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in December 2014, and May 2018 by a Department of Veterans Affairs (VA) Regional Office. In February 2019, the Board remanded multiple claims including the claim for TDIU. The claim for TDIU was remanded to afford the Veteran an opportunity to file a VA Form 21-8940 Application for Increased Compensation Based on Unemployability. The remaining issues that were remanded in February 2019 are not currently before the Board as part of this appeal. While on remand, a June 2020 rating decision granted TDIU, effective August 12, 2014. The Veteran has contended that his left hip disability, among many other disabilities, has rendered him unemployable. We also note that the Veteran has previously claimed entitlement to TDIU on an extraschedular basis. The instant increased rating claims stem from an October 18, 2004 claim for service connection for a left hip disability. The June 2020 rating decision did not grant the Veteran's claim for TDIU in full, and the issue of entitlement to TDIU prior to August 12, 2014, remains on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009); Harper v. Wilkie, 30 Vet. App. 345 (2018). In August 2021, the Board granted an earlier effective date for the Veteran's service-connected left hip arthritis and, in light of the errors found in assigning the effective dates, remanded entitlement to increased ratings for the hip disabilities and remanded entitlement to TDIU to allow the Agency of Original Jurisdiction (AOJ) to assign disability ratings in the first instance. In September 2021, the AOJ issued a Supplemental Statement of the Case denying increased ratings for the Veteran's left hip disabilities and denying entitlement to TDIU before August 12, 2014. The matters now return to the Board for further appellate review. The Board notes that the Veteran's representative requested a 90-day extension in December 2021 to submit additional evidence. The Board granted and observed this request. RATINGS Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45. As required by 38 C.F.R. § 4.59, joints should be tested for pain on both active and passive motion, in weight bearing and non-weight bearing, and if possible, with the range of opposite undamaged joint. Correia v. MacDonald, 28 Vet. App. 158 (2016). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). If the evidence for and against a claim is an equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinksi, 1 Vet. App. 49, 56 (1990). 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 will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. 1. Increased ratings for left hip arthritis. The Veteran seeks higher initial ratings for his left hip arthritis. The arthritis is currently evaluated as 20 percent disabling under Diagnostic Code 5010-5253 for limitation of abduction, 10 percent disabling under Diagnostic Code 5010-55251 for limitation of extension, and 0 percent disabling under Diagnostic Code 5252 for limitation of flexion. Each rating is effective October 18, 2004, the date VA received his claim for service connection for a left hip disability. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the diagnostic codes in use here (5251, 5252, and 5253) were not changed. Specific to the hip joint, Diagnostic Code 5054 (resurfacing or replacement (prosthesis)) and Diagnostic Code 5255 (impairment of femur) were amended. However, there is no medical evidence that the Veteran has undergone hip resurfacing or replacement, or that he has impairment of the femur. The medical evidence of record is sufficient to properly adjudicate the Veteran's increased rating claims specific to the service-connected left hip disorder. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5010 sets forth the rating criteria for arthritis due to trauma substantiated by x-ray findings, and instructs that traumatic arthritis be rated as degenerative arthritis. Diagnostic Code 5003 pertains to degenerative arthritis and, under Diagnostic Code 5003 instructs that the arthritis be rated on the basis of limitation of motion under the specific joints involved. When limitation of motion is noncompensable under an appropriate diagnostic code, a 10 percent rating is warranted when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted where there is x-ray evidence of the involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5251 (limitation of extension of the thigh), a 10 percent evaluation is assigned with extension limited to 5 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5251. The Veteran is in receipt of the schedular maximum rating available under this diagnostic code, which contemplates extension of the thigh limited to 5 degrees or less. Under Diagnostic Code 5252 (limitation of flexion of the thigh), a 10 percent evaluation is assigned with flexion limited to 45 degrees. A 20 percent evaluation is assigned with flexion limited to 30 degrees. A 30 percent evaluation is assigned with flexion limited to 20 degrees. A 40 percent evaluation is assigned with flexion limited to 10 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5252. The Veteran is currently assigned a 0 percent evaluation under this diagnostic code for limited flexion beyond 45 degrees. See 38 C.F.R. § 4.31 (In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met.). The noncompensable evaluation contemplates flexion of the thigh limited to more than 45 degrees. To warrant a compensable rating, flexion must be shown to be limited to 45 degrees or less. Under Diagnostic Code 5253 (impairment of thigh), a 10 percent rating is warranted for limitation of adduction, cannot cross legs, or limitation of rotation, cannot toe-out more than 15 degrees, affected leg. A 20 percent evaluation is warranted for thigh impairment of limitation of abduction, motion lost beyond 10 degrees. The currently assigned 20 percent evaluation contemplates limited abduction such that the Veteran cannot cross his legs, and/or limitation of rotation such that the Veteran cannot toe-out more than 15 degrees, and abduction lost beyond 10 degrees. The Veteran is in receipt of the schedular maximum rating available under this diagnostic code. Normal range of motion of the hip and thigh is flexion from 0 to 125 degrees and abduction from 0 to 45 degrees. 38 C.F.R. § 4.71a, Plate II. In this matter, Diagnostic Codes 5251, 5252, and 5253 are the applicable Diagnostic Codes. Copeland v. McDonald, 27 Vet. App. 333 (2015). The evidence does not show hip prosthesis, ankylosis, flail joint, or impairment of the femur. As will be explained below, the functional equivalent of ankylosis has not been shown, as Diagnostic Code 5250 requires flexion be limited to 40 degrees at most or manifestations that have not been shown here. Furthermore, a 10 or 20 percent rating under Diagnostic Code 5003 alone is not for application because the Veteran's left hip impairment is compensable under otherwise appropriate Diagnostic Codes that rate for limited motion. The Veteran was provided a VA hip examination in April 2017. The Veteran reported severe pain, weakness, numbness, and tingling in his left hip and leg. He denied any flare-ups. Left hip range of motion testing showed flexion to 80 degrees, extension to 5 degrees, abduction to 10 degrees, adduction to 10 degrees, external rotation to 10 degrees, and internal rotation to 5 degrees. Adduction was limited such that the Veteran could not cross his legs. All planes of motion were painful, and the examiner noted that the Veteran could "barely move in all directions." There was pain and tenderness on palpation. There was pain with weightbearing and non-weightbearing. The examiner noted active and passive ranges of motion were the same. Repetitive use testing with at least three repetitions could not be performed due to severe pain. The examiner noted pain, fatigue, weakness, lack of endurance, and incoordination would all cause functional loss with repetitive use over time. Additional factors contributing to disability were noted as less movement than normal, instability of station, disturbance of locomotion, and interference with sitting and standing. Muscle strength was 4/5 with left hip flexion, extension, and abduction, coinciding with active movement against some resistance. The Veteran used a cane due to the arthritis. An addendum opinion was provided in April 2018 addressing use over time and flareups. The examiner explained that the Veteran was not examined immediately after repetitive use over time or during a flareup but, based on the Veteran's records, current examination, and the Veteran's verbal report, the Veteran would experience increased pain, leading to a decrease in functional capacity. However, the examiner determined it was not possible to accurately estimate range of motion loss as the Veteran's limitations are variable depending on the duration of repeated use over time or the severity of a flareup. After a review of the medical and lay evidence, the current evaluations for the left hip are appropriate. In other words, an evaluation in excess of 20 percent is not warranted under Diagnostic Code 5253, an evaluation in excess of 10 percent is not warranted under Diagnostic Code 5251, and a compensable evaluation is not warranted under Diagnostic Code 5252, at any time during the period on appeal. There is pain and limited motion of the left hip. The Veteran is in receipt of a 20 percent evaluation under Diagnostic Code 5253, the maximum schedular rating, which contemplates adduction limited such that the Veteran cannot cross his legs, rotation limited such that the Veteran cannot toe-out the left leg more than 15 degrees, and abduction limited such that motion is lost beyond 10 degrees. All these manifestations were shown at the April 2017 VA examination. The 20 percent rating contemplates the Veteran's pain and limited motion. The Veteran is in receipt of a 10 percent evaluation under Diagnostic Code 5251, the maximum schedular rating, which contemplates extension of the thigh limited to 5 degrees or less. This was shown at the April 2017 VA examination, and the 10 percent evaluation contemplates the Veteran's pain and limited extension. More than the maximum 20 percent assignable under Diagnostic Code 5253 for impairment of the thigh and 10 percent under Diagnostic Code 5251 for limitation of extension of the thigh is not warranted by the evidence. See Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). Regarding Diagnostic Code 5252, a compensable rating requires flexion of the thigh be limited to 45 degrees or less, which has not been demonstrated during the period on appeal. Flexion was limited to 80 degrees with pain. In each instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31. The Board acknowledges that painful joints are entitled to at least the minimum compensable rating for the joint, especially in the context of arthritis. See 38 C.F.R. § 4.59. However, the Veteran is already in receipt of at least the minimum compensable rating for his left hip under Diagnostic Codes 5251 and 5253. The provisions of 38 C.F.R. § 4.59 are inapplicable where, as in this case, a joint disability is already being compensated at a compensable level based on actually painful motion. See Vilfranc v. McDonald, 28 Vet. App. 357, 361 (2017). To warrant a compensable rating under Diagnostic Code 5252, flexion of the thigh must be limited to the functional equivalent of 45 degrees or less, which has not been shown. Pertinently, there is no evidence available showing levels of impairment greater than the April 2017 VA examination report. Medical records throughout the period on appeal generally reflect the Veteran reported left hip pain. The Veteran's lay statements reflect complaints of constant left hip pain and limited motion causing functional impairment and impacting his ability to work. However, even accepting the Veteran's competent reports of his symptoms and impairment, the evidence does not establish that a higher evaluation is warranted under an applicable diagnostic code. The Board again notes that the Veteran is in receipt of the schedular maximum ratings under Diagnostic Codes 5251 and 5253. A compensable evaluation under Diagnostic Code 5252 requires flexion of the thigh be limited to the functional equivalent of 45 degrees or less. In this regard, the most probative evidence is the April 2017 examination reflecting painful flexion to 80 degrees, well above the threshold for a compensable evaluation. The Board also considered whether higher ratings under Diagnostic Codes 5251, 5252, or 5253 might be appropriate based on the DeLuca factors. Upon examination, the examiner did note there would be additional loss of function from pain, fatigue, weakness, lack of endurance, and incoordination with repetitive use or during flareups. The examiner concluded he could not estimate additional impairment in terms of range of motion because doing so would be speculative. In the April 2018 addendum opinion, the examiner explained that it is not possible to accurately estimate range of motion loss as the limitations would be variable depending on the duration of repeated use over time or the severity of a flareup. VA examiners must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flareups before determining that an estimate of motion loss in terms of degrees could not be given. Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The April 2017 examination report reflects the examiner was able to elicit and note information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flareups and repeated use. The Board has considered Sharp with respect to flareups and repeated use over time, the Board accepts the examiner's April 2018 explanation as to why further estimates of range of motion with flareups and repeated use would be speculative. The examiner's explanation that the Veteran's additional impairment would be variable depending on duration and severity is predicated on a lack of medical knowledge among the medical community. Additionally, the record is silent regarding any level of additional impairment caused by repeated use or flareups. The current ratings encompass pain on movement. We note that the Veteran did not report flareups at the VA examination, and there is little evidence to the contrary. A review of the entirety of the period on appeal does not suggest flareups or repeated use cause a level of impairment consistent with an increased rating under the circumstances of this case. The Board is unable to identify findings that would warrant an increased evaluation under 38 C.F.R. § 4.40 and 4.45. Notwithstanding these factors, the Veteran maintained flexion well over 45 degrees, extension was limited to 5 degrees, and abduction, adduction, and rotation are consistent with the assigned maximum schedular rating. There is not further limitation that would warrant an evaluation in excess of 20 percent for impairment of the thigh, a 10 percent for limited extension of the thigh, or a compensable rating for limited flexion of the thigh. Thus, the award of a higher disability rating or ratings is not warranted. The evidence for and against the Veteran's claim for increased ratings is neither evenly balanced nor approximately so. Rather, the evidence weighs persuasively against higher or separate evaluations for left hip disability. Accordingly, the benefit of the doubt doctrine is not for application and the claims for increased ratings are denied. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). 2. Entitlement to a TDIU before August 12, 2014. The Veteran seeks entitlement to TDIU before August 12, 2014. The Veteran was awarded TDIU in a June 2020 rating decision granted TDIU effective August 12, 2014, which is the date the Agency of Original Jurisdiction initially determined the Veteran had met the schedular requirements for TDIU. VA policy provides 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 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. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) 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). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. See 38 C.F.R. § 4.16 (a). When two or more disabilities are treated as one, the ratings for those disabilities are combined using the combined ratings table. 38 C.F.R. § 4.25. The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The determination of unemployability is to be made by a VA adjudicator and is not a medical question. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Here, the Veteran met the schedular requirements for TDIU on October 29, 2010. As of that date, the Veteran had the following disability ratings: left hip arthritis with limitation of abduction rated 20 percent; left hip arthritis with limitation of extension rated 10 percent; left hip arthritis with limitation of flexion rated 0 percent; left knee patellofemoral syndrome rated 20 percent; left knee arthritis with limitation of extension rated 10 percent; left knee arthritis with limitation of flexion rated 0 percent; patellofemoral syndrome of the right knee rated 10 percent; bilateral hearing loss rated 10 percent; tinnitus rated 10 percent; lacerations and abrasions of the left ring finger, left leg, left hip, and left knee rated 10 percent; fracture left fifth toe rated 0 percent; fracture left middle finger rated 0 percent; and fracture right metacarpal was rated 0 percent. His overall disability rating on October 29, 2010 was 70 percent. The Veteran's attorney has argued that the left hip, bilateral knee, fractures, and lacerations all result from a common etiology. See August 2020 Brief. The Veteran has also contended that all his physical disabilities were the result of an accident when a helicopter fell on him. See, e.g., December 2013 Statement in Support of Claim. The precise etiology of the Veteran's musculoskeletal disabilities is somewhat unclear. No singular incident is documented during service as causing each disability. A tail boom of a helicopter fell on his right knee in January 1976 causing right knee patellar chondromalacia. This incident was also determined to be the cause of hs left knee pain during a September 1977 VA examination. In April 2017 a VA examiner determined the Veteran's left hip disabilities were a direct result of a separate motorcycle accident that occurred in August 1976. The left hip arthritis is not service connected as secondary to the Veteran's knee disabilities and appears unrelated to the helicopter accident. We note that the motorcycle accident caused the Veteran's service-connected lacerations and abrasions, right toe fracture, and left finger fracture. Applying 38 C.F.R. § 4.16 (a)(2), as of October 29, 2010 the Veteran did have multiple disabilities resulting from a common etiology or single accident that may be combined into one 40 percent disability, and additional disability to bring his overall rating to 70 percent. The Veteran's bilateral knee disabilities all resulted from the same helicopter accident and combine to equal 40 percent. Assuming the April 2017 VA examiner is correct, the Veteran's left hip disabilities, lacerations, and fractures resulted from the motorcycle accident and combine to equal 40 percent. See 38 C.F.R. §§ 4.16 (a)(2), 4.25. Using either of these common accidents, for the purposes of a TDIU the Veteran had a single disability rated 40 percent with additional disability bringing the total to 40 percent. Additionally, apart from his lacerations, hearing loss, and tinnitus, as of October 29, 2010 the Veteran's disabilities affect the orthopedic/musculoskeletal system. The Veteran's left hip, left knee, and right knee disabilities, as well as his noncompensable toe, finger, and metacarpal fractures all affect the orthopedic/ musculoskeletal system. When combined using the combined ratings table, and for the purposes of TDIU, these disabilities may be considered a single disability affecting a single body system rated 60 percent disabling effective October 29, 2010. See 38 C.F.R. §§ 4.16 (a)(3), 4.25. Given the foregoing, the Veteran met the schedular requirements for TDIU effective October 29, 2010. After reviewing the evidence of record, the Board concludes the evidence is in relative equipoise as to whether the Veteran's service-connected disabilities, in particular his bilateral knee and left hip disabilities, rendered him unable to secure and follow a substantially gainful occupation effective October 29, 2010. The Board will address the period on appeal before that date in the remand section below. The Veteran filed a VA Form 21-8940 Application for Increased Compensation Based on Unemployability in October 2019. He reported that he had worked as a truck driver from 1997 until June 26, 2008. He finished high school and did not report any other education or training. He reported that all his service-connected disabilities prevent him from securing or following a substantially gainful occupation. Other records in the claims file show the Veteran reported that he was a truck driver for 30 years. Private medical records and Social Security Administration (SSA) records reflect that the Veteran injured his back during work on approximately June 24, 2008, just four days before he stopped working. He had multiple back surgeries thereafter. Although the Veteran had previously filed for service connection for back disabilities, he is not service connected for any back disability. This back injury and resulting disability may not be considered for TDIU purposes. The Veteran also has other severe, non-service-connected disabilities affecting his ability to work, including but not limited to chronic obstructive pulmonary disease, stroke and stroke-residuals, diabetes mellitus, transient ischemic attacks, coronary arteriosclerosis, and congestive heart failure. These disabilities also may not be considered for TDIU purposes. Some of the Veteran's service-connected disabilities cause minor impact on his ability to work. VA examinations and medical records reflect that his service-connected fracture left fifth toe, fracture left middle finger, and fracture right metacarpal cause effectively no impairment. At a June 2006 VA examination the Veteran reported that his right hand, left finger, and left toe fracture residuals caused no effect on his usual occupation as a truck driver. We note that these disabilities are each rated 0 percent disabling, suggesting little to no impairment. The Veteran has consistently reported that his hearing loss tinnitus cause difficulty understanding conversations unless the Veteran is looking at the person speaking. Tinnitus is constant. While the Veteran's lacerations and abrasions have been painful, they do not ultimately cause impairment on his ability to obtain or maintain substantially gainful employment. Before August 12, 2014, most of the Veteran's impairment was caused by his service-connected knee and left hip disabilities. At a December 2010 VA knee examination, the Veteran walked with a limp and reported constant knee pain, that he was unable to walk more than 10-15 minutes, was unable to stand more than 10 minutes, and was unable to sit more than 20-30 minutes. He could not do any physical activity with flareups. A December 2014 VA knee examination shows the Veteran reported constant bilateral knee pain, that his knees give out, and that he could not climb. He reported being able to walk for 15-20 minutes before needing to take a break. Notably, the Veteran reported flareups of increased pain and tingling lasting as long as two days that be caused by simple activities including walking 50 yards and rolling over at night. Both flexion and extension of both knees was significantly limited. The examiner noted that the bilateral knee disabilities impacted the Veteran's abilities to perform most physical activities such as lifting, pushing, pulling, and prolonged walking or standing. Of record is an August 2010 SSA decision determining the Veteran has been disabled since June 28, 2008, the date he last reported that he was employed. While SSA decisions are not controlling for VA determinations, they are relevant to the Veteran's claim for TDIU. The Board finds the grant of SSA disability benefits in part due to his service-connected osteoarthritis and bilateral knee disabilities to be probative evidence as to whether TDIU is warranted before August 12, 2014. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). We also note that SSA decision also found that the Veteran could lift up to 10 pounds, could only walk or stand 10 to 15 minutes and sit for 30-45 minutes during an 8-hour workday. However, we note that the SSA decision cited chronic obstructive pulmonary disease, shortness of breath, transient ischemic attack, blurred vision, low back pain with chronic pain syndrome, and laminectomy, as severe impairments contributing to his disability and ultimate inability to work. The Veteran is not service connected for any of these disabilities, and they may not be considered when determining whether he is entitled to TDIU. While the decision also cited depression as a severe impairment, the Veteran was not service connected for depression before August 12, 2014. Regarding his left hip, the evidence available suggests the Veteran's left hip arthritis has remained at a generally consistent level of impairment throughout the relevant period, and at least since service connection was granted effective October 14, 2004. The Veteran has submitted multiple lay statements detailing the impairment caused by his musculoskeletal disabilities. In a March 2005, statement he reported that his knees and hip was constant, affected his ability to do household chores, and made it difficult to walk or sit for any time. In the April 2005 VA Form 9 he reported that his physical disabilities, including his knees and hip, interfered with his occupation as a truck driver and that he could not take prescribed painkillers and still be able to drive a truck. A January 2010 SSA medical consultation and assessment shows the Veteran's knees and hip caused difficulty standing and sitting and contributed to the Veteran's discomfort diving any distance. The Board also finds the 2017 VA examination to be a highly probative as to the level of impairment caused by the Veteran's left hip arthritis. The Veteran had severe pain, weakness, numbness, and tingling affecting his left hip and leg. Range of motion was severely limited, the Veteran could not cross his legs, and all planes of motion were painful. Pertinently, the examiner stated the Veteran could barely move his left hip in any direction, and repetitive use testing could not be performed due to severe pain. Fatigue, weakness, lack of endurance, and incoordination were determined to cause additional impairment. There was less movement than normal, instability of station, disturbance of locomotion, and interference with sitting and standing. Regarding impact on the Veteran's ability to work, the examiner noted severe pain and numbness causing trouble standing, sitting, and walking. Although this examination was provided in April 2017, we note that VA failed to provide the Veteran an examination or to adjudicate his claim for service connection for the left hip for many years after he initially filed his claim in October 2004. The examination is also among the only probative medical evidence regarding the severity of the left hip arthritis and the impairments it causes, and the Veteran's lay statements support finding that his left hip symptoms have remained at a similar level throughout the relevant periods. The Veteran's service-connected musculoskeletal disabilities significantly impacted his ability to work any job. Multiple VA examinations and the Veteran's lay statements reflect his knee and left hip disabilities interfere with standing, walking, and sitting and that he can only each for up to half an hour at a time. Considering the Veteran's work and educational history, he worked primarily as a truck driver for approximately 30 years before he stopped working in 2008. Although this job was heavily sedentary, the Veteran's work as a truck driver was not entirely sedentary. Although precise details of the position are not available, SSA records show the Veteran reported a mixture of physical and sedentary duties. While driving a truck is sedentary, his duties included walking, lifting, kneeling, and bending. We also note the Veteran did injure his back performing physical duties associated with the position. The Veteran has not had substantial work experience or training outside of working as a truck driver. Given the service-connected physical limitations, it is unclear what other type of work the Veteran would be able to obtain. Stated another way, his service-connected knee and hip disabilities severely limit his ability to perform the duties required of the only type of work he did for the last 30 years he worked. In sum, the Veteran met the schedular requirements for TDIU on October 29, 2010. The evidence shows the Veteran's bilateral knee and left hip disabilities significantly impaired his ability to work. The Veteran has multiple severe disabilities that are not service connected, and all contribute to his inability to work. However, these disabilities have not been considered. VA examiners have indicated the Veteran's knees and hip prevent him from standing, walking, or sitting for more than 20 minutes. These symptoms are also reflected in the Veteran's lay statements. His level of impairment has been approximately the same since he met the requirements for TDIU. Resolving any doubt in the Veteran's favor, the evidence supports a finding that the Veteran was unable to secure and follow a substantially gainful occupation because of his service-connected disabilities as of October 29, 2010. Given the above, the Board finds entitlement to TDIU is warranted effective that date. REASONS FOR REMAND TDIU before October 29, 2010 is remanded. The Veteran's claim for TDIU was first raised in the record while the Veteran was pursuing entitlement to service connection for his left hip disabilities. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran reported that his knee and hip disabilities caused significant impairment in his ability to work as a truck driver as early as April 2005. He stopped working on June 28, 2008. As explained above, the Veteran first met the schedular requirements for TDIU on October 29, 2010. Before this date, and for the purposes of TDIU, the Veteran's various musculoskeletal disabilities may be combined into one disability rated 50 percent disabling. However, his total overall rating was at most 60 percent before October 29, 2010. See 38 C.F.R. §§ 4.16 (a), 4.25. As such, he did not have a single disability ratable at 60 percent or more or at least one disability ratable at 40 percent or more with sufficient additional disability to bring the combined rating to 70 percent or more. Where the schedular requirements for a TDIU are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16 (b). This decision grants entitlement to a TDIU effective October 29, 2010 based primarily on the severity of the Veteran's bilateral knee and left hip disabilities. Review of the record reflects these disabilities have maintained reasonably consistent ratings throughout the period relevant to an extraschedular TDIU. We note that the Veteran initially qualified for schedular TDIU when a separate rating for left knee instability was assigned effective October 29, 2010. The other assigned ratings for the left knee, right knee, and left hip have remained the same since October 18, 2004. Besides left knee instability, the severity of the Veteran's service-connected musculoskeletal disabilities, in particular his left hip, remained similar before he met the schedular requirements for a TDIU. The Veteran has consistently maintained that his knee and hip disabilities caused significant interference with his job as a truck driver and contributed to him becoming unemployable. We accept that the Veteran appears to have stopped working in part due to a non-service-connected back disability. However, as the Board has granted schedular TDIU due to service-connected knee and hip disabilities. Evidence suggests these disabilities caused similar levels of impairment on his ability to secure and follow a substantially gainful occupation before and after he met the schedular requirements for a TDIU. See Ray v. Wilkie, 31 Vet. App. 58, 66 (2019) (holding that "the initial extraschedular referral decision under § 4.16 (b) addresses whether there's sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his service-connected disabilities"). The Board does not have the authority to assign an extraschedular TDIU in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rating boards will refer to the Director of the Compensation Service for extraschedular consideration all cases of Veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16 (a). The Veteran's claim for extraschedular TDIU before October 29, 2010 has not been referred to the Director of Compensation Services. Given the foregoing, the Veteran's case should be submitted to the Director of Compensation Service for consideration of TDIU on an extraschedular basis under 38 C.F.R. § 4.16 (b). The matters are REMANDED for the following action: 1. Refer the Veteran's claim for TDIU before October 29, 2010, to the Director of Compensation Service for consideration of TDIU on an extraschedular basis pursuant to 38 C.F.R. § 4.16 (b). 2. After the above development, and any additionally indicated development, has been completed, readjudicate the claim for entitlement to a TDIU. If any the benefits sought are not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. SHAUN S. SPERANZA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morse 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.