Prior to April 11, 2019, an initial 20 percent rating for left knee laxity is granted.
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Citation Nr: A20016959 Decision Date: 11/16/20 Archive Date: 11/16/20 DOCKET NO. 200103-51798 DATE: November 16, 2020 ORDER Prior to April 11, 2019, an initial 20 percent rating for left knee laxity is granted. A 30 percent rating for left knee limitation of flexion is granted. A 20 percent rating for left knee dislocated semilunar cartilage is granted. Entitlement to an evaluation in excess of 10 percent for left leg neuroma is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to December 15, 2011 is granted. FINDINGS OF FACT 1. Resolving doubt in the Veteran’s favor, left knee laxity manifested with moderate instability prior to April 11, 2019. 2. The Veteran’s left knee disability manifests with painful motion, weakness, and limitation of flexion to 15 degrees when flare-ups and functional impairment is considered. 3. The Veteran has left knee dislocated semilunar cartilage (i.e. arthroscopic meniscectomy in June 2018) with frequent episodes of joint “locking”, pain, and effusion. 4. The Veteran’s left leg neuroma is manifested by no more than mild incomplete paralysis. 5. The Veteran’s service-connected disabilities reasonably precluded him from securing or following a substantially gainful occupation prior to December 15, 2011. CONCLUSIONS OF LAW 1. Prior to April 11, 2019, the criteria for an initial 20 percent rating for left knee laxity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 2. The criteria for a separate rating of 30 percent for left knee limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 3. The criteria for a separate rating of 20 percent for for left knee dislocated semilunar cartilage have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 4. The criteria for a rating in excess of 10 percent for left leg neuroma have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8721, 8725. 5. The criteria for TDIU prior to December 15, 2011 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1962 to February 1967. A rating decision was issued under the legacy system in December 2006 and the Veteran submitted a timely notice of disagreement. The appeal was previously in the Legacy case system and has a protracted procedural history that was previously set forth in the most recent Board remand dated September 2016. In December 2019, the agency of original jurisdiction (AOJ) issued a supplemental statement of the case (SSOC). The Veteran opted the claims into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting a January 2020 VA Form 10182, Decision Review Request: Board Appeal, identifying the December 2019 SSOC. Therefore, the December 2019 SSOC is the decision on appeal. Therefore, the Board may only consider the evidence of record at the time of the December 2019 SSOC. 38 C.F.R. § 20.301. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The assignment of staged ratings is also appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 1. Prior to April 11, 2019, an initial 20 percent rating for left knee laxity is granted. 2. Entitlement to a separate rating of 30 percent for left knee limitation of flexion is granted. 3. Entitlement to a separate rating of 20 percent for left knee dislocated semilunar cartilage is granted. A February 2009 rating decision granted service connection for left knee laxity, and assigned a 10 percent disability rating, effective May 24, 2006 under Diagnostic Code 5299-5257. This appeal arises from the grant of service connection. A December 2019 rating decision assigned a 30 percent evaluation for left knee laxity as of April 11, 2019. The Veteran contends that he is entitled to a higher rating because he has difficulty going downstairs, maneuvering at an angle, and is at an increased risk of falling due to his service-connected disability. See August 2010 Decision Review Officer hearing. The Veteran also testified that his knees were extremely painful and kept popping out. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. According to MERRIAM WEBSTER’S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “slight” means small in amount. “Moderate” means limited in scope or effect. “Severe” means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a non-compensable rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. The rating schedule also provides that dislocation of semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 provides for the assignment of a maximum 10 percent rating based on symptomatic removal of the semilunar cartilage. Ratings for the left knee are also affected by the amputation rule, which provides, in pertinent part, that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were an amputation to be performed. 38 C.F.R. § 4.68. As relevant here, amputation of the leg at the knee warrants a 60 percent rating under Diagnostic Code 5162. 38 C.F.R. § 4.71a. In the present case, treatment records note reports of pain, instability, locking, and crepitus. In June 2007 VA treatment records, the Veteran reported increasing pain associated with certain activities to include climbing stairs, prolonged standing, and prolonged walking. The Veteran also reported occasional locking and the need to wear a knee brace. Examination showed positive anterior drawer testing, guarding, and crepitus. In August 2006 private treatment records, the Veteran was noted to have mechanical symptoms in both knees with popping, catching, locking, and pain. The physical examination demonstrated range of motion from 5 to 125 degrees with pain on flexion and rotation, moderate crepitus, and tenderness along the medial joint line. There was no lateral instability. In March 2009 private treatment records, the clinician noted that imaging showed patellofemoral chondromalacia with left knee undersurface meniscal pathology of undersurface tearing of the posterior medial meniscus. See also October 2006 letter from Dr. Smith (indicating bilateral arthritic changes with left knee degenerative fraying of the medial meniscus). Comparatively, September 2015 imaging showed normal bilateral knees without fracture, subluxation, or significant arthropathy. The Veteran consistently reported bilateral knee pain, swelling, aching, stiffness, locking, catching, popping, grinding, pain with weightbearing, and difficulty ambulating during the relevant rating period. See April 2013 private treatment record. Predominantly, the Veteran’s range of motion was, or close, to normal in clinical evaluations. See e.g. May 2013 private treatment records (noting full extension and flexion); September 2015 VA treatment records (noting range of motion 0 to 120 degrees bilaterally with crepitus). However, the Board notes that these evaluations did not consider any estimation of loss during flare ups or with repeated use over time. In support of his claims, the Veteran submitted numerous letters from private clinician who have treated him during the claims process or evaluated him for his claims. In an April 2009 letter, his treating clinician, Dr. Olin, noted that the Veteran continues to have discomfort in his knees with most daily activities, wear a knee brace, and takes medication for nerve related pain. Dr. Olin indicated the Veteran’s most recent diagnosis is of kneecap arthritis or patellofemoral degenerative joint disease. Separately, Dr. Bash and Dr. Montemarano urged that the Veteran’s symptoms of crepitus and locking of the left knee warrant a 20 percent rating. The Veteran was afforded an October 2006 VA examination as to bones fractures and diseases. The Veteran reported left leg symptoms of discomfort and pain. The Veteran endorsed flare-ups brought on by any kind of activity with increase in pain in left calf where the neuroma was removed. At the time, the Veteran also reported that his legs did not lock up or give way. In February 2009 VA examination, the examiner noted diagnoses of bilateral knee arthritic changes, and left knee laxity, among others. The Veteran reported that his knees lockup when going up and down the stairs, and he experiences pain when standing or sitting. The Veteran also reported constant pain, and flares 2 to 3 times per week lasting hours. The examiner did not endorse symptoms of giving way, instability, episodes of dislocation or subluxation, stiffness, or effusion. The examiner endorsed symptoms of pain and locking 1 to 3 times per day. Upon examination, left knee flexion was to 120 degrees with pain on active motion and against gravity. Extension was to 0 degrees without pain on active motion and against gravity. There was no additional limitation on repetitive testing. There was crepitus of the left knee, but no instability or meniscus abnormality. Regarding functional limitations as to standing and walking, the examiner indicated that the Veteran experiences pain after standing a few minutes but self- reported being able to stand all day. The Veteran was also limited to walking under one mile. In April 2014 VA examination as to the knees, the examiner noted a diagnosis of bilateral joint disease. The Veteran reported chronic pain in the left knee and flare-ups with increased exertion. Upon physical examination, the Veteran demonstrated left knee flexion to 135 degrees without objective evidence of painful motion. There was no limitation of extension. The Veteran was able to perform repetitive-use testing with flexion to 140 degrees or greater, and no limitation of extension. There was no additional limitation following repetitive-use testing. Contributing factors of disability included less movement than normal and pain on movement. The Veteran underwent re-examination in September 2015. The examiner noted a diagnosis of left knee instability. The Veteran did not report flare-ups of the knee. Upon testing, the Veteran demonstrated flexion to 130 degrees and extension to 0 degrees. Pain was noted on flexion and caused functional loss. The Veteran was able to perform repetitive use testing without additional functional loss or range of motion. The examiner was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time. There was no crepitus. The examiner did note a moderate history of recurrent subluxation and a moderate history of lateral instability. There was no history of recurrent effusion. Joint stability testing was performed with findings of 1+ on medial instability and lateral instability. The Veteran did not have a meniscus condition. Moreover, the examiner noted frequent episodes of joint pain but only occasional episodes of locking. The Veteran required constant use of an assistive device for his knee by way of a cane. The examiner noted functional impact due to the Veteran’s condition with problems walking or standing for long. The Veteran was again examined in November 2015. The examiner noted a diagnosis of chondromalacia patella, with a date of diagnosis 1966 (during service). The Veteran denied any flares or incapacitating episodes but related chronic and constant pain in both knees. On physical examination, left knee flexion was limited to 130 degrees and extension was to 0 degrees. Pain was noted on flexion but did not result in functional loss. The Veteran was able to perform repetitive use testing without additional functional loss. Again, the examiner was unable to say without mere speculation as to whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time. The examiner noted no history of recurrent subluxation, no history of lateral instability, and no history of recurrent effusion. Joint stability testing was performed but did not show joint instability. There was no meniscus condition. The examiner concluded that there was no functional impact on ability to perform any type of occupational task. As to the question of whether the Veteran’s limitation of flexion and painful motion was connected to his service-connected disability of left knee laxity, the examiner opined that there was no finding of any laxity of either knee on examination. In December 2015, VA obtained another examination of the knees. The examiner noted a diagnosis of bilateral knee joint osteoarthritis with a date of diagnosis in 2006. The Veteran reported laxity in his knees with intermittent popping, pain in the patella ligament, and a feeling of looseness in knees. The Veteran reports flare-ups with increased pain. Examination revealed normal range of motion. Although the examiner indicated the presence of pain, the pain did not result in or cause functional loss. The Veteran was able to perform repetitive use testing without additional functional loss. The examiner indicated that the Veteran was being examined immediately after repetitive use over time. In addition, pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. There was no crepitus, atrophy, or ankylosis. There was also no history of recurrent subluxation, no lateral instability, and no recurrent effusion. Joint stability testing did not reveal any instability. There were no shin splints. There was occasional use of a brace and cane. The examiner noted no functional impact. In March 2019, the Veteran was re-examined. The examiner noted diagnoses of left knee laxity and left knee meniscal tear with a date of diagnosis in 2018. The examiner concluded that the current diagnoses were a progression of his service-connected left knee disability. The Veteran reported bilateral anterior knee pain with limitations as to his ability to crawl, squat or kneel. The Veteran also reported increased pain with excessive walking, locking and giving way. However, the Veteran did not report flare-ups. Upon testing, the Veteran demonstrated flexion to 120 degrees and extension to 0 degrees. Pain was noted on flexion and causes functional loss. The Veteran was able to perform repetitive use testing without additional functional loss. The Veteran was examined immediately after repetitive use over time. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner noted additional factors of disability including instability of station, disturbance of locomotion, and interference with standing. However, the examiner found no history of recurrent subluxation, or recurrent effusion. Joint stability testing was performed with 1+ noted on anterior instability. There were no shin splints. The Veteran did have a meniscus condition on the right side with an arthroscopic meniscectomy noted, but records were not available. The examiner endorsed occasional use of assistive devices, such as a brace and cane. There was functional impact that would preclude the Veteran from any employment which requires kneeling, squatting, crawling, excessive walking, or use of stairs. Most recently, the Veteran underwent a VA examination in April 2019. The examiner noted diagnoses of left knee meniscal tear, instability, shin splint, Baker’s cysts, bone tumor removal, and neuroma removal. The examiner noted a date of diagnosis of April 2019 for all of the diagnoses. The Veteran reported constant daily pain and knees giving out. The Veteran also reported flare-ups of pain which require him to get into a prone position to alleviate the pain/ become comfortable. The Veteran is unable to squat, crawl, or walk more than 30 minutes. Range of motion testing was conducted. The Veteran demonstrated left knee flexion to 65 degrees, and extension to 0 degrees. Pain was noted on both flexion and extension. The Veteran able to perform repetitive-use testing without additional loss of function. Nonetheless, weakness and pain significantly limit left knee functional ability during flare ups or with repeated use over time. As to flare ups and repetitive use over time, the examiner described the functional loss in terms of range of motion with flexion limited to 25 degrees and extension limited to 0 degrees. There were additional contributing factors of disability including less movement than normal; more movement than normal due to flail joints, fracture nonunions, etc; instability of station; disturbance of locomotion; interference with sitting; and interference with standing. The examiner noted a severe history of subluxation, severe history of lateral instability, and recurrent effusion. Joint stability testing was performed with instability of 3+ on anterior instability, medial instability, and lateral instability. The examiner observed that there was severe left knee instability and that the examiner personally witnessed the Veteran’s knee nearly give out twice during the encounter. The Veteran also has bilateral shin splints, but it does not affect his knee or ankle range of motion. The Veteran has a meniscus condition with frequent episodes of joint “locking”, joint pain, and joint effusion. The examiner noted an arthroscopic meniscectomy in June 2018 with residual pain and stiffness. There was functional impact with decreased ability to squat, climb up or down any stairs, sit, walk or stand for prolonged periods of time due to pain and stiffness. There would be need for more frequent breaks in an employment setting. Balance, agility, and the ability to sit for long periods would also be severely impaired. Although the examiner indicated that it is difficult to know how far back the limitation as to motion with flares and repeated use, the examiner indicated that the Veteran’s limitation have been in effect for at least 10 years, but likely declined within a few years or immediately after the in-service accident. Further, the examiner indicated that the left knee instability (laxity) caused the meniscal damage in the left knee and the cyst in the left knee. Based on review of all evidence of record, and resolving doubt in favor of the Veteran, a rating of 20 percent for moderate subluxation is warranted prior to April 11, 2019. Throughout the course of the appeal, the evidence reflects that the Veteran has at times endorsed instability and/or give-way in his left knee, and at other times, denied these symptoms. The evidence does reflect longstanding use of a knee brace though. As for objective evidence of instability and/or recurrent subluxation, it too has been somewhat inconsistent as shown above. Nonetheless, the Board takes notice of the June 2007 VA evaluation showing positive anterior drawer testing. The September 2015 VA examination report also contains objective clinical evidence of left knee laxity, and the examiner specifically noted a history of ‘moderate’ recurrent subluxation and lateral instability. Objectively, joint stability testing was performed with findings of 1+ on medial instability and lateral instability. The Veteran reported laxity in his knees with intermittent popping, pain in the patella ligament, and a feeling of looseness in knees at the September 2015 VA examination although joint stability testing did not reveal any instability. The March 2019 VA examination report also revealed 1+ anterior instability upon joint stability testing. Based on the symptoms summarized above, and resolving reasonable doubt in favor of the Veteran, there is a plausible basis for the assignment of a 20 percent rating for moderate instability for the appeal period prior to April 11, 2019. A maximum rating of 30 percent is not warranted as severe instability, laxity, or recurrent subluxation is not shown prior to April 11, 2019. In that regard, the Board is mindful that several examiners and clinicians found no evidence of such symptoms, while at times, other clinicians did. Moreover, the clinicians that did find objective evidence of such symptoms, assessed the overall severity as moderate in nature. For this reason, a 30 percent rating for severe laxity is not warranted prior to April 11, 2019. In addition, a separate rating of 30 percent is warranted for limitation of flexion. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Initially, the Board notes that the evidence of record is in equipoise regarding whether the Veteran has limitation of motion of the left knee due to his service-connected disability. Most notably, the March 2019 and April 2019 VA examination reports indicated that the new diagnoses were progressions or due to his already service-connected disability. The November 2015 VA examiner noted a diagnosis chondromalacia patella, with a date of diagnosis during service. Thus, the Board will consider the limitation of motion manifested by the Veteran’s service-connected left knee disability. Based on review of all evidence of record, the Board finds that a rating of 30 percent is warranted. Objective testing produced a left knee flexion no worse than 65 degrees and full extension to 0 degrees. However, the Veteran reported flare ups during the relevant rating period. The April 2019 VA examination considered the Veteran’s estimated loss during flare ups and found that the Veteran’s left knee flexion was limited to 25 degrees. The examiner further found that this limitation was most likely in effect for at least 10 years but more likely for the entire duration of the appeal period. Under Diagnostic Code 5260, limitation of flexion to 15 degrees warrants a rating of 30 percent. Considering the DeLuca factors, the Veteran demonstrated painful motion of the knee in flexion and functional loss. Deluca v. Brown, 8 Vet. App. 202, 206-07 (1995). Thus, the maximum 30 percent rating based on functional impairment on flexion under Diagnostic Code 5260 is warranted. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, there is no argument or indication that the Veteran has ankylosis of the knee, impairment of the tibia and fibula, or genu recurvatum, to warrant separate or higher ratings under any other diagnostic code applicable to the knees. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261-5263. The Board acknowledges that the Veteran has a history of meniscal conditions with some locking and pain. The April 2019 VA examiner indicated the Veteran has a meniscus condition (i.e. arthroscopic meniscectomy in June 2018) with frequent episodes of joint “locking”, joint pain, and joint effusion. Based on this evidence a separate rating of 20 percent under Diagnostic Code 5258 is assigned. In conclusion, resolving doubt in the Veteran’s favor, an initial rating of 20 percent is warranted for moderate subluxation; a separate rating of 30 percent is warranted for limitation of flexion; and a 20 percent rating under Diagnostic Code 5258 is also warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to an evaluation in excess of 10 percent for left leg neuroma is denied. The Veteran contends that he is entitled to a higher rating because of pain associated with his neuroma. See August 2010 decision review officer hearing. The appeal period before the Board begins one year prior to May 24, 2006, the date VA received the claim for an increased rating. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010); see May 2006 correspondence. The Veteran’s disability is currently evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8721 for neuralgia of the external popliteal nerve. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Severe incomplete paralysis is rated as 30 disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). In this case, the Veteran has submitted private correspondence and treatment records in support of his claims. In August 2006 private treatment records, the Veteran reported pain and numbness in the lower left leg with examination showing diminished sensation in the area of the neuroma posterior medial lower leg. In March 2008 private treatment records, the Veteran was noted to have complaints of burning dysesthesias. Nerve conduction studies and electromyography were normal. The report noted that a small fiber neuropathy may not be apparent on studies. A September 2008 letter from Dr. Bash noted left sural nerve dysfunction with sural nerve distribution sensation and absent achilles reflexes. The Veteran was examined in October 2006. He reported discomfort, pain, and numbness along the lateral aspect of the left foot. Examination showed decreased perception of light touch along the left foot, but normal muscle strength of the legs. In April 2014 peripheral nerves examination, the examiner noted a diagnosis of status post excision of neuroma left leg. The Veteran reported persistent pain and sensitivity. There was moderate intermittent pain, moderate paresthesia, and moderate numbness. Hypoactive results were seen on deep tendon reflexes of the left knee. There was decreased lower leg and foot toes results for sensation testing for light touch. The examiner indicated that the Veteran had normal lower extremity nerves. The Veteran was afforded another VA examination in March 2019 for peripheral nerves. The examiner noted a diagnosis of neuroma of the left lower extremity. Symptoms include burning pain from the knees to the soles. There was severe constant pain, and severe paresthesias and or dysesthesias. There was normal muscle strength, no atrophy, and normal deep tendon reflexes. On sensation testing for light touch, there was absent sensation in the left lower leg/ankle, and left foot toes. The examiner noted severe incomplete paralysis of the posterior tibial nerve. The examiner also noted a 1992 electromyography which showed left sural nerve mononeuropathy. The Veteran was most recently examined in April 2019. The examiner noted a diagnosis of medial sural neuropathy of the left lower extremity and neuroma of the left leg post-operative. The examiner concluded that the peripheral neuropathy of the median sural nerve would have resulted from the service-connected neuroma. The Veteran reported symptoms of shooting pains and numbness. Symptoms attributable to the peripheral nerve condition include moderate constant pain, severe intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness. Upon testing, there was decreased results for sensation testing for light touch of the lower leg/ankle (L4/L5/S1) and foot/toes (L5). The examiner noted mild incomplete paralysis of left external popliteal nerve. The examiner indicated that there was functional impact with difficulty walking and standing. The pain would also cause decreased ability to sleep and result in lack of concentration. Based on the above, the Board finds that the disability is primarily manifest by sensory disturbance, loss of reflexes, and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by impairment of motor functions, trophic changes, muscle atrophy or complete paralysis. The Board thus finds that the level of impairment is most analogous to mild incomplete paralysis. The Board acknowledges the lay assertions of pain and paresthesias. However, the Board finds the evidence of record, including the April 2019 VA examination, to be more probative because the VA examiner has the appropriate training, expertise and knowledge to evaluate the claimed disability. The examination report included consideration of the Veteran’s reported symptoms. Although the March 2019 VA examination report noted a severe incomplete paralysis posterior tibial nerve, the examiner relied on testing outside the appeal period and the level of impairment is not supported by the other results of the examination itself or other VA examinations and treatment records. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for left leg neuroma. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. There are no additional expressly or reasonably raised issues presented on the record. 5. Entitlement to a TDIU prior to December 15, 2011 is granted. The Veteran asserts that his service-connected PTSD and left leg disabilities cause him to unable to secure and follow a substantially gainful occupation. See August 2013 VA 21-8940; August 2013 correspondence. The RO has already granted TDIU, effective December 15, 2011. However, the claim for a TDIU is part and parcel of the Veteran’s claims of increased ratings for his left knee laxity and left leg neuroma disabilities pursuant to Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Thus, the TDIU appeal period begins on May 24, 2006. See AB v. Brown, 6 Vet. App. 35, 38 (1993); Harper v. Wilkie, 30 Vet. App. 356, 360 (2018). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 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.” See 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 a sufficient additional service-connected disabilities 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. 38 C.F.R. § 4.16 (a). Where these percentage requirements 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. See 38 C.F.R. § 4.16 (b). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16 (b). Prior to December 15, 2011, the Veteran was service-connected for PTSD, rated 70 percent from October 3, 2008; left knee laxity now rated 20 percent from May 24, 2006; left knee limitation of flexion now rated 30 percent from May 24, 2006; right knee arthritis rated 10 percent disabling from May 24, 2006; left ankle arthritis rated 10 percent disabling from May 24, 2006; and right ankle arthritis rated 10 percent disabling from May 24, 2006; neuroma of the left leg rated 10 percent disabling from January 30, 1973; and left status post resection, osteoma of the left fibular rated 10 percent disabling from August 10, 1971. After accounting for the Veteran’s bilateral factors under 38 C.F.R. § 4.26, the Veteran’s combined rating from May 24, 2006 is 70 percent and 90 percent from October 3, 2008. Thus, the schedular criteria is met. The United States Court of Appeals for Veterans Claims (Court), in Ray v. Wilkie, 31 Vet. App. 58 (2019), interpreted the phrase “unable to secure and follow a substantially gainful occupation” under 38 C.F.R. § 4.16 (b). The Court defined the term to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component, which is pertinent in this case, includes consideration of: The Veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Upon review, the Board finds the evidence supports a TDIU from May 24, 2006. On the August 2013 VA Form 8940 and the associated August 2013 correspondence, the Veteran reported that he last worked in 1997. At that time, he was self-employed in carpet sales. The Veteran also reported previously working as a business unit manager, and as a process consultant for an environment services company. The Veteran completed four years of high school. As to education and training, the Veteran reported that he received additional training in Naval flight school, as an aviation machinist, and programming for Texas Instruments and Square D. The Veteran also reported that he has an electrical contracting license, but it is not current. At the February 2009 VA examination, the Veteran reported last working as an automation electrician. Thus, looking at economic considerations during the relevant rating period, the Veteran had the education, training, skills, and work history to perform substantially gainful work in the field of electrician, programming, and sales. Nonetheless, during the relevant rating period, the medical evidence showed the Veteran had severe difficulties due to his service-connected physical disabilities of the bilateral ankles and bilateral knees, among others. As noted above, the Veteran’s left knee and neuroma disabilities result in substantial impairment to his ability to walk, stand, crawl, climb, squat or kneel. These duties would be common in any work as an electrician and would be relevant to sales and business management. These disabilities also result in disruption to concentration due to the degree of pain, and would require numerous breaks to allow the Veteran to deal with the discomfort. In fact, the February 2009 VA examination noted significant effects as he is limited in the number of hours he could work due to bilateral knee and ankle pain. The April 2009 VA examination as to mental disorders also noted that the Veteran was short-tempered, isolative and his psychiatric symptoms would result in some impairment of his employment functions. Ultimately, the Board finds that the evidence is in equipoise as to whether the Veteran’s collective service-connected disabilities precluded him from obtaining substantially gainful employment consistent with his work history, training, education, and skills. Resolving doubt in the Veteran’s favor, a TDIU is warranted from May 24, 2006. See Gilbert v. Derwinski,1 Vet. App. 49, 55 (1990). The Board notes that it has considered whether the Veteran is entitled to an award of special monthly compensation (SMC). See 38 C.F.R. § 3.350 (i)(1); see also Bradley v. Peake, 22 Vet. App. 280 (2008). After consideration of the facts of this case, however, the Board does not find that an SMC rating is for application. The above grant of TDIU was predicated upon the collective effect of the Veteran’s disabilities of his bilateral knees, bilateral ankles, and his PTSD. Accordingly, the Board finds that there is no one disability ratable at 100 percent independent of the other service-connected disabilities. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Vuong, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.