RIGHT KNEE DISABILITY

T. BLAKE CARTER · 2025 · Case ID: 25012179

MIXED

Summary

The Veteran, an Army Veteran who served from April 1994 to January 1998 and December 2001 to September 2003, appeals a June 2017 rating decision. The Veteran sought entitlement to a total disability rating based on individual unemployability (TDIU), claiming that her service-connected irritable bowel syndrome (IBS) prevented her from working. The Board found that the TDIU claim was implicitly raised in connection with an increased rating claim for IBS filed in July 2016. As of that date, the Veteran had a combined rating of 90%, with individual disabilities including major depressive disorder (50%), IBS (30%), and right ovarian endometrioma (30%). The Board considered the Veteran's functional limitations due to her right thumb strain, IBS, endometriosis, and major depressive disorder. The combination of these disabilities, the Board found, rendered her unable to secure or maintain substantially gainful employment, leading to the grant of TDIU on a schedular basis. The Veteran also appeals the denial of service connection for right and left knee disabilities. These claims were remanded for adequate VA medical opinions, as previous opinions were found inadequate due to insufficient medical rationale. Specifically, examiners failed to adequately explain the nexus between the in-service knee injury and current conditions, or to address the Veteran's theory of secondary aggravation of the left knee due to the right knee. The Board requires new opinions to address these issues, including the potential for resolved injuries to cause later disability and the etiology of the knee conditions.

Service Branch

ARMY

Special Benefit

TDIU

Docket No.

19-00 379A

Full Decision Text

Citation Nr: 25012179
Decision Date: 09/26/25 Archive Date: 09/26/25

DOCKET NO. 19-00 379A
DATE: September 26, 2025

ORDER

Entitlement to a rating of total disability based on individual unemployability (TDIU) is granted.

REMANDED

Entitlement to service connection for a right knee disability is remanded.

Entitlement to service connection for a left knee disability is remanded.

FINDINGS OF FACT

1. The Veteran's service-connected disabilities meet the schedular criteria for entitlement to individual unemployability.

2. The combination of service-connected right thumb disability, irritable bowel syndrome, endometrioma, and major depressive disorder preclude the Veteran from securing or maintaining substantially gainful employment.

CONCLUSION OF LAW

The criteria for entitlement to a rating of total disability based on individual unemployability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.16(a), 4.25.

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty in the United States Army from April 1994 to January 1998 and from December 2001 to September 2003. The Veteran had active duty for training (ACDUTRA) service from June 1991 to August 1991 and from May 1992 to July 1992, as well as additional service in the United States Army Reserves. This case comes on appeal of a June 2017 rating decision by the agency of original jurisdiction (AOJ). The Veteran testified before the Board at a March 2020 central office hearing in Washington, DC.

This case has been before the Board on two previous occasions. Most recently, in January 2025, the Board remanded the issues below for additional development. They have now been returned to the Board for further appellate review.

Entitlement to a rating of total disability based on individual unemployability

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. In determining whether unemployability exists, consideration may be given to a veteran's level of education, special training and previous work experience, but not to his or her age or to any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19.

A total disability rating for compensation may be assigned where the schedular rating is less than total when the disabled person is, in the judgment of the rating agency, 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. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. See 38 C.F.R. § 4.16(a). For consideration under these provisions, disabilities resulting from common etiology or a single accident will be evaluated as one disability. Id.

The ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). As such, the focus of the examiner is not on whether the a veteran is unemployable due to his or her service-connected disabilities, but the functional impairment caused solely by his or her service-connected disabilities.

During the March 2020 Board hearing, the Veteran raised the issue of a TDIU, testifying that she had stopped working due to her service-connected irritable bowel syndrome (IBS). Thus, the Veteran explicitly raised the issue of entitlement to a TDIU in connection with the appeal for an increased rating for IBS that was pending at that time. As a result, the Board considers the claim for a TDIU raised in connection with the Veteran's July 21, 2016 claim for an increased rating for IBS. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (noting that a TDIU claim is implicit to a claim of increased rating when raised by the record during the pendency of the increased rating claim). As a result, the Board finds
had stopped working due to her service-connected irritable bowel syndrome (IBS). Thus, the Veteran explicitly raised the issue of entitlement to a TDIU in connection with the appeal for an increased rating for IBS that was pending at that time. As a result, the Board considers the claim for a TDIU raised in connection with the Veteran's July 21, 2016 claim for an increased rating for IBS. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (noting that a TDIU claim is implicit to a claim of increased rating when raised by the record during the pendency of the increased rating claim). As a result, the Board finds that the date of claim for entitlement to TDIU was on July 21, 2016. See id.

As of July 21, 2016, the Veteran has been service connected for: major depressive disorder, at a rate of 50 percent; IBS, at a rate of 30 percent; right ovarian endometrioma, at a rate of 30 percent; a cervical spine and right trapezius strain, at a rate of 10 percent; right thumb strain, at a rate of 10 percent; lumbosacral strain, at a rate of 10 percent; tinnitus, at a rate of 10 percent; asthma, at a rate of 10 percent; left and right breast scars, at a rate of 10 percent; salivary gland resection scars, at a rate of 10 percent; bilateral pes planus, at a rate of 0 percent; left lower extremity lymphedema, at a rate of 0 percent; right lower extremity lymphedema, at a rate of 0 percent; residuals of salivary gland resection, at a rate of 0 percent; bilateral fallopian tube scars, at a rate of 0 percent; and left ovarian endometriosis, at a rate of 0 percent. The combined rating for these disabilities is 90 percent throughout the period on appeal. See 38 C.F.R. § 4.25. Therefore, with a combined disability rating greater than 70 percent, and a single disability rated at 40 percent or more, the Board considers whether TDIU is warranted on a schedular basis pursuant to 38 C.F.R. § 4.16(a) at any time since July 21, 2016.

The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. The economic component requires a determination as to whether a Veteran's income exceeds the poverty threshold. The noneconomic component requires a determination as to a Veteran's ability to secure and follow such employment. With regard to the latter component, attention should be given to the Veteran's history, education, skill, and training. Consideration should also be given to both the Veteran's physical and mental abilities. From a physical standpoint, possible relevant factors include the Veteran's limitations as to lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as audio and visual limitations. Regarding the Veteran's mental ability, possible relevant factors include limitations as to memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. See Ray v. Wilkie, 31 Vet. App. 58 (2019).

Both treatment needs and environmental needs are factors that may reasonably be accommodated in a workplace setting. See LaBruzza v. McDonough, 37 Vet. App. 111 (2024) (finding that legally required workplace accommodations are a component of the general labor market).

In determining whether unemployability exists, consideration should not be given to a veteran's age or to any impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19.

At a VA hand and fingers examination in April 2015, the Veteran reported that she had pain with moving her right thumb between three and four times per week. The examiner determined that the Veteran would have difficulty with keyboarding and writing.

At the same time, the Veteran underwent an examination to evaluate the severity of her IBS. The Veteran reported constant abdominal distension with nausea every other day. The examiner noted frequent episodes of bowel disturbance. These symptoms were also recorded in August 2016 and January 2021 examinations.

In December 2020, the Veteran reported that she would use the bathroom before leaving the house to minimize accidents, but that she could not predict when gas and bloating would occur, which could potentially result in defecation before she could
2015, the Veteran reported that she had pain with moving her right thumb between three and four times per week. The examiner determined that the Veteran would have difficulty with keyboarding and writing.

In December 2020, the Veteran reported that she would use the bathroom before leaving the house to minimize accidents, but that she could not predict when gas and bloating would occur, which could potentially result in defecation before she could reach the bathroom. Similarly, in the January 2021 VA examination, the Veteran reported that she needed to be near a bathroom at work and was unable to work during flares.

In a January 2022 VA examination of the Veteran's endometrial condition, the examiner reported that the Veteran's endometriosis results in pelvic pain, heavy bleeding, and irregular bleeding.

In March 2025, a VA examiner opined on the functional limitations resulting from the Veteran's service-connected major depressive disorder. The examiner reported that the Veteran had difficulty attending to tasks at hand or was easily distracted. She had difficulty maintaining concentration and focus on work over a period of time and tended to skip from one task to another without completion. Her sleep was so disrupted that she would frequently be fatigued at work, making concentration and focus on work assignments difficult. Due to the Veteran's depression, the examiner opined she would have difficulty sustaining energy and motivation to complete assignments at work.

March 2025 and April 2025 VA social work notes identified that the Veteran was engaged in interventions to improve interpersonal skills through group therapy and outings.

Although any one of the disabilities described above might be compensated in the labor market through reasonable accommodations, the Board finds that this combination of disabilities renders the Veteran unable to secure or maintain substantially gainful employment.

The Board first observes that the Veteran's right thumb injury, which impacts the Veteran's ability to write and type, would significantly impair the Veteran's ability to perform most office-related jobs without accommodation.

The Veteran's IBS would require frequent bathroom breaks, the ability to respond to bowel accidents in the workplace, and a flexible schedule to account for flares. Similarly, the Veteran's endometriosis would result in a limited schedule when accounting for exacerbations of pelvic pain.

Finally, the Veteran's major depressive disorder would require a position that could compensate for the Veteran's disturbances of motivation, lack of concentration, and fatigue. The condition also presents difficulties with interpersonal relationships, such that a collaborative workplace or customer-oriented environment would be especially difficult.

The Board finds it unlikely that such a combination of accommodations, as discussed above, would be generally available in the labor market. Given the Veteran's educational and occupational history, and severity of the service-connected disabilities, the Board finds that the most probative evidence of record indicates that these service-connected disability, combined, preclude the Veteran's ability to secure or maintain substantially gainful employment. Accordingly, entitlement to a TDIU is granted on a schedular basis throughout the entire period on appeal. See 38 C.F.R. §§ 3.102, 4.16(a).

REASONS FOR REMAND

1. Entitlement to service connection for a right knee disability

2. Entitlement to service connection for a left knee disability

The Board previously remanded the Veteran's claims for service connection for right and left knee disabilities to obtain adequate VA examinations and opinions. Unfortunately, remand is once again necessary to ensure that VA has fulfilled its duty to assist by affording the Veteran an adequate medical opinion with sufficient medical rationale. An adequate medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

Here, the Veteran reports that her current right knee disability is causally related to an in-service injury she incurred while playing flag football in 2002. She has further reported that her current left knee disability is caused or aggravated by overcompensation due to the right knee disability.

Following the Board's January 2025 remand, the Veteran was provided a VA medical opinion in February 2025. At that time, the VA examiner opined that the Veteran's current right knee disability was less likely than not caused by her in-service injury. However, by way of rationale, the examiner only stated that knee sprains typically heal within four to six weeks with conservative treatment. The examiner further noted that, per the Veteran's report, her in-service knee sprain healed in one to two weeks. There was no discussion as to whether such an injury could cause residual problems such as the Veteran's current disability. The examiner then noted a lack of complaints of right knee pain in the Veteran's record between service and 2014.

At that time, the examiner did not address the Veteran's theory that her left knee disability was secondary to the right knee disability. The examiner only stated that there was no evidence of a left knee condition during active duty or following the first year of separation.

VA obtained an addendum opinion in March 2025. At that time, the reviewing examiner opined that the Veteran's claimed bilateral knee disabilities were less likely than not caused by or incurred in service. In doing so, the examiner acknowledged that the Veteran complained of bilateral knee swelling with running on her separation examination in 2002, but stated this was an acute condition that resolved. The examiner did not provide an explanation for that conclusion.

The March 2025 examiner further opined that the Veteran's report that her knee pain had been continuous since service was contradictory to the medical record. Specifically, the examiner identified that the Veteran started as a new patient with VA in 2006 and, from that point until 2009, the Veteran did not complain of knee pain. The examiner did not provide an explanation as to why that would be contradictory to the Veteran's contentions-to include, for example, whether such complaints would be expected.

The examiner then opined that the cause of the Veteran's current right knee disability was obesity. The examiner did not explain why that etiology was more likely than the Veteran's contention that residuals of her in-service injury have caused her current right knee disability.

In addressing whether the Veteran's right knee disability caused or aggravated her left knee disability, the examiner only stated the left knee disability was caused by obesity with significant weight gain noted following military service.

These opinions are not supported by sufficient medical rationale and are therefore inadequate. As was discussed above, medical rationale must identify the evidence used in support of a conclusory opinion, as well as an explanation as to why such evidence supports the conclusion reached.

In this case, the examiners failed to explain why there was no relationship between the Veteran's resolved right knee sprain and her current disability. The examiners did not explain why the Veteran's 2002 complaint of bilateral knee swelling with running was acute only. The examiners did not explain why a lack of complaints of knee pain between 2006 and 2009 was relevant to the negative nexus opinions. The examiners further did not explain why the Veteran's weight gain was more a more likely etiology for her current knee disabilities than the in-service right knee injury combined or, in the case of the left knee disability, overcompensation for the right knee disability.

As a result, remand is necessary to obtain new medical opinions for these disabilities.

The matters are REMANDED for the following actions:

1. Obtain a medical opinion from an appropriate examiner regarding the Veteran's documented right knee disability. The examiner should review the entire claims file, to include a copy of this Remand, and the opinion should include discussion of the Veteran's documented history and assertions.

The examiner should render an opinion, as to whether the Veteran's right knee disability had onset in, or is otherwise related to service.

In doing so, the examiner should address the following:

- The Veteran's documented in-service right knee sprain during a flag football game.

- The Veteran's complaint of bilateral knee swelling during running at the time of her separation examination.

The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. Complete rationale should include an explanation of the evidence used in support of the conclusion, as well as an explanation as to why such evidence supports the conclusion.

If the examiner finds that an in-service injury resolved, the examiner should discuss whether a resolved injury may or may not
an opinion, as to whether the Veteran's right knee disability had onset in, or is otherwise related to service.

In doing so, the examiner should address the following:

- The Veteran's documented in-service right knee sprain during a flag football game.

- The Veteran's complaint of bilateral knee swelling during running at the time of her separation examination.

If the examiner finds that an in-service injury resolved, the examiner should discuss whether a resolved injury may or may not ultimately cause a new disability later in life.

The examiner is reminded that the Veteran, as a layperson, is competent to describe the symptoms she has experienced. Therefore, if the examiner finds information in the record that they believe contradicts the Veteran's accounts of her symptoms-to specifically include the absence of treatment or complaints for some period in the record-the examiner should explain why that is the case.

Finally, to the extent that the examiner finds an alternative etiology to be more likely to be the cause of the Veteran's current disability than her in-service injuries, the examiner should explain why that alternative etiology is the more likely cause.

2. Obtain a medical opinion from an appropriate examiner regarding the Veteran's documented left knee disability. The examiner should review the entire claims file, to include a copy of this Remand, and the opinion should include discussion of the Veteran's documented history and assertions.

The examiner should render an opinion, as to whether the Veteran's left knee disability is caused or aggravated by the Veteran's right knee disability, to include consideration of overcompensation.

To the extent that the examiner finds an alternative etiology to be more likely to be the cause of the Veteran's current disability than her in-service injuries, the examiner should explain why that alternative etiology is the more likely cause.

(Continued on the next page)

3. Once the above development has been achieved, readjudicate the claims. If any decision is

adverse to the Veteran, issue a Supplemental Statement of

the Case and allow the applicable time for response.

Then, return the case to the Board.

T. Blake Carter

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. Giaquinto

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.

Analyze in VA Law Explorer